Motor Imagery to Facilitate Sensorimotor Re-Learning (MOTIFS) after traumatic knee injury: study protocol for an adaptive randomized controlled trial

Abstract

Background Treatment following traumatic knee injury includes neuromuscular training, with or without surgical reconstruction. The aim of rehabilitation is to restore muscle function and address psychological factors to allow a return to activity. Attention is often on rehabilitation of knee function, but deficiencies often persist. Specific interventions addressing psychological factors are sparing with varying degrees of success. We have developed a novel training program, MOTor Imagery to Facilitate Sensorimotor Re-Learning (MOTIFS), which integrates simultaneous psychological training into physical rehabilitation exercises. The MOTIFS model individualizes rehabilitation to increase central nervous system involvement by creating realistic and relevant mental images based on past experiences. We hypothesize that a 12-week MOTIFS training intervention will improve psychological readiness to return to activity and muscle function to a greater extent than current neuromuscular training (Care-as-Usual). Methods This pragmatic 1:1 single assessor-blinded adaptive cumulative cluster-randomized controlled trial will include 106 knee-injured people with a goal of returning to physical activity. Participants are randomized to either the MOTIFS or Care-as-Usual condition. Primary outcomes are the ACL Return to Sport after Injury Scale and change in injured leg hop performance in a side hop task from baseline to 12 weeks. Secondary outcomes include patient-reported outcomes and assessment of muscle function using a hop test battery and Postural Orientation Errors at 12-week follow-up. At 12-month follow-up, patient-reported outcomes are assessed. A sub-group (7-10 in each group) will be interviewed to gain insight into experiences of rehabilitation. Discussion Strengths of this trial include that it is a randomized and pragmatic trial examining commonly under-studied aspects of rehabilitation following a knee injury. The model uses the patient as a reference, creating simultaneous psychological and physical training exercises with easily adopted principles for clinical practice. Limitations include that blinding is limited due to study design, and shifting the clinical paradigm to a more holistic model is a challenge. If successful, the MOTIFS model has implications for a clinically useful, individualized, and patient-relevant method of improving rehabilitation outcomes by integrating psychological training into physical training. Trial registration ClinicalTrials.gov NCT03473821. Registered March 22, 2018, with ethical approval that has been granted (Dnr 2016/413, Dnr 2018/927). Trial status Trial Status: Protocol Version is 2020, Dec 10 – Version 1

Lived experiences of patients undergoing treatment for traumatic knee injury using integrated psychological training (MOTIFS) in the context of care-as-usual training: a phenomenological interview study

“…This phenomenological interview study is part of the MOTIFS RCT (clinicaltrials.gov registration: NCT03473821), 11 reported according to Consolidated Requirements for Qualitative Research 15 ( online supplemental appendix 1 ) and Standards for Reporting Qualitative Research. 16 …”

“…12 An ongoing randomised controlled trial (RCT) hypothesizes that a 12-week MOTIFS intervention will increase psychological readiness to return to activity and improve muscle function to a greater degree than CaU rehabilitation for traumatic knee injury. 11 Few studies have explored lived experiences of patients undergoing rehabilitation for knee injury, 14 so a qualitative study may provide valuable information to inform current rehabilitation practices. Interviews with knee-injured people can provide a deep and nuanced understanding of rehabilitation experiences and meaning making, providing important information on more holistic strategies.…”

“…We have proposed and are currently evaluating the Motor Imagery to Facilitate Sensorimotor Re-Learning (MOTIFS) model, a novel approach to rehabilitation in which psychological training principles are integrated into physical training exercises. 11 12 Dynamic motor imagery (DMI) is a form of psychological skills training in which one simultaneously mentally and physically simulates an individualised, activity-specific situation. 13 MOTIFS integrates DMI into care-as-usual (CaU) exercises using a set of principles in which the physical therapist (PT) and patient (1) discuss and (2) design an exercise integrating physical and psychological situation-based realism, then (3) execute a meaningful rehabilitation movement and finally (4) evaluate and modify to ensure realism and relevance.…”

“… 13 MOTIFS integrates DMI into care-as-usual (CaU) exercises using a set of principles in which the physical therapist (PT) and patient (1) discuss and (2) design an exercise integrating physical and psychological situation-based realism, then (3) execute a meaningful rehabilitation movement and finally (4) evaluate and modify to ensure realism and relevance. 11 Compared with CaU training, this model has been shown to increase enjoyment and feelings of control in uninjured athletes. 12 An ongoing randomised controlled trial (RCT) hypothesizes that a 12-week MOTIFS intervention will increase psychological readiness to return to activity and improve muscle function to a greater degree than CaU rehabilitation for traumatic knee injury.…”

Addressing Psychological Factors in Sports Injury Rehabilitation – What is a Physical Therapist to do?

“…The MOTIFS training model is currently being evaluated with knee-injured people. 9 Integrating externally focused sport-specific dynamic motor imagery in the clinic is distinctive due to reality-and experience-based re-creation of individually relevant and meaningful situations. This does not simply mean pushing them off balance, reaching towards an external object, or putting a ball in their hands; it means striving for total immersion.…”