Neurocognitive & Motor Control Strategies in ACL Rehab: From the WHAT to the HOW

Transcription

1 Neurocognitive & Motor Control Strategies in ACL Rehab: From the WHAT to the HOW Marc Sherry, PT, DPT, LAT, CSCS, PES Dan Cobian, PT, DPT, PhD, CSCS Kelcie Wittman, PT, DPT, SCS, USAW-L1 Introduction & Background Session Objectives Recognize the discrepancies between the requirements of successful sports performance and the typical rehabilitation environment Understand how neurocognitive and neuromuscular deficiencies prohibit successful recovery and return to activity after ACL injury and reconstruction Develop and employ effective and sport specific exercise parameters to build the foundation for a successful return to sport Learn and implement new clinical strategies for addressing specific neurocognitive and neuromuscular performance deficits to maximize success in ACL rehabilitation ACL Reconstruction and Return to Sport 55-83% of athletes return to sport (RTS) after ACLR (Ardern 2014, Lai 2018) o % may be lower within one year from ACLR o Reduced performance upon RTS Long term deficits in muscle function and movement biomechanics (Noehren et al 2013, Tengman et al 2015) Almost 30% of athletes sustained a 2nd injury less than 24 months following primary ACLR and RTS (Paterno et al 2014) As clinicians, the important question to ask ourselves is: How can we do a BETTER job of ACL Rehab to allow athletes to return to pre-injury level of sport while minimizing re-injury risk? Comparing Sports Environment vs Typical Clinical Environment Sports o External focus of attention o Focus on task outcome, not movement mechanics o Rapid, responsive, changing o Reactionary Clinic o Internal focus of attention o Manual & visual feedback of mechanics o Slow, controlled, sustained o Pre-planned

2 Part 1: Athletic Movement for Return to Sport after ACLR Objectives What is athletic movement? Why is athletic movement an important concept in ACL rehab? How can rehab techniques optimize the recovering and development of athletic movement? Athletic Movement Opposition of arms and legs Multi-joint movement Triple flexion Triple extension Multi-planar with emphasis on rotation Quick changes of base of support Unsupported Unanticipated movement Indirect contact Recovering Athletic Movement Preparing properly Emphasize learning Optimize feedback for the patient not the PT Focus of attention for retention Optimize timing of feedback and practice Sources of Feedback Intrinsic Extrinsic Types of Feedback and Skill Acquisition Manual Creates dependency and reduces retention Should only be used for safety and very low skill performers Visual Motor areas involved in preparation and execution of action is activated by observation (Calvo-Merino 05, Bellelli 2010) Verbal Focus of Attention IFOA (Explicit learning) Direct attention toward the body s components during a task EFOA (Implicit learning) Direct attention toward external effects of action or the goal Several studies have shown improved performance and retention with motor skills and athletic movement performance. Emerging research related to ACL injury prevention and rehabilitation.

3 Delayed Feedback Encourages problem solving and discovery Leads to greater retention Bandwidth Feedback Less feedback can mobilize cognitive processes for performance (Chambers 06) Improves performance (Goodwin 1995) Blocked vs. Random practice Random practice of a motor skill enhances long term learning more than blocked (Overdorf 04) References - Part 1 Alentorn-Geli, E., et al. (2009). "Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors." Knee Surg Sports Traumatol Arthrosc 17(7): Bellelli, G., et al. (2010). "Action observation treatment improves recovery of postsurgical orthopedic patients: evidence for a top-down effect?" Arch Phys Med Rehabil 91(10): Benjaminse, A., et al. (2017). "Motor learning strategies in basketball players and its implications for ACL injury prevention: a randomized controlled trial." Knee Surg Sports Traumatol Arthrosc 25(8): Benjaminse, A. and E. Otten (2011). "ACL injury prevention, more effective with a different way of motor learning?" Knee Surg Sports Traumatol Arthrosc 19(4): Benjaminse, A., et al. (2017). "Video Feedback and 2-Dimensional Landing Kinematics in Elite Female Handball Players." J Athl Train 52(11): Benjaminse, A., et al. (2015). "Novel methods of instruction in ACL injury prevention programs, a systematic review." Phys Ther Sport 16(2): Benjaminse, A., et al. (2018). "Transfer of improved movement technique after receiving verbal external focus and video instruction." Knee Surg Sports Traumatol Arthrosc 26(3): Besier, T. F., et al. (2001). "External loading of the knee joint during running and cutting maneuvers." Med Sci Sports Exerc 33(7): Calvo-Merino, B., et al. (2005). "Action observation and acquired motor skills: an FMRI study with expert dancers." Cereb Cortex 15(8): Chambers. The Sport Psychologist, 2006, 20, Human Kinetics, Inc. Effects of Bandwidth Feedback and Questioning on the Performance of Competitive Swimmers Kristine L. Chambers and Joan N. Vickers University of Calgary, Canada Chappell, J. D., et al. (2002). "A comparison of knee kinetics between male and female recreational athletes in stop-jump tasks." Am J Sports Med 30(2):

4 References - Part 1 (Cont.) Decker, M. J., et al. (2003). "Gender differences in lower extremity kinematics, kinetics and energy absorption during landing." Clin Biomech (Bristol, Avon) 18(7): Durham, K., et al. (2009). "Use of information feedback and attentional focus of feedback in treating the person with a hemiplegic arm." Physiother Res Int 14(2): Fletcher, I. M. and M. M. Monte-Colombo (2010). "An investigation into the effects of different warm-up modalities on specific motor skills related to soccer performance." J Strength Cond Res 24(8): Ford, K. R., et al. (2015). "An evidence-based review of hip-focused neuromuscular exercise interventions to address dynamic lower extremity valgus." Open Access J Sports Med 6: Gergley, J. C. (2009). "Acute effects of passive static stretching during warm-up on driver clubhead speed, distance, accuracy, and consistent ball contact in young male competitive golfers." J Strength Cond Res 23(3): Gokeler, A., et al. (2013). "Feedback techniques to target functional deficits following anterior cruciate ligament reconstruction: implications for motor control and reduction of second injury risk." Sports Med 43(11): Gokeler, A., et al. (2015). "The effects of attentional focus on jump performance and knee joint kinematics in patients after ACL reconstruction." Phys Ther Sport 16(2): Goodwin, J. E. and H. J. Meeuwsen (1995). "Using bandwidth knowledge of results to alter relative frequencies during motor skill acquisition." Res Q Exerc Sport 66(2): Lohse, K. R., et al. (2011). "Neuromuscular effects of shifting the focus of attention in a simple force production task." J Mot Behav 43(2): Overdorf, V., et al. (2004). "Mental and physical practice schedules in acquisition and retention of novel timing skills." Percept Mot Skills 99(1): Popovic, T., et al. (2018). "Implicit video feedback produces positive changes in landing mechanics." J Exp Orthop 5(1): 12. Prapavessis, H., et al. (2003). "Decreasing landing forces in children: the effect of instructions." J Orthop Sports Phys Ther 33(4): Rendell, M. A., et al. (2011). "An implicit basis for the retention benefits of random practice." J Mot Behav 43(1): Rotem-Lehrer, N. and Y. Laufer (2007). "Effect of focus of attention on transfer of a postural control task following an ankle sprain." J Orthop Sports Phys Ther 37(9):

5 References - Part 1 (Cont.) Simic, L., et al. (2013). "Does pre-exercise static stretching inhibit maximal muscular performance? A meta-analytical review." Scand J Med Sci Sports 23(2): Taylor, K. L., et al. (2009). "Negative effect of static stretching restored when combined with a sport specific warm-up component." J Sci Med Sport 12(6): Welling, W., et al. (2016). "Enhanced retention of drop vertical jump landing technique: A randomized controlled trial." Hum Mov Sci 45: Welling, W., et al. (2016). "Enhanced retention of drop vertical jump landing technique: A randomized controlled trial." Hum Mov Sci 45: Welling, W., et al. (2017). "RETENTION OF MOVEMENT TECHNIQUE: IMPLICATIONS FOR PRIMARY PREVENTION OF ACL INJURIES." Int J Sports Phys Ther 12(6): Zachry TL, Wulf G, Mercer JA. Effects of focus of attention on reach height. J Sport Exerc Psychol. 2005;27:S162 S163. Part 2: Rapid Muscle Activation & Force Development Objectives Recognize the importance of rapid muscle activation & force development to athletic movement Understand how ACL injury & reconstruction influences neuromuscular function How to train for rapid rate of muscle contraction through specific dosage of therapeutic exercise while respecting healing constraints post-aclr Muscle Performance after ACLR Quadriceps neuromuscular dysfunction Poor Quad function alters movement mechanics, increases re-injury risk, has potential to impair sports performance Quad and LE strengthening is a fundamental component of ACLR rehab Quad Assessment - Typically quantified as maximal strength o 85-90% LSI for RTS o Persistent dysfunction even with recovery of quad strength symmetry Why Rate is Important Neuromuscular activity (activation of motor units to produce muscle contraction) during typical human movement is characterized by bursts of muscle activation Muscle rapidly turns on / off, resulting in rapid increases and decreases in force production Typical human movement involves repeated patterns of rapid muscle activation and relaxation producing rapid modulations in muscle force production Speed of typical human movement precludes peak muscle force development during most daily and sports activities (in most cases, 200 ms or less)

6 Quadriceps Activation patterns during typical movements Walking Jogging Running Leaping Cutting Changing Directions Movement Sequences w/transitions Quadriceps Rate of Force Development and Rate of Activation after ACLR Rapid quadriceps force development / lower extremity muscle power asymmetries may be greater than strength asymmetries post-aclr (Angelozzi 2012, Knezevic 2014, Mirkov 2016, Neeter 2006) Muscle Power / rate of torque development may be more important to recovery of movement biomechanics than maximal strength post-aclr (Blackburn 2016, Kline 2015, Pua 2018) UW Athletics: Significant asymmetries in knee extensor rate of torque development and quadriceps rate of activation during sports activities 6 and 9 months post-aclr Are we appropriately addressing muscle speed/power in ACL Rehab? WHEN do we perform fast muscle contractions post-aclr? Recovery following ACL injury & surgery People are more sedentary/protective of the injured limb Low intensity exercises (QS, SLR) performed with slow ramp contraction Potential for neuromuscular inhibition limiting both muscle recruitment and rate coding Quadriceps Activation Patterns during Rehabilitation Consider the typical activation patterns and compare when there is a specific focus on speed of contraction o Quad Set o Mini Squat o Forward Lunge o Seated Knee Extension o Weight shifting o Single Leg Squat o Lateral lunge o Leg Press Inducing Rapid Activation Adaptations Keys to training rate of activation: 1) Intent 2) Instruction Review & Summary Consider demands of sport when selecting parameters & dosage of rehabilitation interventions Need muscle strength and power to perform sports activities safely and effectively If we don't provide patients with the tools to move effectively, we are setting them up to fail

7 References - Part 2 ADAMS, D., LOGERSTEDT, D. S., HUNTER-GIORDANO, A., AXE, M. J. & SNYDER-MACKLER, L Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. J Orthop Sports Phys Ther, 42, ANGELOZZI, M., MADAMA, M., CORSICA, C., CALVISI, V., PROPERZI, G., MCCAW, S. T. & CACCHIO, A Rate of Force Development as an Adjunctive Outcome Measure for Return-to-Sport Decisions After Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther, 42, ARDERN, C. L., TAYLOR, N. F., FELLER, J. A. & WEBSTER, K. E Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med, 48, BALSHAW, T. G., MASSEY, G. J., MADEN-WILKINSON, T. M., TILLIN, N. A. & FOLLAND, J. P Trainingspecific functional, neural, and hypertrophic adaptations to explosive- vs. sustained-contraction strength training. J Appl Physiol (1985), 120, BEHM, D. G. & SALE, D. G Intended rather than actual movement velocity determines velocityspecific training response. J Appl Physiol (1985), 74, BLACKBURN, J. T., PIETROSIMONE, B., HARKEY, M. S., LUC, B. A. & PAMUKOFF, D. N Quadriceps Function and Gait Kinetics after Anterior Cruciate Ligament Reconstruction. Med Sci Sports Exerc, 48, CAPPELLINI, G., IVANENKO, Y. P., POPPELE, R. E. & LACQUANITI, F Motor patterns in human walking and running. J Neurophysiol, 95, COBIAN DG, K. K., STIFFLER-JOACHIM MR, COBIAN AG, HEIDERSCHEIT BC 2018a. Recovery of Rapid Quadriceps Activation and Rate of Torque Development post-acl Reconstruction During Muscle Performance Tests, Running, and Jumping in a Division I Collegiate Soccer Player. J Orthop Sports Phys Ther, 48, A34 (SPL11). COBIAN DG, K. K., STIFFLER-JOACHIM MR, COBIAN AG, HEIDERSCHEIT BC 2018b. Reduced Rate of Quadriceps Activation During Running and Jumping in Collegiate Athletes 4 and 8 Months post- ACL Reconstruction. J Orthop Sports Phys Ther, 48, A35 (SPL13). COBIAN DG, K. K., STIFFLER-JOACHIM MR, SANFILIPPO JS, HEIDERSCHEIT BC 2019a. Isometric and Isokinetic Assessments of Rapid Knee Extensor Torque Development are Similarly Correlated with Run and Jump Kinetic Asymmetries in Collegiate Athletes post-anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther, 49, CSM36 (SPL16). COBIAN DG, K. K., STIFFLER MR, COBIAN AG, HEIDERSCHEIT BC Reduced Rate of Quadriceps Activation during Running and Jumping in Collegiate Athletes post-acl Reconstruction. Med Sci Sports Exerc, 49, 497 (1763). COBIAN, D. G., KOCH, C. M., AMENDOLA, A. & WILLIAMS, G. N. 2017a. Knee Extensor Rate of Torque Development Before and After Arthroscopic Partial Meniscectomy, With Analysis of Neuromuscular Mechanisms. J Orthop Sports Phys Ther, 47, COBIAN, D. G., ROBBINS, D. P., YACK, H. J. & WILLIAMS, G. N. 2017b. Leg Press Power and Quadriceps Rate of Force Development are Associated with Reduced Knee Joint Moments and Powers, Hop Performance, and Patient-Based Outcomes 4 to 12 Months after Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther, 47, A36 (SPL16). COBIAN DG, S.-J. M., SANFILIPPO JS, HEIDERSCHEIT BC 2019b. Activation Asymmetries of the Vastus Lateralis and Vastus Medialis are More Pronounced than Rectus Femoris 4 and 6 Months post- Anterior Cruciate Ligament Reconstruction in Collegiate Athletes. J Orthop Sports Phys Ther, 49, CSM37 (SPL17).

8 References - Part 2 (Cont.) GAZENDAM, M. G. & HOF, A. L Averaged EMG profiles in jogging and running at different speeds. Gait Posture, 25, GOKELER, A., WELLING, W., ZAFFAGNINI, S., SEIL, R. & PADUA, D Development of a test battery to enhance safe return to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 25, GRINDEM, H., SNYDER-MACKLER, L., MOKSNES, H., ENGEBRETSEN, L. & RISBERG, M. A Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med, 50, INGERSOLL, C. D., GRINDSTAFF, T. L., PIETROSIMONE, B. G. & HART, J. M Neuromuscular consequences of anterior cruciate ligament injury. Clin Sports Med, 27, , vii. KLINE, P. W., MORGAN, K. D., JOHNSON, D. L., IRELAND, M. L. & NOEHREN, B Impaired Quadriceps Rate of Torque Development and Knee Mechanics After Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft. Am J Sports Med. KNEZEVIC, O. M., MIRKOV, D. M., KADIJA, M., NEDELJKOVIC, A. & JARIC, S Asymmetries in explosive strength following anterior cruciate ligament reconstruction. Knee. KNURR KA, S.-J. M., SANFILIPPO JS, COBIAN AG, HEIDERSCHEIT BC, COBIAN DG Relationships between Isometric and Functional Measurements of Rapid Quadriceps Activation in Division I Collegiate Athletes 7 Months post-anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther, 49, CSM43-44 (SPL33). LAI, C. C. H., ARDERN, C. L., FELLER, J. A. & WEBSTER, K. E Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Br J Sports Med, 52, LEPLEY, A. S., GRIBBLE, P. A., THOMAS, A. C., TEVALD, M. A., SOHN, D. H. & PIETROSIMONE, B. G Quadriceps neural alterations in anterior cruciate ligament reconstructed patients: A 6-month longitudinal investigation. Scand J Med Sci Sports, 25, LORENZ, D. S., REIMAN, M. P., LEHECKA, B. J. & NAYLOR, A What performance characteristics determine elite versus nonelite athletes in the same sport? Sports Health, 5, MIRKOV, D. M., KNEZEVIC, O. M., MAFFIULETTI, N. A., KADIJA, M., NEDELJKOVIC, A. & JARIC, S Contralateral limb deficit after ACL-reconstruction: an analysis of early and late phase of rate of force development. J Sports Sci, 1-6. NEETER, C., GUSTAVSSON, A., THOMEE, P., AUGUSTSSON, J., THOMEE, R. & KARLSSON, J Development of a strength test battery for evaluating leg muscle power after anterior cruciate ligament injury and reconstruction. Knee Surg Sports Traumatol Arthrosc, 14, NOEHREN, B., WILSON, H., MILLER, C. & LATTERMANN, C Long-term gait deviations in anterior cruciate ligament-reconstructed females. Med Sci Sports Exerc, 45, PALMIERI-SMITH, R. M., THOMAS, A. C. & WOJTYS, E. M Maximizing quadriceps strength after ACL reconstruction. Clin Sports Med, 27, , vii-ix. PATERNO, M. V., RAUH, M. J., SCHMITT, L. C., FORD, K. R. & HEWETT, T. E Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. Am J Sports Med, 42, PUA, Y. H., MENTIPLAY, B. F., CLARK, R. A. & HO, J. Y Associations Among Quadriceps Strength and Rate of Torque Development 6 Weeks Post Anterior Cruciate Ligament Reconstruction and Future Hop and Vertical Jump Performance: A Prospective Cohort Study. J Orthop Sports Phys Ther, 47,

9 References - Part 2 (Cont.) RAND, M. K. & OHTSUKI, T EMG analysis of lower limb muscles in humans during quick change in running directions. Gait Posture, 12, ROEWER, B. D., DI STASI, S. L. & SNYDER-MACKLER, L Quadriceps strength and weight acceptance strategies continue to improve two years after anterior cruciate ligament reconstruction. J Biomech, 44, SCHMITT, L. C., PATERNO, M. V., FORD, K. R., MYER, G. D. & HEWETT, T. E Strength Asymmetry and Landing Mechanics at Return to Sport after Anterior Cruciate Ligament Reconstruction. Med Sci Sports Exerc, 47, SCHMITT, L. C., PATERNO, M. V. & HEWETT, T. E The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther, 42, TENGMAN, E., GRIP, H., STENSDOTTER, A. & HAGER, C. K Anterior cruciate ligament injury about 20 years post-treatment: A kinematic analysis of one-leg hop. Scand J Med Sci Sports, 25, TILLIN, N. A., JIMENEZ-REYES, P., PAIN, M. T. & FOLLAND, J. P Neuromuscular performance of explosive power athletes versus untrained individuals. Med Sci Sports Exerc, 42, WILLIAMS, G. N., BUCHANAN, T. S., BARRANCE, P. J., AXE, M. J. & SNYDER-MACKLER, L. 2005a. Quadriceps weakness, atrophy, and activation failure in predicted noncopers after anterior cruciate ligament injury. Am J Sports Med, 33, WILLIAMS, G. N., SNYDER-MACKLER, L., BARRANCE, P. J., AXE, M. J. & BUCHANAN, T. S. 2005b. Neuromuscular function after anterior cruciate ligament reconstruction with autologous semitendinosus-gracilis graft. J Electromyogr Kinesiol, 15, Part 3: Neuroplasticity Objectives Traditional rehab focus What is neuroplasticity Why is neuroplasticity an important concept in ACL rehab How does ACL injury affect neuroplasticity and movement How can we incorporate this concept into training and a rehab program Return to Sport (Ardern et al. 2014) Of athletes recovering from ACL reconstruction: o 81% of people returned to any sport o 65% returned to preinjury level o 55% returned to competitive level sport after surgery How can we improve these outcome percentages?? Traditional Rehab Focus Regain full knee range of motion, normalize gait, eliminate effusion Restore quadriceps activation and strength Knee control and core stability Proprioception Neuromuscular control*

10 o Definition: motor output in response to afferent/sensory input OR precise muscle activation that allows for a coordinated and efficient action Low to high-level athletic activities and sport specific movements to progress an athlete back to sport* o Need to mimic sport with goal of creating long term quality athletic movement **Are we optimizing the last two principles? If not, how can we improve? Three Balance Systems Sensory input o Vestibular o Visual o Proprioceptive Input integration o Cerebellum o Cerebral cortex o Brainstem Motor output o Vestibulo-ocular reflex o Motor impulse Neuroplasticity Ability of the brain to form and reorganize synaptic connections, especially in response to learning or experience or following injury o Positive in response to learning o Negative in response to injury ACL injury Sensory neuroplasticity (altered somatosensory input and processing) Proprioception (decreased joint position sense for motor control) Motor neuroplasticity (altered efferent output, more planning/visual processing needed) Postural control (diminished unless increase in vision/planning) NM Control (visual and cognitive reliance for movement) (Grooms et al. 2015) Research Supported Findings Kaprelli et al o Compared 17 males with right ACL rupture to 18 matched controls >6 months since injury (no reconstruction) o Performed active knee flexion and extension (0-45 ) during an fmri scan o Results: Primary sensorimotor area proprioception and sensation Decreased in ACL group Presupplementary motor area motor planning Increased in ACL group Inferior temporal gyrus visual processing Increased in ACL group Grooms et al o Similar to Kaprelli but compared 15 subjects post ACLR vs controls o fmri scan taken during active knee flexion and extension o Results: Increased in ACLR group

11 CL Primary Motor Cortex movement IL Lingual Gyrus processing visual and sensory feedback IL Secondary Somatosensory Cortex processing sensory stimuli and pain Decreased in ACLR group IL Motor Cortex movement IL Vermis coordination/timing of movement What Could This Mean For Recovering Movement (Grooms et al 2015, 2017) Decrease excitability motor cortex o Increase processing demands for simple movement More visually based strategy for movement Activation of higher level sensory integration area **Unilateral training may further drive neuroplastic changes** Clinical Application Why might these altered strategies for recovering movement be problematic?? o Adaptation mechanisms become overloaded in an athletic environment Is rehab promoting these neuroplastic changes?? Classic Rehab o Focus of attention Usually fully on the movement In sport focus is on the environment not the movement o Increased visual and cognitive strategies promoted in therapy i.e. mirror feedback, think about keeping your knees out Strategies External focus of attention with cueing Direct Visual Disruption Indirect Visual Disruption Direct Visual Disruption Postural Sway increases with ACL injury (Okuda et al. 2005) o Eyes closed o Injured leg SLB but not uninjured Systematic review (Negahban et al. 2014) o Balance deficits B with eyes closed post ACL Easiest Way to disrupt visual system? o Close eyes Limitation to closing eyes? o Activity must stay relatively static (sport is dynamic) Making visual disruption more dynamic o can include obstacles, targets, reaction o Specific examples: Single leg balance vs single leg balance with ball toss Bounding with movement (step cross-over bound) Hopping over hurdles

12 Indirect Visual Disruption Targets Reaction Dual task Other players = anything to increase task complexity and cognitive load Research (Ford et al. 2005) o Overhead goal changes performance and mechanics with drop vertical jump Jump height Stance time Hip moments Knee & ankle angles o Movement changes with use of a target why? Due to focus of attention elsewhere? Want to ensure athlete has optimal quality of movement when focus placed elsewhere Increased effort with targets and goals? Effort may drive movement quality post ACLR (i.e. jump at 50% effort vs 100%) Targets & Reaction o Examples: movement with reactive and targeted reaching outside base of support Squat, lunge, jump o Examples: movement with reaction (stimulus initiates movement or requires a change in movement) Jump, hop, run, lateral change of direction, cut/pivot Can be in response to something visual (i.e. reacting to a light or another person), audible (i.e. clap) Dual Task o Examples: ball tossing, different colors, stating months backwards Can be physical or cognitive When to Implement? Start immediately o Examples: focus of attention when doing a quad set, ball toss with straight leg raise Part 3 Summary Majority ACL research on biomechanics Neuroplasticity and need to consider what s going on cognitively Altered somatosensory Reliance on vision and higher cortical processes Get out of traditional rehab strategies Recreate the environment

13 References - Part 3 Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and metaanalysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21): Ford et al. Use of an overhead goal alters vertical jump performance and biomechanics. J Strength & Cond Research. 2005; 19(2): Gokeler A et al. Feedback techniques to target functional deficits following anterior cruciat ligament reconstruction: implications for motor control and reduction of second injury risk. Sports Med. 2014; Nov 43(11): Grooms D et al. Neuroplasticity associated with anterior cruciate ligament reconstruction. J Orthop & Sports Phys Ther. 2017; 47(3): Grooms D, Applebaum G, Onate J. Neuroplasticity following anterior cruciate ligament injury: a framework for visual-motor training approaches in rehabilitation. J Orthop & Sports Phys Ther. 2015; 45(5): Grooms D, Page S, Onate J. Brain activation for knee movement measured days before second anterior cruciate ligament injury: neuroimaging in musculoskeletal medicine. J Athletic Training. 2015; 50(10): Joseph AM, Collins CL, Henke NM, Yard EE, Fields SK, Comstock RD. A multisport epidemiologic comparison of anterior cruciate ligament injuries in high school athletics. J Athl Train. 2013;48(6): Lepley KL, Grooms DR, Burland JP, Davi SM, Mosher JL, Cormier ML, Lepley AS. Eccentric cross-exercise after anterior cruciate ligament reconstruction: Novel case series to enhance neuroplasticity. Phys Ther in Sport. 2018; 34: Lepley AS, Gribble PA, Thomas AC, Tevald MA, Sohn DH, Pietrosimone BG. Quadriceps neural alterations in anterior cruciate ligament reconstructed patients: A 6-month longitudinal investigation. Scand J Med Sci Sports. 2015; 25: Negahban D et al. A systematic review of postural control during single-leg stance in patients with untreated anterior cruciate ligament injury. Knee Surg Sports Traumatol Arthrosc. 2014; Jul 22(7): Okuda et al. Effect of vision on postural sway in anterior cruciate ligament injured knees. J Orthop Sci. 2005; 10: