Monday, June 29, 2020

Neuroplasticity and ACLR Rehabilitation - Part IV

Last week, we started our discussion talking about explicit strategies (internal focus on the movement itself) and implicit strategies (external focus on the movement effect).  These are types of training or verbal instructions we give to patients during performance of rehabilitation exercises.  What the studies show is that implicit strategies have a better carry over to sport and create greater neuroplastic changes in the higher centers (specifically the motor cortex, somatosensory area and cerebellum).  These types of changes reduces risk for reinjury with return to play as these are the patterns the athlete resorts to during functional activity. 

In our last discussion, we talked about the difference between these two strategies and when using one form of training or instruction may be indicated versus another form.  We also discussed how your verbal instructions can significantly alter movement and I gave the specific example of how this can alter the movement when performing a functional movement assessment. 

When looking at how this might impact our training, we can look at the study by Benjaminse et al Phys Ther Sport 2015.  In this systematic review, the authors looked a different forms of training.  For this example, we will use the ACLR specifically and doing single limb training.  Based on the data we have collected on over 18,000 athletes with the ViPerform AMI, we know control of both the magnitude of frontal plane motion and speed of valgus during single limb performance is critical.  If athletes can control this during training and functional activities (sports) then we know we have impact or mitigate some of the risk with them returning to play.  Based on the neuroplasticity research, there are some innovative ways do accomplish this.

Using a single leg balance on an unstable surface as an example.  In this exercise, I want the athlete to control the magnitude of frontal plane motion and speed of that motion.  In exercise A, I am placing a mirror in front of the athlete and asking them to control their knee,  Don't let the knee go in toward midline.  In this instance, I am using an internal focus, focusing on the movement.  In exercise B, I give the athlete a PVC pipe and ask them to keep the bar horizontal.  In this example, I am using external focus, focusing on the result of the movement. 

What we see here is the result.  In exercise A, although the athlete is successful at controlling her frontal plane motion, she also has a lot of hip motion occurring.  At the same time, what we find (or according to the research) is that this does not carry over as much to her actual movement in sport.  In exercise B, we see that not only is she maintaining better alignment at the knee but her hip position is also much better.  Considering this may have better carry over to sport, then this might be a strategy that I employ.  At the same time, I can add additional stresses to the system to make her maintain that positioning and posturing while specifically targeting her areas of weakness.  If you go back to our blog where we talked about rapid neuromuscular response (RNMR) training, you can see some specific exercises targeting that. 

In the next example, using a single leg squat.  In exercise A, I am placing a mirror in front of the patient and asking them to perform a single leg squat and asking them to keep their knee over their toe and not allow their knee to go in towards midline.  This is again a form of internal focus where I am focusing on the movement.  In exercise B, I am placing a cone in front of the athlete and asking them to reach toward the cone with their knee.  This is a form or external focus or a focus on the result of the movement. 

Again, what you see in exercise A is that the athlete, although better, still has some increase in frontal plane motion at the knee and has a lot more motion at the hips.  In exercise B, we not only have better control of frontal plane motion but also much better positioning and posturing of the entire kinetic chain and core. 

Again, these are two examples but you can see how internal focus versus external focus can be applied with our training.  That said, I want to be clear.  Although the research does say that external focus does have a better carry over to sport and functional activity, as with all training, I believe there the need to use both forms of training.  Similar to OKC and CKC exercise.  Research supports use of CKC exercise but I strongly believe that both OKC and CKC exercise have a place in rehabilitation and performance training.  To focus on just one, I think you miss part of the picture.

I hope you found this valuable and next week, we will continue this discussion.  Specifically, next week I will talk about a device we are using in our ACLR rehab that addresses all this as well as some of the results we are seeing with.  As always, I appreciate all our followers and hope you find this useful in your practice.  If you do, please follow me on instragram @bjjpt_acl_guy and Twitter @acl_prevention.  I also just launched a new website,  My vision is to create a movement revolution in the world of ACL rehab.  Check it out, hear more about my story and where we are headed.  Train hard and stay well.  #ViPerformAMI #ACLPlayItSafe

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI,  ViPerform AMI RTPlay, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent also a Brazilian Jiu Jitsu purple belt and complete BJJ/MMA junkie. 

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