Neuroplasticity Associated With Anterior Cruciate Ligament Injury
Condition: ACL Injury
MeSH terms: Wounds and Injuries; Anterior Cruciate Ligament Injuries
Study type: Interventional

Summary: 
      Activation of the brain for knee movement changes after anterior cruciate ligament (ACL)
      reconstruction. The brain activation profile after ACL reconstruction indicates a shift to a
      visual-motor control strategy, as opposed to a sensory-motor control strategy to control the
      knee movement. Recent research suggests that ACL reconstruction rehabilitation protocols
      should also consider neurocognition and its role in exercise, neuromuscular control, and
      injury risk to improve the effectiveness of the intervention.

      However, there is currently no evidence of the feasibility of neurocognitive exercise in a
      primary rehabilitation program that aims to restore movement function after ACL damage.

      The purpose of this study is to assess whether conventional ACL injury training with
      additional cognitive training based on virtual reality is as effective as the sole
      conventional ACL injury training in participants with ACL injuries.
    

Detailed description: 
      Whereas three percent of amateur athletes injure their anterior cruciate ligament (ACL) each
      year, this percentage can be as high as 15% in elite athletes. Because the ACL contains
      mechanoreceptors it directly influences the neuromuscular control of the knee. ACL deficiency
      leads to partial deafferentiation which, in turn, alters spinal and supraspinal motor
      control.

      Return to sports following ACL injuries is mostly decided based on time since surgery;
      however, this decision process produces unsuccessful outcomes; e.g. high re-injury rates or
      athletes not being able to return to their pre-injury sport levels. The rate of return to
      preinjury play levels for non-professional pivoting athletes for example is 65%. A recent
      evidence-based clinical update revealed that it is currently unclear whether there is a
      benefit of supervised physical therapy rehabilitation compared to home-based rehabilitation
      or no rehabilitation at all, and comparisons between 19-week with 32-week rehabilitation
      programmes show no differences in terms of laxity, range of motion, knee function, or
      measures of leg muscle strength. Evidence-based guidelines suggest practitioners should
      generally follow a moderate recommendation, which means that the benefits of treatment exceed
      the potential harm; however, the quality/applicability of the supporting evidence is not as
      strong. Many rehabilitation programs currently target biomechanical factors; e.g. muscle
      strength, balance and plyometric function, and consider to a rather lesser extend cognitive
      or neurological components.

      Brain activation for knee flexion/extension motion alters following ACL reconstruction. The
      brain activation profile following ACL reconstruction may indicate a shift toward a
      visual-motor strategy as opposed to a sensory-motor strategy to engage in knee movement. This
      recent research evidence suggests that rehabilitation protocols for ACL reconstruction should
      additionally be considering neurocognition and its role in movement, neuromuscular control,
      and injury risk to help improve intervention effectiveness.

      However, there is a lack of evidence concerning the feasibility of implementing
      neurocognitive exercise interventions in a primary rehabilitation program aimed at restoring
      function following ACL injury. New treatments usually have to go through a series of phases
      to test whether they are safe and effective before larger scale studies and application in
      clinical practice are to be considered. The aim of this pilot study was to perform a phase II
      trial according the model for complex interventions advocated by the British Medical Research
      Council to test the feasibility and effects of a conventional ACL injury rehabilitation
      program with added neurocognitive training in a group of ACL injured individuals. This study
      aims to: (1) compare ACL injured individuals with non-injured individuals, (2) develop an
      exercise intervention based on research literature theory and to deliver it to ACL injured
      individuals, (3) evaluate the feasibility of the intervention and the ability to recruit and
      retain ACL injured individuals, and (4) assess whether the treatment has some effect on
      neural drive and physical performance.
    

Intervention name(s): Exergame training; Usual Care Training
Intervention type(s): Other; Other
Intervention description(s): Training on Medical Device (MD): Dividat Senso, DIV-SENSO-H, Dividat GmbH, Software development: ISO 62304:2016; designed to train aspects of executive functions (EFs; divided attention, working memory, inhibition, and shifting) and physical functions through Virtual Reality video game training.
FITT training principles are implemented; Frequency: three times per week, Intensity: individually adapted VG (allowing training progression), Type: combination of cognitive and motor training, and Time: 20 min training sessions. Training lasts 6 weeks (18 training sessions). Participants train 20 min, three times per week. Training includes one session of each VG (4 min) in a pre-defined order and short breaks (~1 min) for game change.; Routine (standard) therapy given based on conventional current-best-evidence Rehabilitation. Preoperative Phase: Diminish inflammation, swelling, and pain; Restore normal range of motion (especially knee extension); Restore voluntary muscle activation Immediate Postoperative Phase (Day 1-7): Restore full passive knee extension; Diminish joint swelling and pain; Restore independent ambulation Early Rehabilitation Phase (Week 2-4): Maintain full passive knee extension; Gradually increase knee flexion; Muscle training Controlled Ambulation Phase (Week 4-10): Restore full knee ROM; Improve lower extremity strength; Enhance proprioception, balance, and neuromuscular control Advanced Activity Phase (Week 10-16): Normalize lower extremity strength; Enhance muscular power and endurance; Improve neuromuscular control; Perform selected sport-specific drills.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: This trial is a two-arm, parallel-group, randomized-controlled pilot trial with a cross-sectional comparison at baseline.
Masking: None (Open Label)
Primary purpose: Treatment