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An obstacle clearance test for evaluating sensorimotor control after anterior cruciate ligament injury: A kinematic analysis
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.ORCID iD: 0000-0003-3219-6493
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.ORCID iD: 0000-0002-6715-6208
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.ORCID iD: 0000-0002-8925-5952
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.ORCID iD: 0000-0003-0626-3154
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2022 (English)In: Journal of Orthopaedic Research, ISSN 0736-0266, E-ISSN 1554-527X, Vol. 40, no 1Article in journal (Refereed) Published
Abstract [en]

Sensorimotor deficits, particularly proprioceptive, are often reported following rupture of the anterior cruciate ligament (ACL). High secondary injury rates and long-term negative consequences suggest that these deficits are not properly identified using current assessment methods. We explored a novel obstacle clearance test to evaluate sensorimotor control in individuals following ACL reconstruction (ACLR) and rehabilitation. Thirty-seven post-ACLR individuals, 23 nonathletic asymptomatic controls (CTRL), and 18 elite athletes stepped over a hurdle-shaped obstacle, downward vision occluded, aiming for minimal clearance. Kinematic outcomes (3D motion capture) for the leading and trailing legs, for two unpredictably presented obstacle heights, were categorized into Accuracy: vertical foot clearance and minimal distance from the obstacle; Variability: end-point and hip/knee trajectory; and Symmetry: trunk/hip/knee crossing angles, hip–knee–ankle movement, and velocity curves. Accuracy was worse for CTRL compared with both other groups. ACLR had less leading and trailing vertical foot clearance with their injured compared with their noninjured leg. ACLR and athletes had less crossing knee flexion in their injured/nondominant legs compared with their contralateral leg, both leading and trailing. ACLR showed greater trunk flexion when crossing with their injured leg, both leading and trailing. For the leading leg, ACLR showed greater asymmetry for the hip–knee–ankle velocity curve compared with elite athletes. Trailing leg trajectory variability was lower for ACLR compared with CTRL and athletes for higher obstacles. Clinical significance: Sensorimotor deficits in individuals post-ACLR were reflected by greater asymmetry and less variable (more stereotypical) trajectories rather than limb positioning ability. This consideration should be addressed in clinical evaluations.

Place, publisher, year, edition, pages
John Wiley & Sons, 2022. Vol. 40, no 1
Keywords [en]
ACL, proprioception, sensorimotor deficits, symmetry, variability
National Category
Physiotherapy
Identifiers
URN: urn:nbn:se:umu:diva-181643DOI: 10.1002/jor.25016ISI: 000627471300001PubMedID: 33650722Scopus ID: 2-s2.0-85102261886OAI: oai:DiVA.org:umu-181643DiVA, id: diva2:1560427
Funder
Swedish Research Council, K2014-99X-21876-04-4Swedish Research Council, 2017-00892Västerbotten County Council, ALF VLL548501Västerbotten County Council, VLL838421Västerbotten County Council, VLL358901Available from: 2021-06-04 Created: 2021-06-04 Last updated: 2023-03-24Bibliographically approved
In thesis
1. Sensorimotor function following anterior cruciate ligament injury: movement control, proprioception and neuropsychological perspectives
Open this publication in new window or tab >>Sensorimotor function following anterior cruciate ligament injury: movement control, proprioception and neuropsychological perspectives
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
Sensorimotorisk funktion efter främre korsbandsskada : rörelsekontroll, proprioception och neuropsykologiska perspektiv
Abstract [en]

Background: The high incidence of anterior cruciate ligament (ACL) injuries in sports suggests an involvement of both biomechanical and neurocognitive risk factors. Athletes are constantly exposed to challenging sports scenarios, which are often characterised by high-intensity movements combined with a multi-stimuli environment and continuous psychological pressure. Post-injury loss of knee proprioception and long-term injury-associated neuroplasticity arguably place an athlete in a disadvantage when coping with such situations when returning to sports (RTS). This is postulated to contribute to a high rate of re-injuries, seen despite achieving RTS eligibility. Psychological factors such as re-injury fears and anxieties are also suggested to influence central sensorimotor processing and to therefore play a role in the generation and control of functional movements. Their assessment is however based on suboptimal tools, particularly when administered to the athletic population. In general, current clinical assessments focus primarily on coarse outcome measures while disregarding aspects such as multi-joint control and the influence of psychological aspects on motor performance. This thesis focuses on the role of proprioception and re-injury anxiety on functional movement control following ACL injury and reconstruction (ACLR), with implications for risks of re-injury.

Methods: This thesis is comprised of four cross-sectional studies (Papers I-IV), that stem from two data collections performed in a motion analysis laboratory. Paper I introduces a novel obstacle clearance test aimed to functionally assess proprioception and sensorimotor control. The goal of the test was to cross an obstacle, downward vision occluded, aiming for minimal foot clearance. Individuals following ACLR and rehabilitation were compared to both mildly active uninjured persons (CTRL) and elite athletes (ATH). A kinematic analysis, using 3D motion capture, included estimates of lower limb movement accuracy, variability and symmetry. Paper II evaluates knee proprioception among the same individuals using a weight-bearing knee joint position sense (JPS) test, and outcomes were compared with associated outcomes from the obstacle clearance test. Paper III explores whether self-reported fear of re-injury is manifested in the biomechanics (kinematics and electromyography) of a standardised rebound side-hop test (SRSH). An ACLR group was stratified into high-fear and low-fear subgroups based on one discriminating question, and compared also to uninjured controls. In Paper IV, a threat-conditioning test paradigm is introduced, aiming to invoke and measure a neurophysiological arousal response to movement-related fear, among uninjured individuals. Conditioned auditory stimuli were occasionally followed by unexpected perturbations of the base of support, and compared with neutral stimuli. Electroencephalography was continuously registered and event-related potentials were explored as potential anxiety biomarkers.

Results: Kinematic asymmetry was observed for the ACLR group during obstacle crossing, both for individual joints and for multi-joint movement and velocity curves. In addition, trailing leg trajectory variability during higher obstacle crossings was lower for ACLR compared to both control groups. The less physically-active CTRL group demonstrated less crossing accuracy (larger obstacle distances and JPS errors) compared to both ACLR and ATH. Moderate positive correlations were observed between knee JPS absolute errors and obstacle distances, for the injured leg of the ACLR group only. Individuals with ACLR, classified as having high fear, demonstrated higher biceps femoris amplitudes and anterior-posterior co-contraction index during landing. Side-hop performance was also distinguishable for ACLR (regardless of fear allocation) with greater hip and knee flexion, while high-fear individuals also had more trunk flexion. Perturbation-related fearful response was reflected as a high-amplitude contingent negative variation (CNV) wave in response to conditioned compared to neutral stimuli. The CNV wave was observed over all electrode cites but most significantly over frontal and central cortical areas.

Conclusions: Even following rehabilitation, individuals with ACLR showed unique sensorimotor function, characterised by less trajectory variability and greater multi-joint asymmetry when proprioception was challenged (i.e., downward vision occluded). However, knee JPS did not seem to be deficient among these individuals, but instead more related to physical activity, than to the ACLR history. Correlations to JPS errors, seen exclusively for the ACLR leg might suggest a tendency to focus attention more internally when crossing an obstacle (generally an external focus task), though this should be investigated further. Higher levels of self-reported fear of re-injury were manifested in the biomechanics of side hops, with seemingly stiffer landings and protective neuromuscular strategy. This has potential implications for joint degeneration hastening as well as reduced motor adaptability, implying a risk for re-injury. Finally, the balance-perturbation test paradigm seemed to provoke threat-associated arousal in the form of a CNV wave among uninjured individuals. The CNV wave should further be explored as a potential biomarker for re-injury anxiety. Future research should implement this paradigm on individuals with different levels of self-reported movement-related fears and anxieties, striving for a more holistic approach in rehabilitation following ACLR.

Abstract [sv]

Bakgrund: Den höga förekomsten av främre korsbandsskador (ACL-skada) i sport tyder på en inblandning av både biomekaniska och neurokognitiva riskfaktorer. Idrottare utsätts ständigt för utmanande idrottsscenarier som ofta kännetecknas av komplexa rörelser i en miljö med många olika stimuli och även psykologisk press. Förlust av knäproprioception efter ligamentskadan och långvariga neuroplastiska förändringar utgör en utmaning för idrottare i sådana situationer efter återgång till idrott (RTS). Detta antas bidra till den höga frekvensen av sekundära skador, trots att man uppfyllt kriterierna för RTS. Psykologiska faktorer som t.ex. rädsla eller oro för sekundära skador antas också påverka central sensorimotorisk bearbetning och därför spela en roll i hur funktionella rörelser genereras och kontrolleras. Bedömning av rädsla för skada är dock en utmaning och baseras vanligen på suboptimala verktyg, särskilt när de används för elitidrottare. Nuvarande kliniska bedömningar utgår främst från grova utfallsmått samtidigt som man bortser från flerledskontroll och psykologiska aspekter på motorisk prestation. Denna avhandling fokuserar på betydelsen av proprioception och rädsla/oro för sekundär skada med avseende på funktionell rörelsekontroll efter ACL-skada som behandlats med rekonstruktion (ACLR) och rehabilitering.

Metoder: Avhandlingen består av fyra tvärsnittsstudier (delarbeten I-IV), som härrör från två datainsamlingar utförda i ett rörelseanalyslaboratorium. Delarbete I introducerar ett nytt test där man kliver över ett hinder med så litet avstånd som möjligt och utan information från nedre synfältet. Testet syftar till att funktionellt bedöma proprioception och sensorimotorisk kontroll. Individer med ACLR och rehabilitering jämfördes med två kontrollgrupper av icke-skadade individer; moderat aktiva personer (CTRL) samt elitidrottare (ATH). En kinematisk analys, med 3D motion capture, inkluderade rörelsenoggrannhet, variabilitet och symmetri i nedre extremiteterna. Delarbete II utvärderar knäproprioception hos samma individer med hjälp av ett viktbärande knäledspositionstest (JPS), och resultaten jämfördes med motsvarande resultat från hindertestet. Delarbete III undersöker om självrapporterad rädsla för ny skada tar sig uttryck i biomekaniken (kinematik och elektromyografi [EMG]) i ett standardiserat s.k. ”rebound side-hop”-test (SRSH). En ACLR-grupp delades in i två undergrupper: de med hög rädsla respektive de med låg rädsla baserat på en diskriminerande fråga, och dessa grupper jämfördes även med personer utan ACL-skada (CTRL). I delarbete IV som är en metodologisk studie introduceras ett testparadigm med kraftiga balansstörningar som syftar till att framkalla och mäta neurofysiologiskt svar på eventuell rörelserelaterad rädsla/oro. Metodstudien fokuserar på oskadade individer. Konditionerade hörselstimuli följdes ibland av en snabb förskjutning av den plattform som testdeltagaren stod på, och detta jämfördes med neutrala stimuli utan efterföljande förskjutning. Elektroencefalografi registrerades kontinuerligt och händelserelaterade potentialer undersöktes som potentiella biomarkörer för ökad uppmärksamhetsgrad möjligen förknippade med oro för rörelse/ny skada.

Resultat: Kinematisk asymmetri observerades för ACLR-gruppen under hindertestet, både för enskilda leder och för flerledsrörelse- och hastighetskurvor. Dessutom var variabiliteten i det efterföljande benets bana för högre hinder lägre för ACLR jämfört med båda kontrollgrupperna. Den mindre fysiskt aktiva CTRL-gruppen visade både lägre noggrannhet under klivet över hindret (större hinderavstånd) och JPS-fel jämfört med både ACLR och ATH. Måttliga positiva korrelationer observerades mellan absoluta fel i knä JPS-testet och hinderavståndet i det funktionella testet endast för det skadade benet i ACLR-gruppen. Individer med ACLR och hög rädsla, visade högre biceps femoris EMG amplitud samt högre anterior-posterior co-kontraktion index under landning vid sidohoppet. Sido-hoppsprestanda kunde också särskiljas för ACLR (oavsett rädsla) med större höft- och knäböjning, medan individer med hög rädsla också hade mer bålböjning. I balansstörningstestet återspeglades möjlig rörelserädsla vid EEG-mätningarna som en hög-amplitud betingad negativ variation (CNV) våg som svar på konditionerade jämfört med neutrala stimuli. CNV-vågen observerades över alla elektrodplaceringar men var mest framträdande över frontala och centrala kortikala områden.

Slutsatser: Även efter rehabilitering uppvisade individer med ACLR en avvikande sensorimotorisk funktion, kännetecknad av mindre rörelsevariabilitet och större asymmetri i flera leder när proprioceptionen utmanades (dvs. när nedre synfältet var blockerat). Knäledspositionskänslan verkade dock inte vara nedsatt bland dessa individer, utan större fel associerades snarare till lägre grad av fysisk aktivitet än till ACLR-historik. Korrelationer till JPS-fel, som endast ses för ACLR-benet, kan tyda på en tendens att fokusera uppmärksamheten mer internt när man korsar ett hinder (vanligtvis en extern fokusuppgift), även om detta bör undersökas ytterligare. Högre grad av självrapporterad rädsla för ny skada uttrycktes i biomekaniken under sidohoppen, med till synes styvare landningar och en neuromuskulär strategi för att skydda knäleden. Detta har potentiella konsekvenser för påskyndande av leddegeneration samt minskad motorisk anpassningsförmåga, vilket kan innebära en risk för ny skada. Slutligen framkallade testparadigmet med balansstörningen en slags hot-associerad ökad uppmärksamhetsgrad i form av en CNV-våg, hittills bara testat på oskadade individer. CNV-vågen bör ytterligare utforskas som en potentiell biomarkör för oro för ny skada. Framtida forskning bör implementera detta paradigm på individer med olika nivåer av självrapporterad rörelserelaterad rädsla/oro, i strävan efter ett mer holistiskt tillvägagångssätt i rehabilitering efter ACLR där psykologiska aspekter tydligt vägs in.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2023. p. 104
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2218
Keywords
ACL, knee injury, sensorimotor control, proprioception, functional test, fear, anxiety, kinematics, electromyography, EMG, electroencephalography, EEG, brain, neuroplasticity, injury prevention
National Category
Physiotherapy
Research subject
Sports Medicine
Identifiers
urn:nbn:se:umu:diva-203089 (URN)978-91-7855-961-9 (ISBN)978-91-7855-960-2 (ISBN)
Public defence
2023-02-10, Aula Biologica, Biologihuset, Linnaeus väg 7, 09:00 (English)
Opponent
Supervisors
Funder
Swedish Research CouncilUmeå UniversitySwedish National Centre for Research in SportsKonung Gustaf V:s och Drottning Victorias FrimurarestiftelseRegion Västerbotten
Available from: 2023-01-20 Created: 2023-01-16 Last updated: 2023-01-17Bibliographically approved

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