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Du C, Jiao J, Zhou J, Chow BC, Shi Q, Zhang X, Liu S, Yang J. Three-month functional training programme improves knee joint function in athletes post-ACL reconstruction surgery. J Rehabil Med 2024; 56:jrm18701. [PMID: 39291912 PMCID: PMC11418274 DOI: 10.2340/jrm.v56.18701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 07/18/2024] [Indexed: 09/19/2024] Open
Abstract
OBJECTIVE Rehabilitation and recovery duration following anterior cruciate ligament reconstructive surgery play a pivotal role in restoring optimal knee functionality in athletes. This study aimed to explore the impact of a 3-month functional training programme aligned with enhanced recovery after surgery on recuperation subsequent to anterior cruciate ligament reconstructive surgery. DESIGN A quasi-experimental study. SUBJECTS A cohort of 34 patients aged 14 to 24, who underwent anterior cruciate ligament reconstructive surgery and adhered to enhanced recovery after surgery protocols during the perioperative period, were allocated to an experimental group and a control group according to their eligibility, capacity, and willingness to engage in the functional training programme. METHODS The participants in the experimental group underwent a 3-month regimen of functional training following anterior cruciate ligament reconstructive surgery, whereas the control group followed a conventional recovery approach. Evaluations were conducted both prior to and following the 3-month recovery interval, utilizing the Y-Balance Test, Functional Movement Screening, and Isokinetic Knee Test. RESULTS Assessment outcomes of the Y-Balance Test, Isokinetic Knee Test, and Functional Movement Screening exhibited significant enhancement (p < 0.05) within the experimental group, as opposed to the control group. These findings underscore that those athletes who undertook the 3-month functional training regimen within the experimental group exhibited heightened dynamic balance capabilities, increased knee joint mobility, and enhanced stability compared with their counterparts in the control group. CONCLUSION Consequently, this underscores the efficacy of the 3-month functional training protocol aligned with enhanced recovery after surgery, as a means to effectively facilitate recuperation subsequent to anterior cruciate ligament reconstructive surgery.
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Affiliation(s)
- Chuanjia Du
- School of Sports Medicine and Health, Chengdu Sport University, Chengdu, China
| | - Jiao Jiao
- Department of Sport, Physical Education and Health, Hong Kong Baptist University, Hong Kong, China; Dr. Stephen Hui Research Centre for Physical Recreation and Wellness, Hong Kong Baptist University, Hong Kong, China
| | - Jihe Zhou
- School of Sports Medicine and Health, Chengdu Sport University, Chengdu, China.
| | - Bik Chu Chow
- Department of Sport, Physical Education and Health, Hong Kong Baptist University, Hong Kong, China; Dr. Stephen Hui Research Centre for Physical Recreation and Wellness, Hong Kong Baptist University, Hong Kong, China
| | - Qiuqiong Shi
- School of Fashion and Textiles, The Hong Kong Polytechnic University, Hong Kong, China
| | - Xiaopei Zhang
- School of Sports Medicine and Health, Chengdu Sport University, Chengdu, China
| | - Siyu Liu
- School of Sports Medicine and Health, Chengdu Sport University, Chengdu, China
| | - Jianchao Yang
- Business School of Hohai University, Nanjing, Jiangsu, China
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Hogg JA, Barger NB, Bruce JR, White CC, Myer GD, Diekfuss JA. Improved Quadriceps Torque Production With Optimized Biofeedback in Patients After Anterior Cruciate Ligament Reconstruction. J Strength Cond Res 2024:00124278-990000000-00510. [PMID: 39074249 DOI: 10.1519/jsc.0000000000004883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
Abstract
Hogg, JA, Barger, NB, Bruce, JR, White, CC, Myer, GD, and Diekfuss, JA. Improved quadriceps torque production with optimized biofeedback in patients after anterior cruciate ligament reconstruction. J Strength Cond Res XX(X): 000–000, 2024—Optimizing performance through intrinsic motivation and attention for learning: prevention rehabilitation exercise play (OPTIMAL PREP) training strategies incorporate motor learning principles to enhance movement acquisition and retention. We aimed to use OPTIMAL PREP biofeedback to evaluate its potential to improve quadriceps and hamstring torque production in patients with anterior cruciate ligament reconstruction (ACL-R). Thirteen subjects 23 ± 19 months post ACL-R completed 5 concentric quadriceps/hamstrings repetitions on an isokinetic dynamometer for each limb and counterbalanced condition at 60°·s−1. For the control condition, subjects were instructed to perform the exercise “as hard and fast as possible.” For the OPTIMAL PREP condition, subjects were additionally told that “Research shows that if you focus on moving the line on the screen (external focus) you will exhibit greater quadriceps output (enhanced expectancies)” and were given the choice of graphical representation for the biofeedback (autonomy support). Quadriceps and hamstrings peak torque, rate of force development, and torque-angle waveforms were analyzed with 2 × 2 RMANOVAs (a priori
>0.06). The ACL-R limb demonstrated increased quadriceps peak torque in the OPTIMAL PREP condition than in the control condition (
= 0.13, interaction p = 0.21, pairwise Cohen's d = 0.63). Anterior cruciate ligament reconstruction limb quadriceps deficits remained near terminal extension (14–45°; peak Cohen's d = 0.57, p < 0.001). For hamstrings peak torque, we observed moderate effects for condition (OPTIMAL PREP greater;
= 0.10, p = 0.29) and limb (uninvolved greater;
= 0.13, p = 0.22). Easily implementable OPTIMAL PREP training strategies improved ACL-R limb quadriceps torque production, resulting in between-limb parity. However, asymmetries still existed near terminal extension.
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Affiliation(s)
- Jennifer A Hogg
- Department of Health and Human Performance, The University of Tennessee Chattanooga, Chattanooga, Tennessee
| | - Nathan B Barger
- Department of Athletics, The University of Tennessee Chattanooga, Chattanooga, Tennessee
| | - Jeremy R Bruce
- Department of Orthopaedic Surgery, University of Tennessee College of Medicine, Chattanooga, Tennessee
| | - Charles C White
- Department of Orthopaedic Surgery, University of Tennessee College of Medicine, Chattanooga, Tennessee
| | - Gregory D Myer
- Emory Sports Performance and Research Center (SPARC), Flowery Branch, Georgia
- Emory Sports Medicine Center, Atlanta, Georgia
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Youth Physical Development Center, Cardiff Metropolitan University, Wales, United Kingdom; and
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Atlanta, Georgia
| | - Jed A Diekfuss
- Emory Sports Performance and Research Center (SPARC), Flowery Branch, Georgia
- Emory Sports Medicine Center, Atlanta, Georgia
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
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Ito N, Capin JJ, Arhos EK, Wellsandt E, Pohlig RT, Buchanan TS, Snyder-Mackler L. Prolonged quadriceps latency during gait early after anterior cruciate ligament injury predicts radiographic knee osteoarthritis 6-years after anterior cruciate ligament reconstruction. Clin Biomech (Bristol, Avon) 2024; 117:106301. [PMID: 38945068 PMCID: PMC11250627 DOI: 10.1016/j.clinbiomech.2024.106301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND The purpose was to explore quadriceps electromechanical function (quadriceps latency) during gait after anterior cruciate ligament injury as a predictor for radiographic knee osteoarthritis 6-years after anterior cruciate ligament reconstruction. Change in latency after preoperative physical therapy was also examined. METHODS Quadriceps latency (time between peak knee moment and quadriceps electromyography) was calculated before preoperative physical therapy (2.4 [0.5-7.5] months after anterior cruciate ligament injury) and after preoperative physical therapy in 24 athletes. Participants were dichotomized into osteoarthritis (Kellgren and Lawrence grade ≥ 2) and non-osteoarthritis groups at 6-years. Forward selection logistic regression was performed using z-score normalized quadriceps latency and demographics. A 2 × 2 repeated measure ANOVA was performed for quadriceps latency between groups before and after preoperative physical therapy. FINDINGS Quadriceps latency before preoperative physical therapy was the only predictor of 6-year radiographic osteoarthritis (p = 0.014, odds ratio [95% confidence interval] = 5.859 [1.435-23.924]). Time by group interaction was observed for quadriceps latency (p = 0.039, η2p = 0.179). In the osteoarthritis group, latency may reduce after training (before preoperative physical therapy = 115.7 ± 20.6 ms, after preoperative physical therapy = 99.5 ± 24.0 ms, p = 0.082). INTERPRETATION Prolonged latency after anterior cruciate ligament injury may predict post-traumatic knee osteoarthritis 6-years after anterior cruciate ligament reconstruction. Latency may shorten with preoperative physical therapy, yet athletes still moved on to develop osteoarthritis. Quadriceps function may need intervention immediately following anterior cruciate ligament injury for prevention of post-traumatic knee osteoarthritis.
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Affiliation(s)
- Naoaki Ito
- Biomechanics and Movement Science Program, University of Delaware, Newark, DE, USA; Department of Physical Therapy, University of Delaware, Newark, DE, USA; Department of Orthopedics and Rehabilitation, University of Wisconsin - Madison, Madison, WI, USA; Badger Athletic Performance Program, University of Wisconsin - Madison, Madison, WI, USA.
| | - Jacob J Capin
- Department of Physical Therapy, Marquette University, Milwaukee, WI, USA; Medical College of Wisconsin, Clinical and Translational Science Institute, Milwaukee, WI, USA
| | - Elanna K Arhos
- Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA
| | - Elizabeth Wellsandt
- Physical Therapy Program, Department of Health and Rehabilitation Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ryan T Pohlig
- Biostatistic Core Facility, College of Health Sciences, University of Delaware, Newark, DE, USA
| | - Thomas S Buchanan
- Biomechanics and Movement Science Program, University of Delaware, Newark, DE, USA; Department of Biomedical Engineering, University of Delaware, Newark, DE, USA; Department of Mechanical Engineering, University of Delaware, Newark, DE, USA
| | - Lynn Snyder-Mackler
- Biomechanics and Movement Science Program, University of Delaware, Newark, DE, USA; Department of Physical Therapy, University of Delaware, Newark, DE, USA
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Rodriguez KM, Moon J, Krishnan C, Palmieri-Smith RM. Conditioning of Motor Evoked Responses After Anterior Cruciate Ligament Reconstruction: Effects of Stimulus Intensity. Sports Health 2024:19417381241257258. [PMID: 38864306 DOI: 10.1177/19417381241257258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Operant conditioning of motor evoked torque (MEPTORQUE) can directly target the corticospinal pathway in patients with anterior cruciate ligament (ACL) reconstruction. However, it remains unclear whether operant conditioning can elicit short-term improvements in corticospinal excitability and whether these improvements are influenced by stimulus intensity. HYPOTHESIS Quadriceps MEPTORQUE responses can be upconditioned in a single session and will elicit short-term adaptations in corticospinal excitability, with higher stimulus intensities eliciting greater effects. STUDY DESIGN Randomized controlled laboratory study. LEVEL OF EVIDENCE Level 2. METHODS Thirty-six participants were assessed during a single session of an operant conditioning protocol. Participants were randomized into 1 of 3 groups for stimulus intensity used during operant conditioning based on the participant's active motor threshold (AMT: 100%, 120%, and 140%). Quadriceps MEPTORQUE amplitude was evaluated during a block of control transcranial magnetic stimulation trials (CTRL) to establish baseline corticospinal excitability, and 3 blocks of conditioning trials (COND) during which participants trained to upcondition their MEPTORQUE. MEPTORQUE recruitment curves were collected to evaluate the effect of operant conditioning on acute corticospinal adaptations. RESULTS Participants with ACL reconstruction could upcondition their MEPTORQUE in a single session (P < 0.01; CTRL, 17.27 ± 1.28; COND, 21.35 ± 1.28 [mean ± standard error [SE] in N·m]), but this ability was not influenced by the stimulus intensity used during training (P = 0.84). Furthermore, significant improvements in corticospinal excitability were observed (P = 0.05; PRE, 687.91 ± 50.15; POST, 761.08 ± 50.15 [mean ± SE in N·m %AMT]), but stimulus intensity did not influence corticospinal adaptations (P = 0.67). CONCLUSION Operant conditioning can elicit short-term neural adaptations in ACL-reconstructed patients. Future operant conditioning paradigms may effectively use any of the 3 stimulus intensities studied herein. CLINICAL RELEVANCE Operant conditioning may be a feasible approach to improve corticospinal excitability after ACL reconstruction.
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Affiliation(s)
| | - Jungsun Moon
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan
| | - Chandramouli Krishnan
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, Michigan
- Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
- Michigan Robotics Institute, University of Michigan, Ann Arbor, Michigan
- Mechanical Engineering, University of Michigan
| | - Riann M Palmieri-Smith
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan
- Department of Orthopaedic Surgery, Michigan Medicine, Ann Arbor, Michigan
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Leung A, Kantak S, Hammoud S, Abraham R, Zarzycki R. Sex differences in corticospinal excitability and quadriceps performance after anterior cruciate ligament reconstruction. J Orthop Res 2024; 42:769-776. [PMID: 37938095 PMCID: PMC10978293 DOI: 10.1002/jor.25725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/20/2023] [Accepted: 10/16/2023] [Indexed: 11/09/2023]
Abstract
Anterior cruciate ligament (ACL) ruptures result in lasting quadriceps dysfunction that contributes to secondary injury risk and development of osteoarthritis. There is evidence of persistent reduced nervous system drive (corticospinal excitability [CSE]) to the quadriceps and sex differences in both quadriceps performance and CSE post-ACL reconstruction (ACLR). The purposes of this study were to investigate the differences in CSE and quadriceps dysfunction after ACLR between sexes and relative to controls. Twenty subjects 4-9 months post-ACLR and 20 age, sex, and activity matched controls participated in this study. Quadriceps performance (peak torque, PT; rate of torque development from onset to 100 ms, RTD100; and RTD from 100 to 200ms, RTD200) and CSE (active motor threshold; slope of the stimulus response (SR) curve, SR curve slope) were measured using an isokinetic dynamometer (HUMAC NORM) and transcranial magnetic stimulation respectively. Significant group differences were found for SR curve slope, PT, RTD100, and RTD200 on the surgical limb. Males after ACLR had higher slopes (higher CSE) than females. Females after ACLR had worse surgical limb quadriceps PT than control males and slower RTD100 and RTD200 than control males and control females. Higher CSE in males after ACLR may point to a potentially adaptive neurological change in males post-ACLR and indicate greater need for novel interventions to address cortical drive in females after ACLR.
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Affiliation(s)
- Anne Leung
- Physical Therapy, Arcadia University, Glenside, PA, USA
| | - Shailesh Kantak
- Physical Therapy, Arcadia University, Glenside, PA, USA
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - Sommer Hammoud
- Orthopaedic Surgery, Sidney Kimmel Medical College, Rothman Institute, Philadelphia, PA, USA
| | | | - Ryan Zarzycki
- Physical Therapy, Arcadia University, Glenside, PA, USA
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Blasimann A, Busch A, Henle P, Bruhn S, Vissers D, Baur H. Bilateral neuromuscular control in patients one year after unilateral ACL rupture or reconstruction. A cross-sectional study. Heliyon 2024; 10:e24364. [PMID: 38268828 PMCID: PMC10803901 DOI: 10.1016/j.heliyon.2024.e24364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 01/26/2024] Open
Abstract
Objectives To compare bilateral neuromuscular control in patients one year after anterior cruciate ligament reconstruction (ACL-R) or conservative treatment (ACL-C) to healthy controls (ACL-I). Design Cross-sectional study. Setting Electromyography of vastus medialis (VM) and lateralis (VL), biceps femoris (BF) and semitendinosus (ST) was recorded during stair descent and anterior tibial translation. Each step of stair descent was divided into pre-activity, weight-acceptance and push-off phase. Pre-activation, short, medium (MLR) and long latency responses (LLR) were defined for reflex activity. Participants N = 38 patients one year after ACL reconstruction (ACL-R), N = 26 participants with conservative treatment one year after ACL rupture (ACL-C), N = 38 healthy controls with an intact ACL (ACL-I). Main outcome measures Normalized root mean squares per muscle and phase (α = 0.05). Results During stair descent, within-group leg differences were found for the quadriceps in ACL-R during all phases and for the BF in ACL-C during weight-acceptance. Between-group leg differences were found for BF in both patient groups compared to ACL-I during push-off.Between-group differences in pre-activation for VM between ACL-R and ACL-C, and between ACL-C and ACL-I were found, and as LLR between patients and ACL-R versus ACL-I. Pre-activation of BF and MLR of ST differed for each patient group compared to ACL-I. Conclusions Bilateral neuromuscular alterations are still present one year after ACL rupture or reconstruction.
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Affiliation(s)
- Angela Blasimann
- Bern University of Applied Sciences, School of Health Professions, Division of Physiotherapy, 3008, Bern, Switzerland
- University of Antwerp, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences and Physiotherapy, 2610, Wilrijk, Belgium
| | - Aglaja Busch
- Bern University of Applied Sciences, School of Health Professions, Division of Physiotherapy, 3008, Bern, Switzerland
- University of Potsdam, University Outpatient Clinic, Sports Medicine & Sports Orthopedics, 14469, Potsdam, Germany
| | - Philipp Henle
- Lindenhof Group AG, Sonnenhof Orthopaedic Center, 3006, Bern, Switzerland
- University of Bern, Bern University Hospital, Inselspital, Department of Orthopaedic Surgery and Traumatology, 3010, Bern, Switzerland
| | - Sven Bruhn
- University of Rostock, Institute of Sports Science, 18051, Rostock, Germany
| | - Dirk Vissers
- University of Antwerp, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences and Physiotherapy, 2610, Wilrijk, Belgium
| | - Heiner Baur
- Bern University of Applied Sciences, School of Health Professions, Division of Physiotherapy, 3008, Bern, Switzerland
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7
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Blasimann A, Busch A, Henle P, Bruhn S, Vissers D, Baur H. Neuromuscular control in males and females 1 year after an anterior cruciate ligament rupture or reconstruction during stair descent and artificial tibial translation. Sci Rep 2023; 13:15316. [PMID: 37714980 PMCID: PMC10504317 DOI: 10.1038/s41598-023-42491-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 09/11/2023] [Indexed: 09/17/2023] Open
Abstract
Neuromuscular alterations are reported in patients with anterior cruciate ligament reconstruction (ACL-R) and conservative treatment (copers with ACL deficiency, ACL-C). However, it is unclear whether sex influences neuromuscular control. The objective was to investigate differences in neuromuscular control regarding sex and treatment type one year after ACL rupture in comparison to a group with an intact ACL (ACL-I). Electromyography of vastus medialis (VM) and lateralis, biceps femoris (BF) and semitendinosus (ST) was recorded in ACL-R (N = 38), ACL-C (N = 26), and ACL-I (N = 38) during stair descent and reflex activity by anterior tibial translation while standing. The movements of stair descent were divided into pre-activity, weight-acceptance and push-off phases, reflex activity in pre-activation, short, medium (MLR), and long latency responses (LLR). Normalized root mean squares for each muscle of involved and matched control limb per phase were calculated and analyzed with two-way ANOVA (α = 0.05). During stair descent, neuromuscular differences of BF were significant during push-off only (p = 0.001). Males of ACL-R and ACL-C had higher BF activity compared to ACL-I (p = 0.009, 0.007 respectively). During reflex activity, VM and BF were significantly different between treatment groups for pre-activation (p = 0.013, 0.035 respectively). VM pre-activation of females was higher in ACL-R compared to ACL-C (p = 0.018), and lower in ACL-C compared to ACL-I (p = 0.034). Males of ACL-R showed higher VM and less BF pre-activation (p = 0.025, p = 0.003 respectively) compared to ACL-I. Males of ACL-C had less BF pre-activation compared to ACL-I (p = 0.019). During MLR, intra-group differences in ST were found for treatment (p = 0.011) and females of ACL-R compared to ACL-I (p = 0.015). During LLR, overall intra-group differences in VM were present for treatment (p = 0.034) and in females (ACL-R versus ACL-C (p = 0.015), ACL-I (p = 0.049), respectively). One year after an ACL rupture, neuromuscular alterations persist regardless of treatment and sex. Standard rehabilitation protocols may not be able to restore neuromuscular control. Future research should include long-term follow up and focus on exercises targeting neuromuscular function.
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Affiliation(s)
- Angela Blasimann
- Division of Physiotherapy, School of Health Professions, Bern University of Applied Sciences, Bern, Switzerland.
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.
| | - Aglaja Busch
- Division of Physiotherapy, School of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
- University Outpatient Clinic, Sports Medicine & Sports Orthopaedics, University of Potsdam, Potsdam, Germany
| | - Philipp Henle
- Sonnenhof Orthopaedic Center, Lindenhof Group AG, Bern, Switzerland
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Bruhn
- Institute of Sports Science, University of Rostock, Rostock, Germany
| | - Dirk Vissers
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Heiner Baur
- Division of Physiotherapy, School of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
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ÖZALTIN GE, TALU B, ÖKTEM U. Functional Outcomes of Motor Learning Interventions in Anterior Cruciate Ligament Injuries. ARŞIV KAYNAK TARAMA DERGISI 2023. [DOI: 10.17827/aktd.1169499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
Anterior cruciate ligament injury is one of the pathologies that affect the daily and professional life of the majority of athletes. When the treatment options are examined, there are two options surgical treatment and conservative treatment. Rehabilitation is essential in both cases, with or without surgery. Especially for returning to sports, long-term rehabilitation after surgery has become essential. While many different exercise methods have been tried in the prevention of anterior cruciate ligament injury and rehabilitation after reconstructive surgery, many have focused on strength training. The abnormal movement pattern that occurs with the somatosensory loss seen after anterior cruciate ligament injury results in a functional loss in the injured extremity and the contralateral extremity in the long term. Considering the incidence of injury, studies to establish the normal movement pattern and restore motor control are very important. For this reason, motor learning-based interventions that support neuroplasticity are of great interest today. This review aims to examine the functional results of current motor learning-based interventions in anterior cruciate ligament rehabilitation in line with the literature.
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9
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Criss CR, Lepley AS, Onate JA, Simon JE, France CR, Clark BC, Grooms DR. Neural Correlates of Self-Reported Knee Function in Individuals After Anterior Cruciate Ligament Reconstruction. Sports Health 2023; 15:52-60. [PMID: 35321615 PMCID: PMC9808834 DOI: 10.1177/19417381221079339] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Anterior cruciate ligament (ACL) rupture is a common knee injury among athletes and physically active adults. Despite surgical reconstruction and extensive rehabilitation, reinjuries are common and disability levels are high, even years after therapy and return to activity. Prolonged knee dysfunction may result in part from unresolved neuromuscular deficits of the surrounding joint musculature in response to injury. Indeed, "upstream" neurological adaptations occurring after injury may explain these persistent functional deficits. Despite evidence for injury consequences extending beyond the joint to the nervous system, the link between neurophysiological impairments and patient-reported measures of knee function remains unclear. HYPOTHESIS Patterns of brain activation for knee control are related to measures of patient-reported knee function in individuals after ACL reconstruction (ACL-R). STUDY DESIGN Cross-sectional study. LEVEL OF EVIDENCE Level 3. METHODS In this multicenter, cross-sectional study, participants with unilateral ACL-R (n = 25; 10 men, 15 women) underwent task-based functional magnetic resonance imaging testing. Participants performed repeated cycles of open-chain knee flexion/extension. Neural activation patterns during the movement task were quantified using blood oxygen level-dependent (BOLD) signals. Regions of interest were generated using the Juelich Histological Brain Atlas. Pearson product-moment correlations were used to determine the relationship between mean BOLD signal within each brain region and self-reported knee function level, as measured by the International Knee Documentation Committee index. Partial correlations were also calculated after controlling for time from surgery and sex. RESULTS Patient-reported knee function was positively and moderately correlated with the ipsilateral secondary somatosensory cortex (r = 0.57, P = 0.005) and the ipsilateral supplementary motor area (r = 0.51, P = 0.01). CONCLUSION Increased ipsilateral secondary sensorimotor cortical activity is related to higher perceived knee function. CLINICAL RELEVANCE Central nervous system mechanisms for knee control are related to subjective levels of knee function after ACL-R. Increased neural activity may reflect central neuroplastic strategies to preserve knee functionality after traumatic injury.
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Affiliation(s)
- Cody R. Criss
- Translational Biomedical Sciences,
Graduate College, Ohio University, Athens, Ohio
- Ohio Musculoskeletal & Neurological
Institute (OMNI), Ohio University, Athens, Ohio
- Cody R Criss, W283 Grover
Center, 1 Ohio University, Athens, OH 45701 (
) (Twitter: @criss_cody)
| | - Adam S. Lepley
- Exercise and Sport Science Initiative,
School of Kinesiology, University of Michigan, Ann Arbor, Michigan
| | - James A. Onate
- School of Health and Rehabilitation
Sciences, The Ohio State University, Columbus, Ohio
| | - Janet E. Simon
- Ohio Musculoskeletal & Neurological
Institute (OMNI), Ohio University, Athens, Ohio
- Division of Athletic Training, School
of Applied Health Sciences and Wellness, College of Health Sciences and Professions,
Ohio University, Athens, Ohio
| | - Christopher R. France
- Ohio Musculoskeletal & Neurological
Institute (OMNI), Ohio University, Athens, Ohio
- Department of Psychology, College of
Arts and Sciences, Ohio University, Athens, Ohio
| | - Brian C. Clark
- Ohio Musculoskeletal & Neurological
Institute (OMNI), Ohio University, Athens, Ohio
- Department of Biomedical Sciences,
Ohio University, Athens, Ohio
- Department of Geriatric Medicine, Ohio
University, Athens, Ohio
| | - Dustin R. Grooms
- Ohio Musculoskeletal & Neurological
Institute (OMNI), Ohio University, Athens, Ohio
- Division of Athletic Training, School
of Applied Health Sciences and Wellness, College of Health Sciences and Professions,
Ohio University, Athens, Ohio
- Division of Physical Therapy, School
of Rehabilitation and Communication Sciences, College of Health Sciences and
Professions, Ohio University, Athens, Ohio
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10
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Patel HH, Berlinberg EJ, Nwachukwu B, Williams RJ, Mandelbaum B, Sonkin K, Forsythe B. Quadriceps Weakness is Associated with Neuroplastic Changes Within Specific Corticospinal Pathways and Brain Areas After Anterior Cruciate Ligament Reconstruction: Theoretical Utility of Motor Imagery-Based Brain-Computer Interface Technology for Rehabilitation. Arthrosc Sports Med Rehabil 2022; 5:e207-e216. [PMID: 36866306 PMCID: PMC9971910 DOI: 10.1016/j.asmr.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 11/09/2022] [Indexed: 12/29/2022] Open
Abstract
Persistent quadriceps weakness is a problematic sequela of anterior cruciate ligament reconstruction (ACLR). The purposes of this review are to summarize neuroplastic changes after ACL reconstruction; provide an overview of a promising interventions, motor imagery (MI), and its utility in muscle activation; and propose a framework using a brain-computer interface (BCI) to augment quadriceps activation. A literature review of neuroplastic changes, MI training, and BCI-MI technology in postoperative neuromuscular rehabilitation was conducted in PubMed, Embase, and Scopus. Combinations of the following search terms were used to identify articles: "quadriceps muscle," "neurofeedback," "biofeedback," "muscle activation," "motor learning," "anterior cruciate ligament," and "cortical plasticity." We found that ACLR disrupts sensory input from the quadriceps, which results in reduced sensitivity to electrochemical neuronal signals, an increase in central inhibition of neurons regulating quadriceps control and dampening of reflexive motor activity. MI training consists of visualizing an action, without physically engaging in muscle activity. Imagined motor output during MI training increases the sensitivity and conductivity of corticospinal tracts emerging from the primary motor cortex, which helps "exercise" the connections between the brain and target muscle tissues. Motor rehabilitation studies using BCI-MI technology have demonstrated increased excitability of the motor cortex, corticospinal tract, spinal motor neurons, and disinhibition of inhibitory interneurons. This technology has been validated and successfully applied in the recovery of atrophied neuromuscular pathways in stroke patients but has yet to be investigated in peripheral neuromuscular insults, such as ACL injury and reconstruction. Well-designed clinical studies may assess the impact of BCI on clinical outcomes and recovery time. Quadriceps weakness is associated with neuroplastic changes within specific corticospinal pathways and brain areas. BCI-MI shows strong potential for facilitating recovery of atrophied neuromuscular pathways after ACLR and may offer an innovative, multidisciplinary approach to orthopaedic care. Level of Evidence V, expert opinion.
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Affiliation(s)
- Harsh H. Patel
- Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, Chicago, Illinois
| | - Elyse J. Berlinberg
- Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, Chicago, Illinois
| | - Benedict Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Riley J. Williams
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Bert Mandelbaum
- Department of Orthopaedic Surgery, Cedars-Sinai Kerlan-Jobe Institute, Santa Monica, California, U.S.A
| | | | - Brian Forsythe
- Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, Chicago, Illinois,Address correspondence to Brian Forsythe, M.D., 1611 W. Harrison St, Suite 360, Chicago, IL 60621
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11
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Quadriceps motor evoked torque is a reliable measure of corticospinal excitability in individuals with anterior cruciate ligament reconstruction. J Electromyogr Kinesiol 2022; 67:102700. [PMID: 36063566 DOI: 10.1016/j.jelekin.2022.102700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/01/2022] [Accepted: 08/26/2022] [Indexed: 12/14/2022] Open
Abstract
This study comprehensively evaluated the test-retest reliability of raw and normalized quadriceps motor evoked responses elicited by transcranial magnetic stimulation (TMS) in individuals with anterior cruciate ligament (ACL) reconstruction. Fifteen participants were tested on three different days that were separated at least by 24 h. Motor evoked responses were collected during a small background contraction on the reconstructed leg across a range of TMS intensities using torque (MEPTORQUE) and electromyographic (MEPEMG) responses. MEPTORQUE and MEPEMG were evaluated using different normalization procedures (raw, normalized to maximum voluntary isometric contraction [MVIC], peak MEP, and background contraction). MEPTORQUE was also normalized to the magnetically-evoked peripheral resting twitch torque. The area under the recruitment curve was computed for both raw and normalized MEPs. Intraclass correlation coefficients (ICCs) were determined to assess test-retest reliability. Results indicated that MEPTORQUE generally showed greater reliability than MEPEMG for all normalization procedures. Vastus medialis MEPEMG generally showed greater reliability than rectus femoris MEPEMG. Finally, both MEPTORQUE and MEPEMG exhibited good reliability, even when not normalized. These findings indicate that MEPTORQUE and MEPEMG offer reliable measures of corticospinal function and suggest that MEPTORQUE is a suitable alternative to MEPEMG for measuring quadriceps corticospinal excitability in individuals with ACL reconstruction.
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12
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Blasimann A, Busch A, Henle P, Bruhn S, Vissers D, Baur H. Neuromuscular Control During Stair Descent and Artificial Tibial Translation After Acute ACL Rupture. Orthop J Sports Med 2022; 10:23259671221123299. [PMID: 36263309 PMCID: PMC9575465 DOI: 10.1177/23259671221123299] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/05/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Anterior cruciate ligament (ACL) rupture has direct effect on passive and
active knee stability and, specifically, stretch-reflex excitability. Purpose/Hypothesis: The purpose of this study was to investigate neuromuscular activity in
patients with an acute ACL deficit (ACL-D group) compared with a matched
control group with an intact ACL (ACL-I group) during stair descent and
artificially induced anterior tibial translation. It was hypothesized that
neuromuscular control would be impaired in the ACL-D group. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Surface electromyographic (EMG) activity of the vastus medialis (VM), vastus
lateralis (VL), biceps femoris (BF), and semitendinosus (ST) muscles was
recorded bilaterally in 15 patients with ACL-D (mean, 13.8 days [range, 7-21
days] since injury) and 15 controls with ACL-I during stair descent and
artificially induced anterior tibial translation. The movements of stair
descent were divided into preactivity, weight acceptance, and push-off
phases. Reflex activity during anterior tibial translation was split into
preactivity and short, medium, and late latency responses. Walking on a
treadmill was used for submaximal EMG normalization. Kruskal-Wallis test and
post hoc analyses with Dunn-Bonferroni correction were used to compare
normalized root mean square values for each muscle, limb, movement, and
reflex phase between the ACL-D and ACL-I groups. Results: During the preactivity phase of stair descent, the hamstrings of the involved
leg of the ACL-D group showed 33% to 51% less activity compared with the
matched leg and contralateral leg of the ACL-I group (P
< .05). During the weight acceptance and push-off phases, the VL revealed
a significant reduction (approximately 40%) in the involved leg of the ACL-D
group compared with the ACL-I group. At short latency, the BF and ST of the
involved leg of the ACL-D group showed a significant increase in EMG
activity compared with the uninvolved leg of the ACL-I group, by a factor of
2.2 to 4.6. Conclusion: In the acute phase after an ACL rupture, neuromuscular alterations were found
mainly in the hamstrings of both limbs during stair descent and reflex
activity. The potential role of prehabilitation needs to be further
studied.
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Affiliation(s)
- Angela Blasimann
- Division of Physiotherapy, Department of Health Professions, Bern
University of Applied Sciences, Bern, Switzerland.,Department of Rehabilitation Sciences and Physiotherapy, Faculty of
Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Angela Blasimann, MSc, Department of Health Professions, Bern
University of Applied Sciences, Murtenstrasse 10, CH-3008 Bern, Switzerland
()
| | - Aglaja Busch
- Division of Physiotherapy, Department of Health Professions, Bern
University of Applied Sciences, Bern, Switzerland.,University Outpatient Clinic, Sports Medicine & Sports
Orthopedics, University of Potsdam, Potsdam, Germany
| | - Philipp Henle
- Sonnenhof Orthopaedic Center, Lindenhof Group AG, Bern,
Switzerland.,Department of Orthopaedic Surgery and Traumatology, Inselspital,
Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Bruhn
- Institute of Sports Science, University of Rostock, Rostock,
Germany
| | - Dirk Vissers
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of
Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Heiner Baur
- Division of Physiotherapy, Department of Health Professions, Bern
University of Applied Sciences, Bern, Switzerland
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13
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Ito N, Capin JJ, Khandha A, Buchanan TS, Snyder-Mackler L. Identifying Gait Pathology after ACL Reconstruction Using Temporal Characteristics of Kinetics and Electromyography. Med Sci Sports Exerc 2022; 54:923-930. [PMID: 35184098 PMCID: PMC9117412 DOI: 10.1249/mss.0000000000002881] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Asymmetrical gait mechanics after anterior cruciate ligament reconstruction (ACLR) are associated with the development of posttraumatic knee osteoarthritis. Current measures of gait mechanics have focused heavily on peak magnitudes of knee kinematics, kinetics, and joint contact forces but have seldom considered the rate of knee loading, cumulative knee load, or the timing of motor input surrounding peaks. The purpose of this study was to introduce and describe novel metrics of gait using temporal characteristics of kinetics and EMG to identify neuromuscular deficits of the quadriceps in patients after ACLR. METHODS Gait mechanics were assessed 6 months (n = 145) and 24 months (n = 116) after ACLR. External knee flexion rate of moment development (RMD) and knee flexion moment impulse (KFMI) leading up to the time of peak knee flexion moment (pKFM), peak RMD between initial contact to pKFM, and cumulative KFMI were calculated. Extensor latencies from the quadriceps, vastus medialis, vastus lateralis, and rectus femoris (time of pKFM - time of peak EMG activity) during the weight acceptance phase of gait were also calculated. Paired-sample t-tests (α = 0.05) were performed between limbs at both time points. RESULTS Slower RMD, smaller KFMI, and longer extensor latencies in the involved compared with uninvolved limb were observed across all measures at 6 months (P < 0.005). At 24 months, RMDpeak was slower, and KFMI50ms, KFMI100ms, and KFMItotal were lower in the involved limb (P < 0.003), but no other asymmetries were found. CONCLUSIONS Slower RMD, smaller KFMI, and prolonged extensor latencies may characterize neuromuscular deficits underlying aberrant gait mechanics early after ACLR. RMD, KFMI, and extensor latencies during gait should be considered in the future to quantify asymmetrical movement patterns observed after ACLR and as markers of recovery.
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Affiliation(s)
- Naoaki Ito
- Biomechanics and Movement Science Program, University of Delaware, Newark, DE
- Department of Physical Therapy, University of Delaware, Newark, DE
| | - Jacob J. Capin
- Department of Physical Therapy, Marquette University, Milwaukee, WI
| | - Ashutosh Khandha
- Department of Biomedical Engineering, University of Delaware, Newark, DE
| | - Thomas S. Buchanan
- Biomechanics and Movement Science Program, University of Delaware, Newark, DE
- Department of Biomedical Engineering, University of Delaware, Newark, DE
- Mechanical Engineering, University of Delaware, Newark, DE
| | - Lynn Snyder-Mackler
- Biomechanics and Movement Science Program, University of Delaware, Newark, DE
- Department of Physical Therapy, University of Delaware, Newark, DE
- Department of Biomedical Engineering, University of Delaware, Newark, DE
- Mechanical Engineering, University of Delaware, Newark, DE
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14
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Yung KK, Ardern CL, Serpiello FR, Robertson S. Characteristics of Complex Systems in Sports Injury Rehabilitation: Examples and Implications for Practice. SPORTS MEDICINE - OPEN 2022; 8:24. [PMID: 35192079 PMCID: PMC8864040 DOI: 10.1186/s40798-021-00405-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 12/29/2021] [Indexed: 11/22/2022]
Abstract
Complex systems are open systems consisting of many components that can interact among themselves and the environment. New forms of behaviours and patterns often emerge as a result. There is a growing recognition that most sporting environments are complex adaptive systems. This acknowledgement extends to sports injury and is reflected in the individual responses of athletes to both injury and rehabilitation protocols. Consequently, practitioners involved in return to sport decision making (RTS) are encouraged to view return to sport decisions through the complex systems lens to improve decision-making in rehabilitation. It is important to clarify the characteristics of this theoretical framework and provide concrete examples to which practitioners can easily relate. This review builds on previous literature by providing an overview of the hallmark features of complex systems and their relevance to RTS research and daily practice. An example of how characteristics of complex systems are exhibited is provided through a case of anterior cruciate ligament injury rehabilitation. Alternative forms of scientific inquiry, such as the use of computational and simulation-based techniques, are also discussed-to move the complex systems approach from the theoretical to the practical level.
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Affiliation(s)
- Kate K Yung
- Institute for Health and Sport, Victoria University, Melbourne, Australia.
| | - Clare L Ardern
- Musculoskeletal and Sports Injury Epidemiology Centre, Department of Health Promotion Science, Sophiahemmet University, Stockholm, Sweden
- Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Australia
- Department of Family Practice, University of British Columbia, Vancouver, Canada
| | - Fabio R Serpiello
- Institute for Health and Sport, Victoria University, Melbourne, Australia
| | - Sam Robertson
- Institute for Health and Sport, Victoria University, Melbourne, Australia
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15
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Arthrogenic Muscle Inhibition Following Anterior Cruciate Ligament Injury. J Sport Rehabil 2022; 31:694-706. [PMID: 35168201 DOI: 10.1123/jsr.2021-0128] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 10/06/2021] [Accepted: 10/28/2021] [Indexed: 11/18/2022]
Abstract
Arthrogenic muscle inhibition (AMI) is a common impairment in individuals who sustain an anterior cruciate ligament (ACL) injury. The AMI causes decreased muscle activation, which impairs muscle strength, leading to aberrant movement biomechanics. The AMI is often resistant to traditional rehabilitation techniques, which leads to persistent neuromuscular deficits following ACL reconstruction. To better treat AMI following ACL injury and ACL reconstruction, it is important to understand the specific neural pathways involved in AMI pathogenesis, as well as the changes in muscle function that may impact movement biomechanics and long-term structural alterations to joint tissue. Overall, AMI is a critical factor that limits optimal rehabilitation outcomes following ACL injury and ACL reconstruction. This review discusses the current understanding of the: (1) neural pathways involved in the AMI pathogenesis following ACL injury; (2) consequence of AMI on muscle function, joint biomechanics, and patient function; and (3) development of posttraumatic osteoarthritis. Finally, the authors review the evidence for interventions specifically used to target AMI following ACL injury.
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16
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Hunt ER, Davi SM, Parise CN, Clark K, Van Pelt DW, Confides AL, Buckholts KA, Jacobs CA, Lattermann C, Dupont-Versteegden EE, Butterfield TA, Lepley LK. Temporal disruption of neuromuscular communication and muscle atrophy following noninvasive ACL injury in rats. J Appl Physiol (1985) 2022; 132:46-57. [PMID: 34762530 PMCID: PMC8742731 DOI: 10.1152/japplphysiol.00070.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Many patients with anterior cruciate ligament (ACL) injuries have persistent quadriceps muscle atrophy, even after considerable time in rehabilitation. Understanding the factors that regulate muscle mass, and the time course of atrophic events, is important for identifying therapeutic interventions. With a noninvasive animal model of ACL injury, a longitudinal study was performed to elucidate key parameters underlying quadriceps muscle atrophy. Male Long-Evans rats were euthanized at 6, 12, 24, or 48 h or 1, 2, or 4 wk after ACL injury that was induced via tibial compression overload; controls were not injured. Vastus lateralis muscle size was determined by wet weight and fiber cross-sectional area (CSA). Evidence of disrupted neuromuscular communication was assessed via the expression of neural cell adhesion molecule (NCAM) and genes associated with denervation and neuromuscular junction instability. Abundance of muscle RING-finger protein-1 (MuRF-1), muscle atrophy F-box (MAFbx), and 45 s pre-rRNA along with 20S proteasome activity were determined to investigate mechanisms related to muscle atrophy. Finally, muscle damage-related parameters were assessed by measuring IgG permeability, centronucleation, CD68 mRNA, and satellite cell abundance. When compared with controls, we observed a greater percentage of NCAM-positive fibers at 6 h postinjury, followed by higher MAFbx abundance 48 h postinjury, and higher 20S proteasome activity at 1 wk postinjury. A loss of muscle wet weight, smaller fiber CSA, and the elevated expression of run-related transcription factor 1 (Runx1) were also observed at the 1 wk postinjury timepoint relative to controls. There also were no differences observed in any damage markers. These results indicate that alterations in neuromuscular communication precede the upregulation of atrophic factors that regulate quadriceps muscle mass early after noninvasive ACL injury.NEW & NOTEWORTHY A novel preclinical model of ACL injury was used to establish that acute disruptions in neuromuscular communication precede atrophic events. These data help to establish the time course of muscle atrophy after ACL injury, suggesting that clinical care may benefit from the application of acute neurogenic interventions and early gait reloading strategies.
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Affiliation(s)
- Emily R. Hunt
- 1Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steven M. Davi
- 2Department of Kinesiology, University of Connecticut, Storrs, Connecticut
| | - Cassandra N. Parise
- 3Department of Athletic Training and Clinical Nutrition, University of Kentucky, Lexington, Kentucky
| | - Kaleigh Clark
- 4Department of Physical Therapy, University of Kentucky, Lexington, Kentucky,5Center for Muscle Biology, University of Kentucky, Lexington, Kentucky
| | - Douglas W. Van Pelt
- 4Department of Physical Therapy, University of Kentucky, Lexington, Kentucky,5Center for Muscle Biology, University of Kentucky, Lexington, Kentucky
| | - Amy L. Confides
- 4Department of Physical Therapy, University of Kentucky, Lexington, Kentucky,5Center for Muscle Biology, University of Kentucky, Lexington, Kentucky
| | - Kimberly A. Buckholts
- 3Department of Athletic Training and Clinical Nutrition, University of Kentucky, Lexington, Kentucky
| | - Cale A. Jacobs
- 6Department of Orthopedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Christian Lattermann
- 1Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Esther E. Dupont-Versteegden
- 4Department of Physical Therapy, University of Kentucky, Lexington, Kentucky,5Center for Muscle Biology, University of Kentucky, Lexington, Kentucky
| | - Timothy A. Butterfield
- 3Department of Athletic Training and Clinical Nutrition, University of Kentucky, Lexington, Kentucky,5Center for Muscle Biology, University of Kentucky, Lexington, Kentucky
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17
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Effectiveness of Unilateral Training of the Uninjured Limb on Muscle Strength and Knee Function of Patients With Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis of Cross-Education. J Sport Rehabil 2022; 31:605-616. [DOI: 10.1123/jsr.2021-0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 11/18/2022]
Abstract
Context: Unilateral training of the uninjured limb could be a useful therapeutic tool to induce cross-education in periods of immobilization, however, the effectiveness of this training in patients with anterior cruciate ligament (ACL) reconstruction is unknown. Objective: To determine the effectiveness of unilateral training of the uninjured limb on muscle strength and knee function in patients with ACL reconstruction. Design: Systematic review and meta-analysis. Evidence Acquisition: An electronic search was performed in the MEDLINE, LILACS, CENTRAL, Embase, Scopus, Web of Science, CINAHL, SPORTDiscus, and PEDro databases from inception until March 2021. The authors included randomized clinical trials that evaluated the effectiveness of unilateral training of the uninjured limb on muscle strength and knee function in patients after ACL reconstruction. Evidence Synthesis: Seven clinical trials met the eligibility criteria, and for the quantitative synthesis, 5 studies were included. The standardized mean difference for isometric quadriceps strength was 0.60 at 8 to 12 weeks (95% confidence interval, 0.29 to 0.92; P = .01; I2 = 6%). There was a high quality of evidence according to the Grading of Recommendation, Assessment, Development and Evaluation rating. Four studies assessed knee function through different self-administered questionnaires at 8, 24, and 26 weeks. Only one study reported significant differences in knee function at 8 weeks, favoring the unilateral training group. Conclusions: There was a moderate to high quality of evidence, with statistical significance that the addition of unilateral training to standard rehabilitation improved the cross-education of quadriceps strength after ACL reconstruction. More research is needed to assess the consistency of these results. International Prospective Register of Systematic Reviews registration number: CRD42020199950.
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18
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Mechanisms of Arthrogenic Muscle Inhibition. J Sport Rehabil 2021; 31:707-716. [PMID: 34470911 DOI: 10.1123/jsr.2020-0479] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 06/07/2021] [Accepted: 06/28/2021] [Indexed: 11/18/2022]
Abstract
CONTEXT Arthrogenic muscle inhibition (AMI) continues to be a limiting factor in joint rehabilitation as the inability to volitionally activate muscle significantly dampens recovery. New evidence acquired at higher brain centers and in clinical populations continues to reshape our perspective of what AMI is and how to treat it. This review aims to stimulate discussion about the far-reaching effects of AMI by exploring the interconnected pathways by which it evolves. OBJECTIVES To discuss how reflexive inhibition can lead to adaptations in brain activity, to illustrate how changes in descending motor pathways limit our ability to contract muscle following injury, and to summarize the emerging literature on the wide-reaching effects of AMI on other interconnected systems. DATA SOURCES The databases PubMed, SPORTDiscus, and Web of Science were searched for articles pertaining to AMI. Reference lists from appropriate articles were cross-referenced. CONCLUSION AMI is a sequential and cumulative neurological process that leads to complex clinical impairments. Originating with altered afferent information arising from an injured joint, patients experience changes in afferent information, reflexive muscle inhibition, deficiencies in somatosensation, neuroplastic compensations in higher brain centers, and ultimately decreased motor output to the muscle surrounding the joint. Other aspects of clinical function, like muscle structure and psychological responses to injury, are also impaired and influenced by AMI. Removing, or reducing, AMI should continue to be a focus of rehabilitation programs to assist in the optimization of health after joint injury.
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19
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Piskin D, Benjaminse A, Dimitrakis P, Gokeler A. Neurocognitive and Neurophysiological Functions Related to ACL Injury: A Framework for Neurocognitive Approaches in Rehabilitation and Return-to-Sports Tests. Sports Health 2021; 14:549-555. [PMID: 34236003 PMCID: PMC9214902 DOI: 10.1177/19417381211029265] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Context: Only 55% of the athletes return to competitive sports after an anterior cruciate ligament (ACL) injury. Athletes younger than 25 years who return to sports have a second injury rate of 23%. There may be a mismatch between rehabilitation contents and the demands an athlete faces after returning to sports. Current return-to-sports (RTS) tests utilize closed and predictable motor skills; however, demands on the field are different. Neurocognitive functions are essential to manage dynamic sport situations and may fluctuate after peripheral injuries. Most RTS and rehabilitation paradigms appear to lack this aspect, which might be linked to increased risk of second injury. Objective: This systematic and scoping review aims to map existing evidence about neurocognitive and neurophysiological functions in athletes, which could be linked to ACL injury in an integrated fashion and bring an extensive perspective to assessment and rehabilitation approaches. Data Sources: PubMed and Cochrane databases were searched to identify relevant studies published between 2005 and 2020 using the keywords ACL, brain, cortical, neuroplasticity, cognitive, cognition, neurocognition, and athletes. Study Selection: Studies investigating either neurocognitive or neurophysiological functions in athletes and linking these to ACL injury regardless of their design and technique were included. Study Design: Systematic review. Level of Evidence: Level 3. Data Extraction: The demographic, temporal, neurological, and behavioral data revealing possible injury-related aspects were extracted and summarized. Results: A total of 16 studies were included in this review. Deficits in different neurocognitive domains and changes in neurophysiological functions could be a predisposing risk factor for, or a consequence caused by, ACL injuries. Conclusion: Clinicians should view ACL injuries not only as a musculoskeletal but also as a neural lesion with neurocognitive and neurophysiological aspects. Rehabilitation and RTS paradigms should consider these changes for assessment and interventions after injury.
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Affiliation(s)
- Daghan Piskin
- Exercise Science and Neuroscience Unit, Department Exercise and Health, University of Paderborn, Paderborn, Germany
| | - Anne Benjaminse
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,School of Sport Studies, Hanze University Groningen, Groningen, The Netherlands
| | - Panagiotis Dimitrakis
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Alli Gokeler
- Exercise Science and Neuroscience Unit, Department Exercise and Health, University of Paderborn, Paderborn, Germany.,OCON Sports Medicine Clinic, Hengelo, The Netherlands.,Amsterdam Collaboration for Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, VU University Medical Center, Amsterdam, The Netherlands
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20
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Machan T, Krupps K. The Neuroplastic Adaptation Trident Model: A Suggested Novel Framework for ACL Rehabilitation. Int J Sports Phys Ther 2021; 16:896-910. [PMID: 34123541 PMCID: PMC8169005 DOI: 10.26603/001c.23679] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/09/2020] [Indexed: 01/01/2023] Open
Abstract
Anterior Cruciate Ligament (ACL) injuries are common in athletic populations and there are many factors that contribute to a return to play decision. Human movement is diverse and variable, and it is important for patients recovering from an ACL injury to develop a variety of movement strategies for athletic performance. Variability of movement during sport may help to decrease injury risk by preparing the individual to handle many different situations and improve problem solving. ACL injuries result in neurophysiological dysfunction due to a disruption of the afferent information from the native mechanoreceptors in the ligament. Following injury, the brain enters a neuroplastic state and can adapt and change positively or negatively based on the rehabilitation or lack thereof. This commentary presents a novel framework for rehabilitation called the Neuroplastic Adaptation Trident Model that takes into account respected methods for attempting to achieve positive neuroplastic changes. This structured framework provides clinicians with reproducible methods to employ as part of the rehabilitation process to maximize motor control and motor learning. Suggested dosage and implementation are proposed to lead to a consistent and gradually progressive challenge throughout the entire rehabilitation process that takes advantage of the time from surgery until return to play. The purpose of this clinical commentary is to describe the Neuroplastic Adaptation Trident model and provide examples for clinical implementation. This method should be studied further to determine true effectiveness; currently, it is presented as a theoretical model based on best current evidence regarding ACL injury and rehabilitation of neurophysiologic dysfunction. LEVEL OF EVIDENCE 5.
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21
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Criss CR, Melton MS, Ulloa SA, Simon JE, Clark BC, France CR, Grooms DR. Rupture, reconstruction, and rehabilitation: A multi-disciplinary review of mechanisms for central nervous system adaptations following anterior cruciate ligament injury. Knee 2021; 30:78-89. [PMID: 33873089 DOI: 10.1016/j.knee.2021.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 02/18/2021] [Accepted: 03/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite surgical reconstruction and extensive rehabilitation, persistent quadriceps inhibition, gait asymmetry, and functional impairment remain prevalent in patients after anterior cruciate ligament (ACL) injury. A combination of reports have suggested underlying central nervous system adaptations in those after injury govern long-term neuromuscular impairments. The classic assumption has been to attribute neurophysiologic deficits to components of injury, but other factors across the continuum of care (e.g. surgery, perioperative analgesia, and rehabilitative strategies) have been largely overlooked. OBJECTIVE This review provides a multidisciplinary perspective to 1) provide a narrative review of studies reporting neuroplasticity following ACL injury in order to inform clinicians of the current state of literature and 2) provide a mechanistic framework of neurophysiologic deficits with potential clinical implications across all phases of injury and recovery (injury, surgery, and rehabilitation) RESULTS: Studies using a variety of neurophysiologic modalities have demonstrated peripheral and central nervous system adaptations in those with prior ACL injury. Longitudinal investigations suggest neurophysiologic changes at spinal-reflexive and corticospinal pathways follow a unique timecourse across injury, surgery, and rehabilitation. CONCLUSION Clinicians should consider the unique injury, surgery, anesthesia, and rehabilitation on central nervous system adaptations. Therapeutic strategies across the continuum of care may be beneficial to mitigate maladaptive neuroplasticity in those after ACL injury.
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Affiliation(s)
- Cody R Criss
- Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, OH, USA.
| | - M Stephen Melton
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Sergio A Ulloa
- OhioHealth Physician Group Heritage College: Orthopedic and Sports Medicine, OhioHealth O'Bleness Memorial Hospital, Athens, OH, USA
| | - Janet E Simon
- Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, OH, USA; Division of Athletic Training, School of Applied Health Sciences and Wellness, College of Health Sciences and Professions, Ohio University, Athens, OH, USA
| | - Brian C Clark
- Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, OH, USA; Department of Biomedical Sciences, Ohio University, Athens, OH, USA
| | - Christopher R France
- Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, OH, USA; Department of Psychology, College of Arts and Sciences, Ohio University, Athens, OH, USA
| | - Dustin R Grooms
- Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, OH, USA; Division of Athletic Training, School of Applied Health Sciences and Wellness, College of Health Sciences and Professions, Ohio University, Athens, OH, USA; Division of Physical Therapy, School of Rehabilitation and Communication Sciences, College of Health Sciences and Professions, Ohio University, Athens, OH, USA
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22
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Rodriguez KM, Palmieri-Smith RM, Krishnan C. How does anterior cruciate ligament reconstruction affect the functioning of the brain and spinal cord? A systematic review with meta-analysis. JOURNAL OF SPORT AND HEALTH SCIENCE 2021; 10:172-181. [PMID: 32707098 PMCID: PMC7987657 DOI: 10.1016/j.jshs.2020.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/17/2020] [Accepted: 06/24/2020] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To examine the effect of anterior cruciate ligament (ACL) reconstruction on spinal-reflex and corticospinal excitability of the quadriceps muscle. METHODS A comprehensive electronic database search was performed to identify studies that objectively measured Hoffmann reflex to muscle response ratio, motor threshold, and motor evoked potentials after ACL reconstruction. Pooled standardized mean differences (SMDs) were computed using a random effects meta-analysis model. RESULTS A total of 13 studies were eligible for analysis. The Hoffmann reflex to muscle response ratio was significantly higher on both the reconstructed and non-reconstructed legs when compared with the healthy control leg (SMD = 0.28, 95% confidence interval (95%CI): 0.08-0.49, p = 0.006 and SMD = 0.22, 95%CI: 0.04-0.40, p = 0.016, respectively) but did not differ between legs (SMD = 0.10, 95%CI: -0.01 to 0.21, p = 0.078). The motor threshold was significantly higher on both the reconstructed (SMD = 0.76, 95%CI: 0.40-1.12, p < 0.001) and non-reconstructed legs (SMD = 0.47, 95%CI: 0.00-0.95, p = 0.049) when compared with the legs of healthy controls. The reconstructed leg also had a higher motor threshold when compared with the non-reconstructed leg (SMD = 0.20, 95%CI: 0.06-0.34, p = 0.005). These changes were paralleled by bilateral reductions in quadriceps strength (ACL reconstructed: SMD = -0.78, 95%CI: -1.07 to -0.49, p < 0.001; non-reconstructed: SMD = -0.32, 95%CI: -0.63 to -0.01, p = 0.042) and quadriceps voluntary activation (ACL reconstructed: SMD = -0.73, 95%CI: -0.97 to -0.50, p < 0.001; non-reconstructed: SMD = -0.55, 95%CI: -0.82 to -0.27, p < 0.001) when compared with healthy controls. CONCLUSION There is increased excitability of the spinal-reflex pathways and reduced excitability of the corticospinal pathways following ACL reconstruction. These changes are paralleled by reductions in quadriceps strength and voluntary activation, suggesting that rehabilitation interventions should focus on normalizing the excitability of neural pathways to effectively address quadriceps dysfunction after ACL reconstruction.
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Affiliation(s)
| | - Riann M Palmieri-Smith
- School of Kinesiology, University of Michigan, Ann Arbor, MI 48109, USA; Department of Orthopaedic Surgery, Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Chandramouli Krishnan
- School of Kinesiology, University of Michigan, Ann Arbor, MI 48109, USA; Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI 48108, USA; Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA; Michigan Robotics Institute, University of Michigan, Ann Arbor, MI 48109, USA.
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23
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Tayfur B, Charuphongsa C, Morrissey D, Miller SC. Neuromuscular Function of the Knee Joint Following Knee Injuries: Does It Ever Get Back to Normal? A Systematic Review with Meta-Analyses. Sports Med 2021; 51:321-338. [PMID: 33247378 PMCID: PMC7846527 DOI: 10.1007/s40279-020-01386-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Neuromuscular deficits are common following knee injuries and may contribute to early-onset post-traumatic osteoarthritis, likely mediated through quadriceps dysfunction. OBJECTIVE To identify how peri-articular neuromuscular function changes over time after knee injury and surgery. DESIGN Systematic review with meta-analyses. DATA SOURCES PubMed, Web of Science, Embase, Scopus, CENTRAL (Trials). ELIGIBILITY CRITERIA FOR SELECTING STUDIES Moderate and high-quality studies comparing neuromuscular function of muscles crossing the knee joint between a knee-injured population (ligamentous, meniscal, osteochondral lesions) and healthy controls. Outcomes included normalized isokinetic strength, muscle size, voluntary activation, cortical and spinal-reflex excitability, and other torque related outcomes. RESULTS A total of 46 studies of anterior cruciate ligament (ACL) and five of meniscal injury were included. For ACL injury, strength and voluntary activation deficits were evident (moderate to strong evidence). Cortical excitability was not affected at < 6 months (moderate evidence) but decreased at 24+ months (moderate evidence). Spinal-reflex excitability did not change at < 6 months (moderate evidence) but increased at 24+ months (strong evidence). We also found deficits in torque variability, rate of torque development, and electromechanical delay (very limited to moderate evidence). For meniscus injury, strength deficits were evident only in the short-term. No studies reported gastrocnemius, soleus or popliteus muscle outcomes for either injury. No studies were found for other ligamentous or chondral injuries. CONCLUSIONS Neuromuscular deficits persist for years post-injury/surgery, though the majority of evidence is from ACL injured populations. Muscle strength deficits are accompanied by neural alterations and changes in control and timing of muscle force, but more studies are needed to fill the evidence gaps we have identified. Better characterisation and therapeutic strategies addressing these deficits could improve rehabilitation outcomes, and potentially prevent PTOA. TRIAL REGISTRATION NUMBER PROSPERO CRD42019141850.
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Affiliation(s)
- Beyza Tayfur
- Sports and Exercise Medicine, Queen Mary University of London, London, UK.
| | | | - Dylan Morrissey
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Physiotherapy Department, Barts Health NHS Trust, London, E1 4DG, UK
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24
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Targeted Application of Motor Learning Theory to Leverage Youth Neuroplasticity for Enhanced Injury-Resistance and Exercise Performance: OPTIMAL PREP. ACTA ACUST UNITED AC 2021. [DOI: 10.1007/s42978-020-00085-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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25
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Alterations in Quadriceps Neurologic Complexity After Anterior Cruciate Ligament Reconstruction. J Sport Rehabil 2021; 30:731-736. [PMID: 33440341 DOI: 10.1123/jsr.2020-0307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/08/2020] [Accepted: 10/25/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Traditionally, quadriceps activation failure after anterior cruciate ligament reconstruction (ACLR) is estimated using discrete isometric torque values, providing only a snapshot of neuromuscular function. Sample entropy (SampEn) is a mathematical technique that can measure neurologic complexity during the entirety of contraction, elucidating qualities of neuromuscular control not previously captured. OBJECTIVE To apply SampEn analyses to quadriceps electromyographic activity in order to more comprehensively characterize neuromuscular deficits after ACLR. DESIGN Cross-sectional. SETTING Laboratory. PARTICIPANTS ACLR: n = 18; controls: n = 24. INTERVENTIONS All participants underwent synchronized unilateral quadriceps isometric strength, activation, and electromyography testing during a superimposed electrical stimulus. MAIN OUTCOME MEASURES Group differences in strength, activation, and SampEn were evaluated with t tests. Associations between SampEn and quadriceps function were evaluated with Pearson product-moment correlations and hierarchical linear regressions. RESULTS Vastus medialis SampEn was significantly reduced after ACLR compared with controls (P = .032). Vastus medialis and vastus lateralis SampEn predicted significant variance in activation after ACLR (r2 = .444; P = .003). CONCLUSIONS Loss of neurologic complexity correlates with worse activation after ACLR, particularly in the vastus medialis. Electromyographic SampEn is capable of detecting underlying patterns of variability that are associated with the loss of complexity between key neurophysiologic events after ACLR.
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26
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Assessment of Quadriceps Corticomotor and Spinal-Reflexive Excitability in Individuals with a History of Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Sports Med 2021; 51:961-990. [PMID: 33400217 DOI: 10.1007/s40279-020-01403-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Differences in the excitability of motor generating neural pathways are reported following anterior cruciate ligament reconstruction (ACLR) that is associated with quadriceps dysfunction and theorized to prevent the full recovery of muscle function. OBJECTIVE The aims of this systematic review and meta-analysis were to compare quadriceps neural excitability between the involved ACLR limb, the uninvolved limb, and uninjured controls, and to determine at what time intervals these differences are present after surgery. METHODS We conducted a search of PubMed, SPORTDiscus, Embase, and Web of Science, and extracted measures assessing difference of quadriceps spinal-reflexive, corticospinal, and intracortical excitability from studies that compared (1) involved limb to the uninvolved limb, (2) involved limb to a control limb, or (3) uninvolved limb to a control limb. We stratified time at 24 months, since this represents a period of heightened risk for reinjury. A modified Downs and Black checklist and Egger's test were used to determine the methodological quality of individual studies and risk of bias between studies. RESULTS Fourteen studies comprising 611 participants (371 individuals with a history of ACLR; median time from surgery: 31.5 months; range 0.5-221.1 months) were included in the review. Overall, the involved (g = 0.60, 95% CI [0.24, 0.96]) and uninvolved (g = 0.49, 95% CI [0.00, 0.98]) limbs exhibited greater motor threshold (MT) in comparison to uninjured controls. Motor-evoked potential (MEP) amplitudes were greater in the uninvolved limb in comparison to uninjured controls (g = 0.31, 95% CI [0.03, 0.59]). Lesser intracortical inhibition was exhibited in the uninvolved limb compared to uninjured controls (g = 0.54, 95% CI [0.14, 0.93]). When stratified by time from surgery, MEP amplitudes were greater in the uninvolved limb compared to uninjured controls (g = 0.33, 95% CI [0.03, 0.63]) within the first 24 months after surgery. When evaluated more than 24 months after surgery, the involved limb exhibited greater Hoffmann reflex (H-reflex) compared to uninjured controls (g = 0.38, 95% CI [0.00, 0.77]). MT were greater in the involved limb (g = 0.93, 95% CI [- 0.01, 1.88]) and uninvolved limb (g = 0.57, 95% CI [0.13, 1.02]) compared to uninjured controls. MEP amplitudes in the involved limb were lesser compared to uninjured controls when evaluated more than 24 months after ACLR (g = -1.11, 95% CI [- 2.03, - 0.20]). CONCLUSIONS The available evidence supports that there are neural excitability differences within the corticospinal tract in individuals with ACLR when compared to uninjured controls. Future research should focus further on longitudinal assessments of neural excitability prior to and following ACLR. Identifying interventions aimed to facilitate corticospinal excitability after ACLR appears to be warranted to improve quadriceps function. TRIAL REGISTRATION Registered through PROSPERO CRD42020158714.
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27
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Zarzycki R, Morton SM, Charalambous CC, Pietrosimone B, Williams GN, Snyder-Mackler L. Athletes after anterior cruciate ligament reconstruction demonstrate asymmetric intracortical facilitation early after surgery. J Orthop Res 2021; 39:147-153. [PMID: 32181907 DOI: 10.1002/jor.24666] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 01/21/2020] [Accepted: 02/22/2020] [Indexed: 02/04/2023]
Abstract
Quadriceps dysfunction persists after anterior cruciate ligament reconstruction (ACLR), yet the etiology remains elusive. Inhibitory and facilitatory intracortical networks (ie, intracortical excitability) may be involved in quadriceps dysfunction, yet the investigation of these networks early after ACLR is sparse. The purposes of this study were to examine (a) changes in intracortical excitability in athletes after ACLR compared to uninjured athletes during the course of postoperative rehabilitation, (b) the association between intracortical excitability and quadriceps strength in athletes after ACLR. Eighteen level I/II athletes after ACLR between the ages of 18 to 30 years and eighteen healthy sex, age, and activity matched athletes were tested at three-time points: (a) 2 weeks after surgery, (b) achievement of a "quiet knee" defined as full range of motion and minimal effusion, (c) return to running time point defined as achievement of a quadriceps index ≥80% and at least 12 weeks post-ACLR. Short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF), measured via transcranial magnetic stimulation and isometric quadriceps strength were examined bilaterally at each time point. There was a significant group × limb interaction (P = .017) for ICF. The ACLR group demonstrated asymmetric ICF (greater in the nonsurgical limb) compared to controls and a significant relationship between SICI and quadriceps strength of the surgical limb at the quiet knee time point (P = .018). ACLR individuals demonstrate differential effects on ICF between limbs. Also, SICI is associated with isometric quadriceps strength after ACLR, suggesting increased inhibition of the motor cortex may contribute to impaired quadriceps strength following ACLR.
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Affiliation(s)
| | - Susanne M Morton
- Biomechanics and Movement Science, University of Delaware, Newark, Delaware.,Physical Therapy, University of Delaware, Newark, Delaware
| | - Charalambos C Charalambous
- University of Nicosia Medical School, Basic and Clinical Sciences & Center for Neuroscience and Integrative Brain Research (CENIBRE), Nicosia, CY, Cyprus
| | - Brian Pietrosimone
- Exercise and Sport Science, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Glenn N Williams
- Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, Pennsylvania
| | - Lynn Snyder-Mackler
- Biomechanics and Movement Science, University of Delaware, Newark, Delaware.,Physical Therapy, University of Delaware, Newark, Delaware
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28
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Can We Capitalize on Central Nervous System Plasticity in Young Athletes to Inoculate Against Injury? ACTA ACUST UNITED AC 2020. [DOI: 10.1007/s42978-020-00080-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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29
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Examination of Corticospinal and Spinal Reflexive Excitability During the Course of Postoperative Rehabilitation After Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther 2020; 50:516-522. [PMID: 32741329 PMCID: PMC9361008 DOI: 10.2519/jospt.2020.9329] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate corticospinal and spinal reflexive excitability and quadriceps strength in healthy athletes and athletes after anterior cruciate ligament reconstruction (ACLR) over the course of rehabilitation. DESIGN Prospective cohort study. METHODS Eighteen athletes with ACLR and 18 healthy athletes, matched by sex, age, and activity, were tested at (1) 2 weeks after surgery, (2) the "quiet knee" time point, defined as full range of motion and minimal effusion, and (3) return to running, defined as achieving a quadriceps index of 80% or greater. We measured (1) corticospinal excitability, using resting motor threshold (RMT) and motor-evoked potential amplitude at a stimulator intensity of 120% of RMT (MEP120) to the vastus medialis, (2) spinal reflexive excitability, calculating the ratio of the maximal Hoffmann reflex to the maximal M-wave to the vastus medialis, and (3) isometric quadriceps strength. RESULTS The ACLR group had higher RMTs in the nonsurgical limb and higher MEP120 in the surgical limb at all time points. The healthy-athlete group did not have interlimb differences. The RMT was positively associated with quadriceps strength 2 weeks after surgery; MEP120 was associated with quadriceps strength at all time points. CONCLUSION Compared to healthy athletes, athletes after ACLR had altered corticospinal excitability that did not change from 2 weeks after surgery to the time of return to running. J Orthop Sports Phys Ther 2020;50(9):516-522. Epub 1 Aug 2020. doi:10.2519/jospt.2020.9329.
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30
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Lepley LK, Davi SM, Burland JP, Lepley AS. Muscle Atrophy After ACL Injury: Implications for Clinical Practice. Sports Health 2020; 12:579-586. [PMID: 32866081 DOI: 10.1177/1941738120944256] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
CONTEXT Distinct from the muscle atrophy that develops from inactivity or disuse, atrophy that occurs after traumatic joint injury continues despite the patient being actively engaged in exercise. Recognizing the multitude of factors and cascade of events that are present and negatively influence the regulation of muscle mass after traumatic joint injury will likely enable clinicians to design more effective treatment strategies. To provide sports medicine practitioners with the best strategies to optimize muscle mass, the purpose of this clinical review is to discuss the predominant mechanisms that control muscle atrophy for disuse and posttraumatic scenarios, and to highlight how they differ. EVIDENCE ACQUISITION Articles that reported on disuse atrophy and muscle atrophy after traumatic joint injury were collected from peer-reviewed sources available on PubMed (2000 through December 2019). Search terms included the following: disuse muscle atrophy OR disuse muscle mass OR anterior cruciate ligament OR ACL AND mechanism OR muscle loss OR atrophy OR neurological disruption OR rehabilitation OR exercise. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 5. RESULTS We highlight that (1) muscle atrophy after traumatic joint injury is due to a broad range of atrophy-inducing factors that are resistant to standard resistance exercises and need to be effectively targeted with treatments and (2) neurological disruptions after traumatic joint injury uncouple the nervous system from muscle tissue, contributing to a more complex manifestation of muscle loss as well as degraded tissue quality. CONCLUSION Atrophy occurring after traumatic joint injury is distinctly different from the muscle atrophy that develops from disuse and is likely due to the broad range of atrophy-inducing factors that are present after injury. Clinicians must challenge the standard prescriptive approach to combating muscle atrophy from simply prescribing physical activity to targeting the neurophysiological origins of muscle atrophy after traumatic joint injury.
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Affiliation(s)
- Lindsey K Lepley
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan
| | - Steven M Davi
- Department of Kinesiology, University of Connecticut, Storrs, Connecticut
| | - Julie P Burland
- Spaulding National Running Center, Harvard Medical School, Boston, Massachusetts
| | - Adam S Lepley
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan
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31
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Davi SM, Lepley AS, Denegar CR, DiStefano LJ, Edgar CM, Lepley LK. Quadriceps Inhibition After Naturally Occurring Patellar Tendon Damage and Pain. J Athl Train 2020; 55:608-614. [PMID: 32348153 DOI: 10.4085/1062-6050-27-19] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT After knee-joint injury, pain, effusion, and mechanoreceptor damage alter afferent signaling, which can result in quadriceps inhibition and subsequent weakness. The individual contributions of each factor to inhibition remain unclear due to confounding knee-joint injuries and indirect experimental models. OBJECTIVE To characterize the influence of naturally occurring knee damage and pain on quadriceps neuromuscular function in individuals with patellar tendinopathy. DESIGN Cross-sectional study. SETTING Research laboratory. PATIENTS OR OTHER PARTICIPANTS Twenty participants who self-reported patellar tendinopathy (PT) and 10 healthy control individuals underwent ultrasonic tendon assessment. Injured participants were dichotomized by an orthopaedic surgeon into groups with (1) pain and structural tendon abnormality and (2) regional pain alone. MAIN OUTCOME MEASURE(S) Quadriceps inhibition was assessed with the Hoffman reflex and the central activation ratio via the superimposed-burst technique. Normally distributed measures were analyzed using a 1-way analysis of variance and post hoc independent t tests. Kruskal-Wallis tests with post hoc Mann-Whitney U tests were used to analyze nonnormally distributed data. An a priori α level of P ≤ .05 was set. RESULTS Control participants presented with more spinal-reflex excitability (0.37 ± 0.23) than the PT (0.10 ± 0.06; P = .03) and regional-pain (0.18 ± 0.05; P = .02) groups. Knee-extension strength was greater in the control (3.37 ± 0.59 Nm/kg) than in the PT (2.41 ± 0.67 Nm/kg; P = .01) group but not the regional-pain group (3.05 ± 0.66 Nm/kg; P = .24). Control individuals presented with more quadriceps activation (97.93% ± 3.12) than the PT (84.44% ± 16.98; P < .01) and regional-pain (91.17% ± 10.56; P = .01) groups. No differences were present for any measures between the PT and regional-pain groups (P values > .05). CONCLUSIONS Deficits in spinal-reflex excitability, quadriceps activation, and strength were present in both the PT and regional-pain groups. A combination of pain and structural damage appeared to have the greatest negative effect on quadriceps function, as only the PT group presented with neuromuscular outcomes that failed to meet clinical thresholds.
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Affiliation(s)
- Steven M Davi
- Department of Kinesiology, University of Connecticut, Storrs
| | - Adam S Lepley
- School of Kinesiology, University of Michigan, Ann Arbor
| | - Craig R Denegar
- Department of Kinesiology, University of Connecticut, Storrs
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32
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Krishnan C. Effect of paired-pulse stimulus parameters on the two phases of short interval intracortical inhibition in the quadriceps muscle group. Restor Neurol Neurosci 2020; 37:363-374. [PMID: 31306142 DOI: 10.3233/rnn-180894] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Short interval intracortical inhibition (SICI) is commonly used to assess inhibition in the motor cortex and is known to be affected by the paired-pulse stimulus parameters (i.e., interstimulus interval [ISI], conditioning stimulus intensity [CSI] and test stimulus intensity [TSI]) used during testing. While the effects of stimulus parameters are well-studied in the upper-extremity, evidence in the lower-extremity is lacking. OBJECTIVE To comprehensively examine the effects of alterations in paired-pulse stimulus parameters on the two phases of SICI in the quadriceps muscle group. METHODS Seventeen adults (8 males, 9 females) volunteered to participate in this study. SICI was examined over a range of CSIs (70-90% active motor threshold [AMT]), TSIs (100-140% AMT), and ISIs (1.0-3.0 ms) using both EMG and torque responses elicited by transcranial magnetic stimulation (TMS). RESULTS The results indicated that SICI at 1.0 ms ISI was best revealed with a CSI of 70% and TSI ≥110% AMT, whereas SICI at 2.5 ms ISI was best revealed with a CSI of 80-90% and a TSI of ≥130% AMT. Unlike upper-extremity muscles, evaluating SICI with a CSI of 70% AMT and an ISI of 1.0 ms produced the greatest inhibition for all TSIs. In general, inhibitory effects were contaminated by facilitatory effects when using a TSI of 100% AMT. CONCLUSIONS The amount of inhibition was dependent on the stimulation parameters used during testing. A CSI of 70% AMT, ISI of 1.0 ms, and TSI of ≥110% AMT appear to be optimal for measuring SICI in the quadriceps muscle; however, other parameters can be used if careful consideration is given to the described interaction between the parameters.
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Affiliation(s)
- Chandramouli Krishnan
- NeuRRo Lab, Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA.,Michigan Robotics Institute, University of Michigan, Ann Arbor, MI, USA.,School of Kinesiology, University of Michigan, Ann Arbor, MI, USA.,Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
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33
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Gokeler A, Neuhaus D, Benjaminse A, Grooms DR, Baumeister J. Principles of Motor Learning to Support Neuroplasticity After ACL Injury: Implications for Optimizing Performance and Reducing Risk of Second ACL Injury. Sports Med 2020; 49:853-865. [PMID: 30719683 PMCID: PMC6548061 DOI: 10.1007/s40279-019-01058-0] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Athletes who wish to resume high-level activities after an injury to the anterior cruciate ligament (ACL) are often advised to undergo surgical reconstruction. Nevertheless, ACL reconstruction (ACLR) does not equate to normal function of the knee or reduced risk of subsequent injuries. In fact, recent evidence has shown that only around half of post-ACLR patients can expect to return to competitive level of sports. A rising concern is the high rate of second ACL injuries, particularly in young athletes, with up to 20% of those returning to sport in the first year from surgery experiencing a second ACL rupture. Aside from the increased risk of second injury, patients after ACLR have an increased risk of developing early onset of osteoarthritis. Given the recent findings, it is imperative that rehabilitation after ACLR is scrutinized so the second injury preventative strategies can be optimized. Unfortunately, current ACLR rehabilitation programs may not be optimally effective in addressing deficits related to the initial injury and the subsequent surgical intervention. Motor learning to (re-)acquire motor skills and neuroplastic capacities are not sufficiently incorporated during traditional rehabilitation, attesting to the high re-injury rates. The purpose of this article is to present novel clinically integrated motor learning principles to support neuroplasticity that can improve patient functional performance and reduce the risk of second ACL injury. The following key concepts to enhance rehabilitation and prepare the patient for re-integration to sports after an ACL injury that is as safe as possible are presented: (1) external focus of attention, (2) implicit learning, (3) differential learning, (4) self-controlled learning and contextual interference. The novel motor learning principles presented in this manuscript may optimize future rehabilitation programs to reduce second ACL injury risk and early development of osteoarthritis by targeting changes in neural networks.
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Affiliation(s)
- Alli Gokeler
- Exercise Science & Neuroscience Unit, Department Exercise and Health, Faculty of Science, Paderborn University, Paderborn, Germany. .,Luxembourg Institute of Research in Orthopedics, Sports Medicine and Science (LIROMS), Luxembourg, Luxembourg. .,Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Dorothee Neuhaus
- Exercise Science & Neuroscience Unit, Department Exercise and Health, Faculty of Science, Paderborn University, Paderborn, Germany
| | - Anne Benjaminse
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,School of Sport Studies, Hanze University Groningen, Groningen, The Netherlands
| | - Dustin R Grooms
- Division of Athletic Training, School of Applied Health Sciences and Wellness, College of Health Sciences and Professions, Ohio University, Athens, OH, USA.,Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, OH, USA
| | - Jochen Baumeister
- Exercise Science & Neuroscience Unit, Department Exercise and Health, Faculty of Science, Paderborn University, Paderborn, Germany.,Exercise Neuroscience and Health Lab, Institute of Health, Nutrition and Sport Sciences, University of Flensburg, Flensburg, Germany.,Division of Physiotherapy/Central Analytical Facilities (CAF) 3D Human Biomechanics Unit, Faculty of Medicine and Health, Stellenbosch University, Stellenbosch, South Africa
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Functional Brain Plasticity Associated with ACL Injury: A Scoping Review of Current Evidence. Neural Plast 2019; 2019:3480512. [PMID: 31949428 PMCID: PMC6948303 DOI: 10.1155/2019/3480512] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/16/2019] [Accepted: 11/30/2019] [Indexed: 01/01/2023] Open
Abstract
Anterior cruciate ligament (ACL) injury is a common problem with consequences ranging from chronic joint instability to early development of osteoarthritis. Recent studies suggest that changes in brain activity (i.e., functional neuroplasticity) may be related to ACL injury. The purpose of this article is to summarize the available evidence of functional brain plasticity after an ACL injury. A scoping review was conducted following the guidelines of the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The terms “brain,” “activity,” “neuroplasticity,” “ACL,” “injury,” and “reconstruction” were used in an electronic search of articles in PubMed, PEDro, CINAHL, and SPORTDiscus databases. Eligible studies included the following criteria: (a) population with ACL injury, (b) a measure of brain activity, and (c) a comparison to the ACL-injured limb (contralateral leg or healthy controls). The search yielded 184 articles from which 24 were included in this review. The effect size of differences in brain activity ranged from small (0.05, ACL-injured vs. noninjured limbs) to large (4.07, ACL-injured vs. healthy control). Moreover, heterogeneity was observed in the methods used to measure brain activity and in the characteristics of the participants included. In conclusion, the evidence summarized in this scoping review supports the notion of functional neuroplastic changes in people with ACL injury. The techniques used to measure brain activity and the presence of possible confounders, as identified and reported in this review, should be considered in future research to increase the level of evidence for functional neuroplasticity following ACL injury.
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Krishnan C, Washabaugh EP, Dutt-Mazumder A, Brown SR, Wojtys EM, Palmieri-Smith RM. Conditioning Brain Responses to Improve Quadriceps Function in an Individual With Anterior Cruciate Ligament Reconstruction. Sports Health 2019; 11:306-315. [PMID: 30951444 DOI: 10.1177/1941738119835163] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Persistent quadriceps weakness and activation failure are common in individuals with anterior cruciate ligament (ACL) reconstruction. A growing body of evidence indicates that this chronic quadriceps dysfunction could be partly mediated due to reduced corticospinal excitability. However, current rehabilitation approaches do not directly target corticospinal deficits, which may be critical for restoring optimal clinical outcomes after the surgery. This case study tested the feasibility of operant conditioning of torque responses evoked by transcranial magnetic stimulation (TMS) to improve quadriceps function after ACL reconstruction. HYPOTHESIS Operant conditioning of motor evoked torque responses would improve quadriceps strength, voluntary activation, and corticospinal excitability. STUDY DESIGN Case study and research report. LEVEL OF EVIDENCE Level 5. METHODS A 24-year-old male with an ACL reconstruction (6 months postsurgery) trained for 20 sessions (2-3 times per week for 8 weeks) to increase his TMS-induced motor evoked torque response (MEP torque) of the quadriceps muscles using operant conditioning principles. Knee extensor strength, voluntary quadriceps muscle activation, and quadriceps corticospinal excitability were evaluated at 3 time points: preintervention (pre), 4 weeks (mid), and immediately after the intervention (post). RESULTS The participant was able to successfully condition (ie, increase) the quadriceps MEP torque after 1 training session, and the conditioned MEP torque gradually increased over the course of 20 training sessions to reach about 500% of the initial value at the end of training. The participant's control MEP torque values and corticospinal excitability, which were measured outside of the conditioning paradigm, also increased with training. These changes were paralleled by improvements in knee extensor strength and voluntary quadriceps muscle activation. CONCLUSION This study shows that operant conditioning of MEP torque is a feasible approach to improving quadriceps corticospinal excitability and quadriceps function after ACL reconstruction and encourages further testing in a larger cohort of ACL-reconstructed individuals. CLINICAL RELEVANCE Operant conditioning may serve as a potential therapeutic adjuvant for ACL rehabilitation.
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Affiliation(s)
- Chandramouli Krishnan
- Neuromuscular and Rehabilitation Robotics Laboratory (NeuRRo Lab), Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.,Biomedical Engineering, University of Michigan, Ann Arbor, Michigan.,School of Kinesiology, University of Michigan, Ann Arbor, Michigan.,Robotics Institute, University of Michigan, Ann Arbor, Michigan
| | - Edward P Washabaugh
- Neuromuscular and Rehabilitation Robotics Laboratory (NeuRRo Lab), Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.,Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Aviroop Dutt-Mazumder
- Neuromuscular and Rehabilitation Robotics Laboratory (NeuRRo Lab), Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Scott R Brown
- Neuromuscular and Rehabilitation Robotics Laboratory (NeuRRo Lab), Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.,Sports Performance Research Institute New Zealand (SPRINZ), Auckland University of Technology, Auckland, New Zealand
| | - Edward M Wojtys
- Department of Orthopaedic Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Riann M Palmieri-Smith
- Neuromuscular and Rehabilitation Robotics Laboratory (NeuRRo Lab), Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.,School of Kinesiology, University of Michigan, Ann Arbor, Michigan
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