Visual Perturbation to Enhance Return to Sport Rehabilitation after Anterior Cruciate Ligament Injury: A Clinical Commentary

Abstract

Anterior cruciate ligament (ACL) tears are common traumatic knee injuries causing joint instability, quadriceps muscle weakness and impaired motor coordination. The neuromuscular consequences of injury are not limited to the joint and surrounding musculature, but may modulate central nervous system reorganization. Neuroimaging data suggest patients with ACL injuries may require greater levels of visual-motor and neurocognitive processing activity to sustain lower limb control relative to healthy matched counterparts. Therapy currently fails to adequately address these nuanced consequences of ACL injury, which likely contributes to impaired neuromuscular control when visually or cognitively challenged and high rates of re-injury. This gap in rehabilitation may be filled by visual perturbation training, which may reweight sensory neural processing toward proprioception and reduce the dependency on vision to perform lower extremity motor tasks and/or increase visuomotor processing efficiency. This clinical commentary details a novel approach to supplement the current standard of care for ACL injury by incorporating stroboscopic glasses with key motor learning principles customized to target visual and cognitive dependence for motor control after ACL injury. Level of Evidence 5

Preliminary brain-behavioral neural correlates of anterior cruciate ligament injury risk landing biomechanics using a novel bilateral leg press neuroimaging paradigm

“…For example, stroboscopic glasses are a novel ancillary tool that allow clinicians to incrementally increase the level of visual perturbation [ 82 , 83 ]. Whereas clinicians were previously limited to eyes-open and eyes-closed conditions, stroboscopic glasses allow clinicians to perturb an athlete’s vision during any exercise to varying degrees [ 84 ]. This type of visual perturbation can increase the proprioceptive integration demand during motor control, potentially similar to the dynamic sport environment [ 85 , 86 ].…”

Adaptations of postural sway dynamics and cortical response to unstable stance with stroboscopic vision in older adults

“…For older adults with SV, those who demonstrated greater negative ND-theta (or smaller mid-frontal theta power in the SV condition) tended to have smaller SV-induced increases in postural fluctuations (smaller postural fluctuations in the SV condition) during stabilometer stance ( Figure 5A ). Hence, under the condition of SV, better prediction of postural errors (or fewer unexpected visual consequences of postural performance) is a prerequisite to gaining superior stance stability, which should be achieved by compensatory upregulation of proprioceptive/vestibular inputs and a reduction of the reliance on intermittent visual feedback ( Wilkins and Appelbaum, 2020 ; Wohl et al, 2021 ). Balance-related increases in theta activity could also extend to the centro-parietal regions, which are involved in sensorimotor coordination for multi-segment movements ( Sipp et al, 2013 ).…”

The Effects of Visuomotor Training on the Functional Recovery of Post-Surgery Musculoskeletal Conditions: A Randomized Controlled Trial

“…The incorporation of motor learning principles may facilitate the acquisition of lasting, injury-resistant movement patterns that can facilitate neuroplasticity [31]. Specifically, the use of an external focus of attention and implicit learning may serve an adjunctive role [32]. Human motion is based on the refined interplay between the intention of moving and continuous monitoring from sensory information that adjusts such motor action [33].…”