Chapters Transcript Video Neuromechanical Rehabilitation of the ACL Injured Patient: A Brain, Body and Behavior Approach James Onate, Ph.D., A.T.C., F.N.A.T.A., presents at the Johns Hopkins Department of PM&R’s Grand Rounds on May 18, 2021. um real quick just uh, the agenda is a little different than probably the agendas that you normally see with these grand objectives and so many different take home points and so on and so forth. I really wanted to go back. Um, and I've been really studying some different things about critical thinking and really I've been talking with middle school teachers that I coach baseball with one individual coaches, our coaches, high school baseball with me and he teaches 7th and 8th graders. And I said, man, you know, a lot of our incoming college freshmen are just lacking some basic things. And he said, yeah, like what I said, well you know, just asking questions the typical five Ws and an H. Uh so who, what, where, when, why? And I said, oh I think I'm gonna use that in a major presentation that from the Ohio State University to the johns Hopkins University. I mean these these are world known names. So we're gonna, we're gonna have this agenda as our, as our process here. So financial disclosures, I I advise for a supplement company and financial support, everything from names to the Department of Defense. Um, I do some stuff with the special operations community also. So those are a little bit different hats that I wear. Hopefully everybody sees this thing right now. So this is a frog, right? I don't know what type of frog. I don't know what jungle. I don't know what species, I don't know. But I know that the view of the frog is very, very much concerned with a small radius around itself. It deals with what's right in front of it, right into the side of it and right behind it. And as clinicians often times this is where we stop. We just deal with what we see right in front of us, what we need to take care of, right what checkpoints we need to do, whether that's paperwork as educators, we do the same thing. What class do we need to teach today and what do we need to get done? And we sometimes don't see the rest of the forest. Then there's the administrator side or the big picture side or the program director side or whatever hat you want to wear. And you see this big landscape and you're trying to understand how to get this uh you know, ecosystem in order. And you see in this whole mountain landscape and everything and sometimes we forget what that day to day feels like and what problems we need to solve and what issues we need to address in either patients or colleagues or staff members or so on and so forth. So I wear both these hats. I normally live in this from a research standpoint, the bird's eye view. So if you're expecting me to give you the details of F. M. R. I. And exactly what boggles we do and so on and so forth. That's not me. That's why I have students and that's why we have staffing for those types of things, but I can give you the ideas and the general idea. So we're gonna have a big overview or a bird's eye view of a lot of things today. So my laboratory history is from the traditional laboratories with vO two maxes and biomechanics, uh cutting and pivoting, jumping and landing. But I also do a lot in weight rooms and on the fields. I'm a certified athletic trainer. So I've been involved in the medical side of those things, But I also have 2° in exercise science and I'm also involved in the sport performance side of things. I also coach, high school baseball and summer travel, baseball at a high level. Um and so I've been involved in the clinical side of those types of things and then understanding the patient rehabilitation are our center is right attached to the physical therapy area that we have. So that just gives you a little background on where I'm coming from. So let's just think about the who and some of you, this may be very familiar information or it may not be close to what you do, but just think about taking this information to who you work with and and it's really more of a paradigm focused than it is techniques and specifics. So one of the things that has always interested me is this whole neuro versus Ortho world. Um and we see this a lot within the physical therapy community. We see this a lot in the athletic trainer community. We see this a lot in the occupational therapy physician so on and so forth. Um To me I really don't understand the difference because they're all kind of together. So I really view clinicians and I don't mean uh a certain type of clinician, I mean all clinicians. So for me clinicians from rehabilitation specialists to physicians to coaches to me are clinicians are really applied neuromuscular scientists and we need to understand and embrace those things as we go through. So let's just kind of have a question of what's neural load and I we're not gonna get too much into our questions here. I'm gonna make it a little bit easier for you to interact. But let's just consider one of the basics that we do for knee rehabilitation. These are quad sets. This is one of the earliest things that we do for somebody post surgical. These are some of the things that we do trying to create muscle activation for somebody who's had you name it. Nicastro arthritis, A. C. L. Injury so on and so forth. And we probably would consider that to be a low neural load. So now let's just move up into a higher category a single leg hop. Now we have to bear weight. Now we have to do that on a single balance system. Now let's think about changing direction. We have a single leg hop we cut onto one leg and now we have to pivot and come off. Now we have to do that with a ball whether it's a football or basketball or soccer ball so on and so for chasing a ball and then we have to do that while keeping track of players. Now our neural load is starting to go up and up and up. Yet. Oftentimes we in our clinical setting and with things that aren't really the reality of what they're returning to. So we have to think about all these things but it's no different than in my head of a clinician. My mother was just here, she's 86 years old and we hadn't cut the grass yet in the yard and she was trying to diverse the the yard and it wasn't easy why because the surface was really difficult for her. The grass was high, she was moving and we had to provide more support. Also the dogs running around. Also there's neighborhood kids waving. So it's an entirely different environment than than a closed environment of working in a clinical setting. And it challenged her and we you know we worked on those types of things but it's the same concept, the same concept for an athlete and an a. c. l. injury. Same concept for my mother who is 86 years old with some balance issues. So population of who this population tends to be a young active individuals and they seem to get younger and younger every year. Um And we can go through the whole incidents. This is for those of you who aren't really familiar with the A. C. L. Aspects A cl. Is the anterior cruciate ligament, one of the primary stabilizers in the knee. We see that we have approximately 200,000 a year. Our cost in the billions. One of the biggest concerns though is that we have a second injury. Now there's a variety of factors that can go into that why returning to early returning we're not ready. Obviously there's patient values to those types of things so they want to be back sooner rather than later. And then the bigger long term cost is the knee osteoarthritis associated with that And then the long term disability that we are concerned about. So just a real quick getting into the function of the A. C. L. Resist anterior translation of the tibia and the femur. Very simple piece very important for deceleration and landing components. Let's see if you guys can see this video and pick out where this happens. So left foot plant. Nobody hit him got hit afterwards. So not only did he tear his A. C. L. And then he gets hit afterwards and he misses the entire season. So that's A NFL quarterback going through some issues. Now this is where we get response. So this is a injury or not injury. You have to determine if this individual got injured on this play. Those are your soccer fans, you may have a little advantage. That's a pretty impressive feet that he just accomplished and we're gonna see that again because I want to give you a little bit of highlights and this is gonna be our discussion points here. So if I can get the video going, big jump, perturbation gets hit aligns, has to head the ball into a goal, lands on one leg comes down. Now the question is, did he get hurt or not? So let's see in the chat or reactions or you can talk or you can do something to interact a little bit, but did he injure his knee or not? It might be just me and Tracy just talking here, he didn't. Pablo said dr sell nick, is that correct? I'll go by Pablo on those things. I go by jimmy for everyone. So please don't call me James, I should have changed my name on here. No, no, no, no, no. So we either have a ton of soccer fans, football fans, for those of you from, uh, from the mother countries of football participate in the next game. So no dissipated for us. We're coming down the left upper extremity, very good, no injury, no injury, nope. So we have a lot of people who have stating no. Now the question is hard impact on an angle will look like the absorbed the force. Exactly. So he didn't, I mean he was very, very high in the air. getting perturbed by an individual almost undercutting him having to head the ball into a goal after having run probably up and down the field at least a couple of times. So it may be in a fatigue state or those types of things. Why didn't he terrorist a ceo. So that's that's a big question. Why does somebody else tear their A. C. L. In such a simple fashion. So that question has been driving me for. Yeah. Now you can see my white chin hair for at least two decades or more than two decades. Almost three decades. Why why does somebody get hurt? To begin with? Why does somebody get reinjured? And how can we prevent those things from happening? And that's a really, really really difficult piece. Yes. Greatest athlete on earth genetics training at a high, high neural load, uh, neuro muscular adaptations. Yes. Yes. And yes. How do we measure it? How do we translate that to other people? How do we help some of these individuals go through and maybe we can't. And that's one of the things that I'm coming to realize is that we're number one, not going to be able to help everybody. Number two. Uh Number two, are we going to be able to help some individuals messi's better? I'm not quite sure he might be a little bit tactically better, but his athleticism isn't the same. I like this group. This is good. You guys are good. Uh So my parents so just to give you a little background my parents grew up in chile. They they immigrated to the United States about six years before I was born. Uh They grew up watching and playing soccer. Um They follow every Chilean national member and so my tv this past weekend was on everything. Premier league wherever a Chilean was playing they were watching. Um So that's my extent of football knowledge. Alright so what happens here? So let's just think of this um What happens into this thing? So we have a normal 6 to 12 month rehabilitation. Some people are asking for two years. Some people come back really really early when I was an undergraduate student. It was the early return to sport and early back then was we were returning people 2.5 months post surgery. So an individual who tore their A. C. L. In the beginning of football camp in college in august was back on the field playing in october so for some of you that might seem like whoa and then there's other people on this call. May be remembering saying hey we used to throw people in a cast a full length cast after A. C. L. Reconstruction. So we have some different gametes of these types of things but let's just think about this process and most of the time we focus on the traditional Ortho techniques, right strength balance movement so on and so forth understanding that we have this whole neurological component that is associated with it that we often times just um test aside on a lot of these things. So we know that second A. C. L. Injuries highest risk when their first few months returned into activity. We know that quadricep strength deficits still have major impact. One of my research colleagues, dr Schmidt is very very good on those side. So we've kind of partnered up into the P. T. A. T. World to be able to do some of these things together. So we know that we have these deficits um and we know that this is the problem. So so we have some out of sensory injury, the easiest thing for me to and instead of getting into all the techniques of the brain stem or the cerebral regions which we'll get into in a little bit and going into every single piece. We have reconnected the biomechanical aspects of things by putting the ligament back in when we do a cl but we haven't reconnected the wiring. We haven't grown new wiring, we haven't been able to piece it together with duct tape which I know works on so many things but probably doesn't work in this matter sensory system but that concept is there there are people working on some of those aspects to try to think about a duct tape type of idea um and how can we create this environment to be able to manage these things. So one of the things that dr grooms doctor grooms was is at Ohio University to different places. Ohio University is about an hour and a half away from Ohio state but he was my doctoral student here at Ohio State. So a lot of this work is dr grooms dissertation work and then his post work. Um and it's great to have that but theoretically we put out this kind of concept of this theory of, we have sensory neural plasticity so our affair and input gets disrupted. So the information coming into the system gets disrupted disrupted, we get appropriate receptive disruption and then we create this motor neural plasticity. How are we going to still achieve the task that we need to achieve if our input is out but we're going to still generate some output so then we get decreased postural control and then movement control starts to change. And one of the biggest things that we're looking at is the visual aspects. Now, many of you with your own backgrounds and heavy neuro backgrounds like understand that it's it's commonplace to have this visual system in the visual disruption but in the athletic world um we often don't think about those things and training those pieces so so just thinking about this sensory motor reorganization. Um One of the biggest things is altered processing of sensory and visual information from motor planning basically what we're seeing is that we see alterations in the primary motor cortex, secondary somatosensory cortex, the lingual gyrus and so on and so forth. There's more than just that. We rely on greater visual feedback after we terrorist ceo. Now the question is is this a good thing or a bad thing? So I'm gonna come back to it. This is your last question. So you guys get full participation by just answering two questions. Is this a good or a bad thing and why the why is the hard part? So do we do relying more on vision after a muscular skeletal disruption problem? Is that a good thing or a bad thing? And we can just stop right there and just say good or bad, Bad eric eric goes bad. We're not unable to coordinate an appropriate septic system as well. Bad, bad good. Okay, so we now have some controversy. Bad thing. Ronaldo couldn't see where he was landing, I agree, but Ronaldo could see that the ball was coming, could see that the individual was undercutting them so it could have some visual contributions to his movement control. So let's just think about that in the background. I know that everybody wants to make this a bad thing because our appropriate reception in our whole joint position sense and everything else with it. Okay, but let's just open our minds to the possibility of it being an okay thing as we kind of go down this path and and don't shoot the messenger yet because we don't have all the data on these pieces but we have theories and that's that's what the research is all about. Alright, so let's go back. Great so let's think about the wear motion. So we know within the literature that there's a variety of different alterations go on as we go through these things um within the brain structure. So we see um century areas, we see motor planning areas, we see balanced areas, we see visual integration areas, we see Um a variety of somatic sensory areas. So we know that we have that going on. Our very first piece that Dustin did um was really going down and and doing a very simple complex. Right? So when I was a student in the 90's I kept on going, oh I just can't wait until we can do F. M. R. I. Because now we can really do jumping and landing tasks. Well three decades later we're still just doing very simple knee extension deflection. We've actually added a closed chain type of peace and now we're gonna add a force loading type of peace but it's still very simplistic and I can't wait for the days in the future. We will be able to do a little bit more dynamic movement. But the problem is with the brain in the head movement we can only kind of do so much on those things but you can see our paradigm on those things and a little bit of the background of the research design and this is really kind of spread out through a variety of different groups and different people. So what our findings were is that we see the lingual gyrus or the sensory sensory visual integration up regulates. Um We see that go up in our individuals with a cl tears versus the controls and then we see this matter sensory go up and into those types of pieces. We also see whoops, we see the contra lateral century motor system go up and we see the cerebellum really go down into those things. So that was our initial work. Um and so we kind of came to the conclusion of the brain. Men may never be the same after post a CLR right, so we have this uh loss of some out of sensory potential. How do we get that back? Are we going to get that back? And what's the problem of trying to go seek that? A new thought that we are working on here and this is a little bit of some of the work with uh dr Schmidt and I know some other people in the country are doing some similar stuff is this is really a chicken and the egg problem. Maybe the brain wasn't the same to begin with. Maybe pre injury, they had some ports amount of sensory information capabilities, Maybe they have lack of movement, adaptability, athleticism deficiencies. A lot of people want to put it into sport specialization aspects or lack of multi sport or people want to put it into P. E. Or the americanization of these elite athletes at a very young age. And we don't know measuring those types of things would be a great idea but it's a large large undertaking. So let's look at the cartoon of A. C. L. Tear surgery. Right? So this is from a brace company and this is cartoonish uh for some some variety of things like because it's it's so easy to put rehab in this. Just a very simple complex right? 1 to 2 weeks after surgery used crutches, ice compression, elevation, lots of rest to reduce swelling and increasing the extension. Like that's so easy to do. Um And maybe we're really missing our mark there uh 2 to 6 weeks after surgery began exercising so on and so forth. And then 3 to 6 months after surgery, ready to play and maybe begin to play around 6 to 9 months. It's not that easy. And this isn't the talk to go through the specifics of each part of that. But I want you to think about most of the literature is really showing that the best time frame is going to be one year plus post operatively. And I can put up a you know a couple other lit reviews, systematic reviews, meta analysis that are going to show the same thing. So let's just think about the rehab process and we have our stars kind of align in here. The lightning bolts of thinking about things. So, from a rehabilitation standpoint, from a orthopedic standpoint and then the neurological components within that orthopedic, when is the best time frame to really start intervening to see if this visual processing piece is coming into play is up regulating as we're rehabbing? Are we causing this or is this just part of their system for adaptation that they have? We don't know any of those pieces. Almost all the data that we have is post usually two years after. So we're really starting to look at these earlier timeframes and starting to look at when is the best time frame to be able to kind of intervene. And so this study was the very first one for us was we call it. It's very simple, there's many authors on this, but we just basically call it the first author Capelli study and they found some pre activity in some brain plasticity within that, a cl deficiency that started us off. But think about this injury risk behavior and you see these models all the time in dynamic Vegas and so on and so forth. I can tell you that I've done a tremendous amount of screening in my lifetime. Uh, we've just finished up in our uh, one that did um, over 6000 high school athletes doing jumps like this. So we probably screened jumping off of a box, about 10,000 kids From 18, 18, 18 years of age, all the way down to six years of age, About 10,000 and not one single individual has ever territory cl jumping off a box. So are we just not assessing our screening uh to the level of where their risk behavior is? So I would say that uh 10,000 sample size and zero a CLS doesn't match up within that age, population and demographics. So maybe we're not challenging enough in our return to sport activities, brain behavior relationships. We can see that the neural plasticity aspects under visual stress changes so we can see that the A. C. L. R. Individuals have a different visual stress change than the controls do. So let's just think about our pro perception and there's a variety of different things out there. So pro perception highly correlated with blind hops. So vision, we increase visual reliance when we decrease a fair and information. So this is basic information for most individuals you sit there going yes visual conditions um when we get vision we utilize that more. When we don't have vision, we have problems. So now let's think about it from an injury risk standpoint. And this isn't just for a cl individuals you see visual input within the military for doing especially special forces doing night landings and things without or decreased visual pieces and we see these at risk movement patterns and then same thing within non contact injury. So that could be ankle sprains or different types of aspects. So let's just think about also a neuro cognition load and this is some of the early work from Botswana. We showed some things that have also come in with this that we see some neurocognitive function relationships, so slow reaction, time processing speed, worst visual and verbal memory, and then his dad associated with neuro Moscow control. We are seeing a proliferation of new information relative to concussions, in athletics and in the relationship to musculoskeletal injury. So we understand that there is this kind of continuum of the brain body kind of relationship, which just makes sense. So let's just think about our century waiting or re weighting system. So this is this is a little bit of kind of the new ideas of these things. So we're not gonna put a scale to this, but you just see everything's at 100%. Let's just imagine that so that all three areas are contributing equally and then following injury, we see this amount of sensory area go down. The question becomes, we see a visual reliance go up to make up for that Samantha century go down. Let's just imagine that vestibular stays the same for that. Some of you are vestibular therapist, you we can argue back and forth on all these things. But I'm just for argument's sake, let's just say that vestibular stays the same. Well, there's not much in the literature that shows that we're going to be able to get to some out of sensory information to up regulate all the way back to normal. And you can see this with those losses of the mechanic receptors. Are we going to be able to duct tape the A. C. L. And make it perfect? Again, I don't think so in my lifetime, but maybe we'll have some big breakthroughs on these types of things and the human duct tape will becoming a a lot better. So shouldn't we also think about utilizing the visual system while also up regulating the somatosensory system. And I know that's a little bit controversial, especially how you answered in the no responses that we need to have appropriate deceptive or maybe a short term effect, but it's not going to be long term. What I mean by that is not only up regulating the visual system but up regulating the visual system to detect problems that may occur. So seeing things better on the field, seeing things better in the environment, having the system of the vision piece not only being just that my eyes are open or closed or disturbed, but that I can kind of get the sense that I've been in this environment. Now the problem is when we start looking at uncontrolled environments and there's where the strategies come into play and start thinking about strategies. So again, just kind of recapping some of the pieces there? Do we have a neuro controlled preference strategy as individuals. Does it change following injury? Does it change following rehabilitation? Does it persist over time? So thinking about these preference strategies is very simple. Um conceptually it's much harder to apply. So let's just take one area and we're gonna do this with two areas, posterior secondary somatosensory areas. So painful stimuli, Samantha sensory with appropriate reception, thermal pressure. What are ways that we can try to up regulate that? So is that part of the knee sleeve concept? Is that part of the knee brace concept? Do we have to have some things that help up regulate that knee when it's in a quote unquote, decreased amount of sensory environment. Is this possibly where I haven't seen a tremendous amount of literature that supports it, but you see athletes all over the place and the olympics uh will come up eventually and you'll see KT tape all over people again, is there potential for that to be able to have a small amount of sensory effect? Let's think about the posterior superior temporal gyrus. So, another area that we've seen visual cortex involved in strategy and integration of information, is that gonna be something that we can see? Let's just think about this environment, we can create these pictures and put them into a virtual environment and an individual can virtually be back on the field while they're doing the rehabilitation in the clinic we can think about them and fear avoidance and being able to control those types of things so that we can try to limit and minimize these types of pictures. Now, let's kind of gear up into a movement preference strategy standpoint. So a motor somatosensory vision. This concept is again just a straight concept. But as animals do, we have different motor movement preferences. I can tell you if I jumped up in the air like Cristiano Ronaldo, there's no way I could utilize the same strategies that you utilized to be able to avoid injury. Uh I would definitely do a double leg landing. I would definitely roll and drop on the floor to absorb the acceleration. Um and I would definitely have to utilize more vision to basically, probably not even jump. So you have to think about what are some of those movement preferences when we go through? Very similar to the posture control strategy preferences that have historically been involved in all balance type of assessment. So do we have systems that we can try to assess people's preference and be able to up regulate? Uh those types of systems based on what they've done? So is there a neuro preference strategy for movement control? Is it fixed or can it be altered following musculoskeletal injury? Does the rehabilitation process contribute to altering this neuro preference strategy? Can we create targeted rehab interventions? Those are things that we're working on. We don't have all those answers right now. So just a little bit of framework and what this is dr grooms uh Department of defense uh and that I'm a co investigator on but this is a concept that we've kind of put out there and really follow along in the yellow. And for many of you this is like oh sure this is what we've always been taught to do. Well I can tell you for 20 years ago, this is not what we were taught to do and this is not what we're preaching to do relative to a. C. L. Injuries. Uh sensory visual motor training utilization of somatic sensation via modified visual feedback and then creating an adaptive sensory motor control strategy. So just a little trigger warning for those of you who have a little problems visually. Um but we started thinking how can we create vision disturbances or changes without just closing eyes and opening eyes. And so Nike had these things now they're synaptic glasses and goggles and these are some of the things that we do actually. I use these things as baseball coach also in training individuals. So not only from an injury rehabilitation but an injury prevention standpoint. So can we create some different training paradigms. Can we create those within our rehabilitation setting? Can we create some up regulation or down regulation of a system? Not sure. So let's just think, you know, outside of the goggles and these are things that I know all of you promote on a regular basis. So third person point of view on mirrors, First person watch self fixate on the visual point versus a visual interference and it could just be hands in front of face and different types of things putting a flag in front of somebody or or those types of things changing the gaze fixation point, making near and make it further feedback monitor. So this is from the central on um and you know, device I know some of you might use some of the BT products but we're looking at trying to control uh not necessarily the amount, but can I take this window that they have to be in and can I tighten it and widen it so that I can see their control parameters. Can we use some of these fit lights to be able to get some measurement outcomes back while they're also doing standing dynamic and we can get some measurements of how long and how fast they can do some of those types of things. And then some of the traditional type of clinical ideas, right? So dense foams and both do squats and so on and so forth. And then doing our normal stuff that we've been doing for decades tennis balls and different types of balls. But can we also have things that just have to challenge the system a little bit more? Catch the pink one? Not the yellow one only block the black one. Don't catch it. Catch the even numbers for the ping pong balls things to kind of up regulate the demands prior to getting out on the field. We can do these things early early, early in rehab. And then let's just also think about holistic screening of athletes. Instead of just looking at one biomechanical variable or one posture control variable or one vestibular variable. Let's think about everything that we have around it. Let's think about the physical characteristics and functional outcomes that they have. Let's think about the environment, the environment for us, an athlete um even though they may be carrying weight like a football player is entirely different than a military soldier or a firefighter or a police officer carrying weights. So we have to think about that and get closer to that. What neurological components can we do from a screening standpoint, Can we match up with other neurological assessments that are being done um in the concussion world or the traumatic brain injury world and those types of things. obviously injury history. The biggest thing that came out of the R1 that I just finished was Previous injury history is still the strongest predictor. 2.7 for a cl tears and ankle sprains and high school athletes. So 2.7 times greater if you've previously had an injury that that's there. So it's still the pre you know, understanding individuals history is important and then behavior and psychological aspects, risk aversion, risk seeking fear, those types of things and how they drive movement. So nearing the end here I think one of the big things that as clinicians we need to always understand. We need to find our y but we need to find our patients why also and and really help to shape that and understand why is it that they're doing? Why are these things happening and what can I do to be able to help them? So just a little kind of plug for for the you know the the eyes or the vision, is it a good thing, It was a bad thing. I'm not still sure you guys can reach me, we can talk anytime. Uh you follow me on twitter and know all that stuff and and whatever you want. Thank you for your time. Thank you for everybody attending. Hopefully I gave you a little bit of ideas and hopefully I reached one person with one thought, that's it, that was my goal. Questions I put everybody asleep. This is where my class will start asking hi doctor analogy this is pretty Raghavan and I'm the vice chair for research in the department. Thank you for a very stimulating talk. I wanted to ask you if stiffness is one of the issues that you come across and you know how that interacts with tomato sensory dysfunction. You were talking about, you know how how do the muscles compensate for this? A. C. L. Injury. Yeah that's a whole another line of inquiry physiological line of inquiry on on stiffness and is having some increased joint stiffness following the injury. Right. A good thing or a bad thing and we see this um within the structure. Right? So one is a protective mechanism right? So if we can increase the stiffness we're gonna increase the capabilities muscle stiffness, hamstring stiffness following this. So the hamstrings counteracts with the A. C. L. Does it does it uh collaborates with the A. C. L. To prevent anterior tibial translation. So if we increase hamstring stiffness are we going to be able to aid or help the A. C. L. Within its function? That's one theory um problem with that is especially for those who follow in the soccer community the number of hamstring tears and the hamstring capabilities um can cause a similar of a problem as an A. C. L. Tear. So I I think stiffness is again another uh area to investigate. It is a protective mechanism but just like a lot of things that we do in our our human system we tend to over protect. Um And then that causes a line of other problems. So I think that's a great idea to investigate further and further and further in that area just to the entire mechanical properties and how do they change during the time and how do they change during rehabilitation? And often times we see the you know we're animals. What's our first instinct? Our very first instinct is protective mechanisms. They don't align very well with performance capabilities. So thank you. Thank you. All the messy fans out there. You're not, you're not upset that I didn't put them up on the screen. Maybe there's, maybe there's mLS us soccer fans out there wondering why I didn't put any us folks in there. Well, let us say thank you. That's good. Well, I'm wide open. I know I tried to give you a lot of information in a very short period of time. I didn't want to go, uh, super into, uh, so many different findings. I just really wanted to put the thought in your head. Um, we've been so appropriate receptive driven. Uh, trying to get to some out of sensory systems back up and running. And yes, we need that. We have seen just this up regulation of vision. And one of the ideas that's been kind of promoted is to try to down regulate the visual dependence. Um, and that is a, um, I'm not sure that's still the best answer. Uh, I saw the last chat, so Stephen, yes, us women's soccer team. I was at north Carolina when, um, and working camps when the nineties soccer team were basically camp counselors, the best soccer in the world was the coach's games prior to them. Uh, they were on the national team, but they weren't obviously getting all this publicity and they would play the coaches games with no referees and it was phenomenal soccer. It was the best women playing basically pick up football, soccer and uh nobody got injured. No it was it was amazing. So yes the the U. S. Women's national team accurately. Yes I do have a question for me. Okay. And I'll answer eric after, yep. Okay. So the question is is kind of a comparison, right? So you know, with A. C. L. Injury and then reconstruction oftentimes players don't return to like the same level of play. But when you compare it to like a Tommy john surgery, the throwers are actually often times better at throwing like higher speeds of their of their throws. So I wonder, you know, in your own research, do you feel that has to deal with more like appropriate receptive and just kind of rehab um issues or do you think although the A. C. L. That's been, you know, grafted is much stronger, it's just not as functional. Um I think there's two parts to that. Uh First I'll unpack the uh the Tommy john side. I'm not sure they're all better in that side. From coming back from Tommy john surgery. Um We just see their stories more often. Um So there's definitely some literature on that uh from the A. C. L. Standpoint. Yes. Obviously ligament is stronger uh from a mechanical standpoint but weakened from a neural standpoint. And I think that's one of the pieces that's uh difficult to try to assess. I think we also have a really different environment for those things. Um The baseball throwing environment especially if it's a picture is a very closed loop environment, very simple closed system. They do the same thing over and over again. That can be helpful in that their strategies can you be be really predetermined and they can do the same thing over and over again where in the A. C. L. It's really hard to get them set and prepared. Um So again I don't know if there's ever been a study that shows that Tommy john returns higher than than previously and a CLS returned less. Um I would say both return less optimally except for in some cases and and those get glorified um Gotcha. I would argue that yes Adrian Peterson came back in the NFL from his A. C. L. Surgery in a very very amazingly short time. But I would also say he's probably not the same running back he was previously but also he got a little bit older too. So you never know on those sides of things. Gotcha. Thank you. Um eric so what are some general preventative strategies for A. C. L. Injuries for us who are getting older and still like to engage in recreational sports? Well one uh play with people who understand that uh taking your legs out is uh probably not the best idea on a weekend or night soccer game. Um Because winning the championship, little trophy or the beer keg or whatever, there's going to be there for, it's probably not as important as your 1 to 2 year a cl recovery. So I would say the environment that you're playing is very important as just goes up. I would say number two is just normal uh strategies of everything, maintaining, you know, good strength, good posture, control, good vision, understanding what the system can and can't do. I play basketball. Still, I also realized I can't do some of the same things um, every once in a while I forget that I'm going to go up and try to do some stuff and uh, I coach high school kids, so I'm playing basketball with 15 to 18 year olds, that's not the easiest thing in the world. So sometimes I just let them go by and I have to swallow my pride, which is very large. So hopefully that helps a little bit. Alright, well We're done early. Right? So this goes till 1:00. So I'd like to grant the ability of providing 10 minutes to your life. I think that's one of the best things that we can do and zoom. I'll stay on if you want to uh unless there's other questions, thank you so much. This was a really fun and interesting presentation. We really appreciate you joining us. Um and uh this will be recorded, This was recorded, so if people want to be able to watch it, it'll be available on the Hopkins website very shortly and I'm sure that folks will reach out if they have other questions again. Thank you. Yeah, I appreciate it. This has been fun. I hopefully, again, like I said, you learned one thing and hopefully we had a little fun. Um, that that's my goals every day in life. So thank you. Yeah, it was wonderful. Thank you so much. Have a great day. All right. Take care, James. I have a question. My name is john, I'm a therapist um here, john good, good. Um, we do a lot. I mean obviously there's thousands, hundreds of tests to do to assess kind of readiness or assess risk. And you know, how would you just assess this? You know, I mean, I think this is something I've been following for the last couple of years. It's kind of gained traction. How would you best to assess someone's in short of doing an FMRI um like how are you going to assess this component of rehab or readiness to compete um, in your assessment, I think you do it very similar to a lot of other things that you do. Right? So, uh, let's take the single leg hop as an example. Um you know, we can measure it for distance horizontally. We can measure it for vertical height. We can measure it for uh, postural control. Right. We can measure it on an X. And how far away do they land from the X. Right. Are those some ideas that you guys do or triple hop or any of those types of things? Yeah I mean we do do all that looking at both quality and quantity. Um I mean we used the synaptic glasses here. So I do triple op testing with and without the glasses. I think that's your you're right on it. You're you're doing your triple hop hop testing with and without glasses you're doing triple hop testing with and without with eyes closed. Um You know I think you can make some modifications to the synaptic glasses so that they are uh you know um there's a little bit of crease underneath it and and and making a more snow goggle kind of type. So it's a little lighter so adding some foam underneath so that you do that. Um But I think you're right on it. I mean you're basically testing in one environment and then testing in another environment and you can see how much does the visual interference or the lack of vision. Right. So interference with this rotoscoping goggles and then eyes closed and does movement quality change tremendously? Does the um you know obviously the uh the quantitative measures, right, do they jump half the distance do they jump? And those are things that we need to get better at looking at the normative aspects of those things. So um I would be really thrilled to see your data uh of people with and without those types of things. I mean you just tracking that information What should be normal? Should we see a 15% deficit when they go to visual interference and should we see a 50% deficit when they go to eyes closed? I don't we don't know that. Right? Yeah, that's a great point. I didn't think to measure. I mean I was I do more so video than with the goggles to look at inequality versus what's the difference in distance? Yeah, I think you can do both. I mean I really think you're you're looking at both the quantitative and qualitative. I mean we I can show you some some biomechanical video that we had a single leg jump in the individual, You know, it's pretty straight up and down. And then once you had the eyes closed or all over the place and you know that is really somebody who is visually dependent. We looked at their fmR. Either visual, they're visual centers just sparked up everywhere and it's like, okay, this person has a really visual preference strategy um you know, we used to call it well, I still sometimes refer to it as visually dominant. We're trying to change it to visual preference but and and then the question becomes, is that the way they've always been, is that why they got injured? To begin with? What if we start down regulating that now they're in even more trouble. Um so that's kind of where we're at. I don't we're still very, very early in this stuff. You know Dustin um in Ohio is doing a lot. He's collaborating with some folks down in Atlanta and emery. Um, you know, we're still early. I would, you know, me and our doctoral student adam Culliver who's a, who's a really good petey. Um and he's going through this area also. He's going to be doing some FMR I stuff. I said we're about 5% into this race. He goes, I think we're about 1% in this race. And that's that's exactly true. And and I think you guys out there in the, in the clinical world like collaborating on looking at Struga scope goggles, triple hop versus single hop with and without would be great. I mean, just measure, you know what I mean consistently? That's a good component. Because I know I've seen Dusty talk several times. Um, and just kind of the stuff he always brings is kind of eye opening. And just again, another component that we're probably missing. Yeah. Yeah. And Dustin does a great job. I mean he really, really, really knows the F. M. R. I stuff. Um You know the question I always have for him is the chicken and the egg. Do we know if this stuff happened before or after. And then the question is um yeah, we see this visual regulation up regulation and we need to kind of century reweighting and really get it back to normal. Number one. Can we get it back to normal? Number two? Is that a bad thing? Right. Right, awesome. Thank you. Created by
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