September 4, 2024 • 45 mins
On this episode, we dive into a different side of ACL rehabilitation with our esteemed guest, Meredith Chaput, PhD, PT, DPT, SCS, from the University of Central Florida. Meredith, a physical therapist with a PhD in translational biomedical science from Ohio University, shares her extensive knowledge and research on the visual cognitive progression during recovery from ACL reconstruction.
We explore a range of topics, including:
- The integration of neurocognitive training in ACL rehab
- The importance of early intervention and maintaining traditional rehab principles
- How to effectively measure and implement dual-task exercises
- The role of cross-modal brain regions in recovery
- Future directions in neurocognitive research and its implications for physical therapy
This episode is packed with valuable insights for clinicians and anyone interested in cutting-edge rehabilitation techniques. Don't miss the fascinating discussion on how blending cognitive and physical training can enhance recovery outcomes.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Music.
(00:12):
This is Dr. Benner, and I'm here with our co-host, Scott Bauman,
again tonight for another episode of the Shelburne East Center Podcast.
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(00:55):
and health economics in that one. So make sure to go check that one out and
all of our previous content.
Tonight, we have another great episode. We have a great guest.
We have Meredith Chaput from the University of Central Florida.
She's a physical therapist and a pretty remarkable educational background,
and we're going to discuss with her the visual cognitive progression during
recovery from ACL reconstruction, specifically a recent paper that she had published
(01:18):
in JOSPT earlier this year.
Meredith is, like I said, a physical therapist and PhD researcher.
She got her DPT from Creighton, went on from there and did a sports residency
at Vanderbilt Orthopedics in Nashville, as well as Belmont University.
She is SCS certified. from there she went
and got her PhD in translational biomedical science from Ohio
University and she's currently involved in the
(01:38):
APTA specifically the educational lead for the sports
performance SIG through the APTA and her current position
is assistant professor of PT in the School of Kinesiology and Rehabilitation
Science at the University of Central Florida and specifically her research is
involved with compensatory nervous system plasticity after lower extremity musculoskeletal
injury which is really what we're
(01:59):
looking to talk with her about today and obviously being an e-podcast,
this is specific to the ACL and post-op after ACL reconstruction.
So we want to get all the details about this specific topic and we will eventually
hit the paper that she wrote in JOSPT as well.
So before we get started, Meredith, thanks for joining us on the podcast.
Thanks for having me. I'm really excited for the discussion today.
(02:22):
So before we get started, Meredith, if you could just kind of introduce yourself.
I know we gave you more of the educational background, but just tell us a little
bit about yourself and your path and how you got into PT and specifically orthopedics.
Yeah. So I am originally from Minnesota. I did my undergraduate at the University
of Minnesota, Duluth in exercise science.
And before I got there, I was actually college basketball hopeful.
(02:48):
Studying elementary education.
And I wanted to be a basketball coach and elementary educator.
And then I had a history of three knee surgeries and a broken leg that led me
into a lot of physical therapy and decided not to play basketball anymore.
And my mom actually convinced me to try physical therapy.
(03:12):
She was like, you've been through enough of it. Don't you think you would be good at helping people?
And I was like, well, maybe, but it's kind of boring is what I thought.
I didn't like my physical therapy I went through.
And then she was like, why don't you just say you You didn't like your physical therapist.
No, Dave was great. Dave and Big Stone Therapy is awesome.
(03:34):
But she was really the one that sort of inspired me to like go for it.
And then once I actually switched my major from elementary education to exercise
science, I really realized like, oh, I love exercise and I love physiology,
learning about it and working with people.
And so it was through my own experiences and then through my mom's help and
(03:55):
education that That sort of pushed me down the road of PT, specifically ortho.
Now, once you got into PT school and figured out that was going to be your career,
you know, now that you're in orthopedics, and I went to physical therapy school
as well, so I know that you're going to go through two different tracks.
There's the neuro track and there's the orthopedic track. And if you're anything
like me, you are not a fan of the nervous system. But obviously,
(04:16):
that's what you're doing now.
You've kind of mixed the two, which is, I wouldn't say it's the most common
thing in physical therapy, especially orthopedics.
Everything is usually joint specific. And that's why I find your research so fascinating.
And we chatted before we got online. I've heard you speak at many conferences
and followed you on Twitter and things.
And one of your co-authors is Dustin Grooms.
And I know he's big into the nervous system as it relates to post-op ACL as
(04:39):
well. So I really find this stuff fascinating.
But we talked about your path into PT and orthopedics. What got you interested
in this specific realm of PT in that it's dealing with the nervous system?
Yeah. Yeah, I actually at Creighton, I was mentored by Terry Grindstaff and
he is a sports physical therapist.
But one of the best pieces of advice he gave me actually as a curious student,
(05:03):
I told him I wanted to be a PT in the NFL.
And his advice to me as I picked my clinicals was, well, do a neuro rotation. Okay.
Don't shy away from doing an outpatient neural rotation. And I didn't really
understand like the, the reason why behind that until I was on my rotation and
(05:25):
I would just have discussions with him.
And I realized like, oh, everything in ortho comes back to the nervous system.
And so from a, I would say like an early part in my education with him,
we were able to have pretty in-depth conversations.
And I was able to ask pretty in-depth questions to him about like the neurophysiologic
(05:45):
differences after knee injury.
And it all sort of started with arthrogenic muscle inhibition.
And then it expanded out from there. And then it wasn't until I was in residency
that I found Dustin Grooms' research.
And so it was like one of his first clinical commentaries in JOSBT on visual perturbation.
(06:06):
And it was the first time I really read anything about sensory reweighting.
I read it. I immediately started implementing with my patients and just sort
of like using them as my research subjects, right, for this.
And I saw like an immediate anecdotal change.
And it started with actually like psychological readiness and like just willingness
to participate in activity that they might have shied away from before.
(06:31):
And then I ended up down the neuro rabbit hole for good. And that's how I ended up with him for my PhD.
You mentioned your own experience having knee injuries and multiple lower extremity surgeries,
once you started to learn about that, it had to be an interesting Pandora's
box to open and it had to all of a sudden, I can imagine, take you back to the
(06:51):
time when you were going through that and think, well, wow, I never really thought
about this and all these things that I'm reading about.
Maybe that's why this went this way and that went that way when I was going through it myself.
So talk to us a little bit about that, how once you started to get into that
realm of the cognitive progression during recovery, all that kind of stuff,
how you related that back to your own experience and, you know,
(07:11):
really grew to love this topic.
I don't think that I ever had like the rigor, honestly, of like sports rehab
that I needed to like play the elite level basketball that I wanted to.
And but I was provided at the time, you know, and so I think that really stuck
with me throughout my education.
(07:32):
And I always felt like something was missing, but I didn't know what.
Like I as an athlete, I always felt like my mind was always ahead of where my
body could be. and like always constantly saying to myself, I could do this before.
Why can't I do it now? Like I'm lifting weights, I'm running,
I'm doing all of the things.
I never struggled with like psychological readiness, but I think,
(07:53):
I think the gap was honestly a lot of this nervous system research that's coming out now.
So I experienced that as athlete. And so I think I was not as resistant as a
clinician to like, just try.
I think a lot of the times you figure out what works well for you and you're
(08:15):
like, Hey, my athletes get like strong.
They get their full range of motion back. They get back to sport and you get
used to a routine and it's more difficult to change that routine.
And so then we come in and we're like, Hey, add dual tasks into your ortho rehab.
And it sort of shakes things up a little bit, but I think overall,
I've always been somebody that I just try to like find the gap in something.
(08:39):
And for me, I felt it. And so I never intervened on myself with this stuff,
but I did with my athletes and I saw immediate changes.
So anecdotally, that was enough for me. You said something pretty interesting
when you were going through it yourself.
You said that your mind was really ahead of your body. And I'm sure you've I've
(09:00):
seen patients that are similar, but also the complete opposite.
You've had patients that you swear up and down, they're ready to go back and
they say, I don't know what to tell you. I'm just not ready.
Something's going on, whether it's a fear, whether it's something in the nervous system.
I don't know. And that's why we're here to see if we can pick your brain on.
But I find it fascinating that there's just such a wide variety of those cases.
(09:23):
You can have an ACL reconstruction, but they can present at six,
nine months, two very different ways, similar to how you were.
And then, like I said, the opposite where your brain almost seems behind.
So knowing there is that wide variety and knowing this is one of your specialties,
what does the current literature say?
You mentioned gaps and things. And is there a general consensus as to what the
(09:44):
literature is saying as it relates to the central nervous system and the role
it has specifically with ACL reconstruction? Yeah.
Yeah, that's a loaded question. So in general... You got five minutes, go.
There's a lot that goes into central nervous system plasticity, right?
Like I study whole brain using brain MRI and specifically my specialty area
(10:06):
is cognition and attention.
But there's a lot of factors that
go into play of like how somebody might compensate at a whole brain level.
And it could start with arthrogenic muscle inhibition.
So we know from a very early phase in recovery that inhibition of your quad
(10:30):
leads to alterations in gait mechanics.
If that persists for a long time, that's going to instill a different motor
pattern than you had before.
And so I think what's really challenging,
honestly, about studying the central nervous system is there's so many factors
that compound together over the course of nine months that I can't say like
(10:51):
this is like only because of the injury.
It's the injury, surgery, and then all of these other factors and the setbacks
that we know so well as clinicians, you know, as patients that then compound
into this whole brain change right at the time of return to sport.
And so something that I think we're still trying to figure out, honestly,
(11:13):
is like, what does regular exercise do to that research is being done right
now by like Greg Myers group at Emory in partnership with Ohio University and
Dustin Grooms, just from like an injury prevention training perspective.
Perspective, what happens to the whole brain after these prevention programs,
all the way to, we still don't know necessarily.
(11:34):
Like, okay, if I implement this perfect dual-task training program.
Does it have the same impact or does it compound impact for a better benefit
compared to standard training?
I think we theorize a lot of things, but that's like the direction that the
research is headed, in my opinion. Yeah.
Let's dig into the actual study that brought us here tonight,
(11:56):
your study in JOSPT that was recently published that talks a lot about visual
cognitive progression during recovery from ACL reconstruction.
I'll be honest with you, as a bone doctor like myself who doesn't know what
lots of these big words meant,
it was a lot of flashbacks to my neurophysiology training way back in medical
(12:17):
school about 8,000 years ago when I was a medical student.
And it was an interesting read, but it It was a tall order for me to read this
paper and try to make heads or tails of this.
So I'm just interested in explaining those concepts to somebody like me who
used to think about this stuff back when I absolutely had to,
but doesn't necessarily think about it on an everyday basis.
(12:39):
Kind of dig in on some of those concepts.
The first one we had down here on our little outline was cross-modal brain regions
being affected following musculoskeletal injury, specifically in the ACL.
Let's ask a simple, what the hell does that mean?
I love that. These are my favorite brain regions.
And they're not usually talked about like when you learn neuroanatomy, right?
(13:01):
You learn like frontal cortex, working memory, primary motor cortex,
parietal cortex, sensory.
And so you learn everything just like ortho in physical therapy.
You learn everything very segmented
and it's rare that you learn learn how everything comes together.
And so cross-modal brain regions are situated basically at the anatomical junctions
(13:25):
of all of these like primary motor sensory regions.
And essentially what they do is they try to map together multiple sensations.
So the ones after ACL injury that are are most impacted are those that map together
proprioception and vision to then produce quality and accurate motor control.
(13:49):
Now, your cerebellum and your basal ganglia are also impacted,
and they also help do that.
But this cross-modal plasticity or increased activation in cross-modal regions
is not specific to ACL injury.
It actually occurs in individuals who have severe visual impairment,
(14:10):
sensory neural hearing loss, aging, like the list goes on.
And the similarity between
all of these regions is that they're highly
connected or related to attention and so
attention is super powerful i can choose to attend to something and i can choose
(14:31):
to actively ignore other things and attention regulates these regions so that's
why dual tasking we think can be used to help sort of modulate what's going on.
So these regions, this comes from some of Dustin's work that they're working
on now, they're not necessarily increased until later on in rehab.
(14:57):
So sort of the shift in brain activity goes from like being prefrontal cortex
or working memory driven, you have increased activation in cognitive processing
regions, all the way to cross-modal plasticity at end-stage rehab.
And that's tough. That means that this is probably like a really ingrained pattern by that time.
(15:19):
I really thought it was interesting when you gave the analogy in the paper about
a corner kick, about how there are kind of two different ways of looking at
the reactions and the kind of athletic participation things that you actually
have to do when you're actually playing sports.
You know, we spend a lot lot of time talking about getting your range of
motion back getting your strength back doing things in the weight room doing
(15:39):
things in the training room but obviously then you're trying to take
that and put it into into into practice on the
field in which you have to respond to a lot of different stimuli and a lot of
different external factors that aren't really related directly to any of those
things that we really focus on from a rehab perspective one part of the paper
where you talked about when there's a corner kick if you're a striker in the
(16:01):
down in the scoring zone,
you're thinking about, all right, when this ball gets in the air,
who am I going to have to react to?
Where's the ball going to be? What am I going to have to jump?
What am I going to have to do? And you're thinking about that and planning for it before it happens.
And then somebody else who's maybe two or three players down from you is just
reacting to what, what is happening.
Maybe the ball goes in the air and that first person goes and does what they plan on doing.
(16:24):
Then the ball ricochets towards them. And all of a sudden something unexpected expect that happens.
And there's a whole different region of the brain, a whole different neuropathway
that's involved in that reactionary period and how to link those together.
I thought that was pretty fascinating.
So as we relate that now to ACL rehab, you know, how do we integrate concepts like that?
And how does that play in specifically to ACL rehab? And how does it differ early versus late?
(16:49):
I think, honestly, it goes straight into our interventions.
So which was like the whole purpose of the paper was I was very passionate about providing clinicians,
hopefully an easy resource that had like a flow to follow of how do I implement
dual tasks progressively with the exception of I've seen a lot just on social media,
(17:15):
even about just like you can implement any dual task.
You can't because every dual
task the way that you implement it is going to have a different like
neural source let's say so like
if i implement just a divided attention task like serial seven subtraction that's
working memory that's like primarily prefrontal cortex that's not going to target
(17:38):
these cross-modal brain regions necessarily so that's what like the purpose
of this framework work is,
is to, like, ground these interventions in neurophysiology and appropriate progression.
So it starts with divided attention, where...
(17:58):
You are just basically following direction or you're doing two things at once.
So I can't remember exactly what we say in the paper, but a simple example of
this that I show videos of a lot is like if you're going to do like a three-way lunge to cones,
you might have three different colored cones out and then you might have a light
(18:20):
or a PowerPoint screen on your computer that flashes the colors,
and now the patient just lunges to the cone that matches the color.
That's very different than just
like the patient self-selecting their own exercise or their own direction.
And so that just starts at a very basic level to introduce, to then imply motor control,
(18:47):
which is what's needed in sport, all the way up to like the high chaos level,
which is like the highest one where you're actually trying to do what you described,
like you might have physical perturbation plus responding to,
you know, a visual stimuli.
And that's what sport is. That's what the corner kick situation is.
And so I think our overall, we're trying to advocate for integrating this early,
(19:12):
which is also why we use the examples of like quad sets and straight leg raises
and very early interventions because this likely sets in very early.
And so it's important that we intervene early.
And that's sort of a side, that's sort of a side tangent. I don't know how you want to go down there.
(19:33):
Well, but before we get too far into the progression, my surface level question
is when you, I have two questions.
First one is when you're attacking this, are you under the impression that you're
preventing decline? decline or are you treating a deficit or both?
Or does it depend? So,
I am working to almost mitigate the compensation that could set in neurologically
(20:01):
or that will set in by just like concentrating on movement.
And so I think that's also like a huge myth buster is like in sports performance,
you hear like, I'm going to improve neurocognitive processing with whatever intervention.
I don't think by doing a dual task with math, I'm going to make you better on
the soccer pitch per se neurocognitively. But what I do think is I can use that
(20:24):
intervention to dissociate cognitive processing and motor control.
Because what we see is that those two things come together.
They like for very simple knee movement, you're engaged in these cognitive and
visual regions that when you return to sport, they have to be scanning your
environment, making decisions.
They can't help you maintain neuromuscular control of your joint.
(20:46):
And so by implementing these early on, my goal is to mitigate that neural compensation.
Now, take this with a grain of salt because I'm very orthopedics-based here
and not central nervous system-based.
But when you're talking general orthopedics, if somebody's weak,
you strength test. And if somebody feels loose, you do a Lachman.
(21:06):
There's always these tests you treat. And then for the strength example,
you can retest. And so you're able to measure how effective was my intervention
of strength because I can just easily measure their strength again to see what's working.
So with this type of treatment, when you're doing more visual cognitive things,
first question is, how do you assess initially that somebody needs this?
(21:29):
And is there any type of retesting them to see, hey, is what we're doing helping
what we're trying to accomplish? Sure.
That's a good question. And I think you've identified maybe another gap that
we need more research on.
And I think we're trying to figure that out. So there's a good body of literature
that's now supporting that if somebody scores lower on like a computerized assessment
(21:53):
of neurocognitive function, like an impact test,
then like a healthy person that's never been injured, they might have like an
at-risk neural profile or a biomechanical profile file for ACL injury.
And so that literature is there.
I don't know if I would put my eggs in that basket.
(22:15):
I would actually put my eggs in more of like the functional dual task basket.
So this work, the one study that I'm thinking of right now off the top of my
head was done by Dave Sherman and Grant Norte.
And what they did is they measured EEG and they had individuals after ACL reconstruction
(22:37):
kick to like a soccer player paradigm.
And it was a go, no-go task where you had to kick based off of what side the soccer ball was on.
But then also if it was like a teammate or an opponent journey or jersey,
you kicked versus you didn't have to kick.
And what's interesting about ACL individuals is that when they do this response
(22:59):
inhibition task, they have the same exact reaction time, but they make more
errors, cognitive errors.
So in order to preserve physical performance, which in this case was reaction
time, they committed more errors, which isn't good when you think about,
okay, this person's returning to sport, right?
They're just like willing to give up cognitive accuracy for performance.
(23:22):
And I think that's sort of what we're doing when we put our people back into the field of play.
So I would err more towards using dual task assessments.
And you can calculate what we call like a dual task effect or dual task cost,
which just means you take the change in performance between doing the normal
(23:42):
task and something with a dual task and seeing how much does performance drop.
In our preliminary data, it should be about less than 10% in almost every one
of our assessments that we've done it in so far, a healthy person.
Our ACL individuals, it's between like 10 to 20% deficit sometimes that we see
(24:03):
when we dual task them. We actually had a COPR case.
She, on our dual task hop test, she only had like a 9% deficit on her COPR classification visit.
She went through nine months of pretty standard rehab that was like focused on strength training.
She passes basically every return to sport outcome, psychological readiness,
(24:27):
strength, all of the traditional hops.
And at the time of return to of sport, her final assessment,
the one thing she didn't pass was her dual task hop.
And now she had a 20% performance drop on her involved limb when dual tasked.
So that's what I would do.
So now you're talking about these tests and you recognize deficits or even just
(24:48):
trying to prevent further decline of this.
You mentioned in your paper, the visual cognitive control chaos continuum.
Can you describe what that is and how that progression or what that progression
looks like, especially as it pertains to patients following ACL reconstruction?
So the goal of this is to just progress from your regular activity or exercise
(25:12):
or intervention that you're doing in high eye control across four graded stages
of dual task progression.
And so moderate control, and this goes from moderate control being phase two
is just like a divided attention task, and then switching into visual selective attention,
(25:34):
which is really the cognitive process that you're engaging a lot in, in sport.
These processes, like they occur together, But I think...
The progressive nature of the dual task is important.
And so the goal is similar to motor learning.
We tend to categorize people into motor learning categories,
(25:57):
like you're in the cognitive phase of learning or the autonomous phase of learning.
The goal of this continuum is that like in any one rehab session,
you might use four to, you might use all five of these phases depending on stage
of recovery and what challenge that patient needs.
(26:18):
And so let's say all of your table type exercises,
you have progressed to moderate or high chaos, but now you're starting to introduce
maybe, I don't know, like an isometric lunge or something like that.
And it's the first time the patient has done it.
You would start back down at high control for that, but you might only need,
(26:38):
if they understand the goal of the task and they're able to complete it with
like little cueing, then in order to take away cognitive compensation,
you might go up to moderate control where you just have them repeat back a Stroop
test or a Flanker task to you while they do it.
And so the goal is that this is like very flexible based off of the standard
(27:00):
of care that you're already providing.
Now with the standard care that you're already providing and whatever your frequency
and duration may be for that particular stage, how do you integrate this type
of therapy into that standard of care?
Is this something you're doing every single time you see the athlete or patient?
And when it comes to exercises at home, do you even mess with this when it comes
(27:26):
to the home exercise program, or do you just do that in the clinic?
I think it depends on your goal. So I'll be the first to say that if you don't
get range of motion back and you don't get strength back, like those two things are more important.
Thank you for that. Agreed. And we have like we have neural data that shows
like these changes are more pronounced when you don't recover strength as quickly.
(27:52):
And so those things matter.
And I think, yeah, I'm very cautious of that. do the basics well,
and then this augments what you're doing.
I don't mean to cut you off, but I couldn't agree more.
I think, unfortunately, when I hear people talk about these topics,
it's as if we're trying to figure out which one can negate the other,
rather than trying to figure out how can these complement each other?
(28:14):
How can we do the right things in this realm?
But when we're doing the right things there, don't forget about this.
And to me, that's where the biggest gap is. And honestly, why we were anxious
to talk to you is because I think at Shelbourne E-Center, I think we do a tremendous
job at the first two months of rehabilitation and that our patients look so good at two months,
full extension, nearly full flexion,
(28:37):
approaching symmetry on strength.
And then what do we do from month two to month four or five?
And we're starting to talk about letting people go back to sport.
When I think about early rehab.
A lot of the times, right, people are using NMES and like other modalities and such.
And I always say that like, if I'm using NMES and I'm using the approach where
like I'm having my patient contract with it, or even if I guess if you're using it passively,
(29:01):
like they don't have to think about contracting that, right?
They already have the cue to contract.
So like, it does me no good to stare at my quad and like do that more when I
can, I can easily put on a dual task for that.
That's why like post-op week one easily implementable while
you're on the table and because i would
(29:23):
argue that like physiologically they're still
being underdosed like in early rehab and that's
why late strength training is so hard to like
if you don't get it early right it's just like harder as you go and
so i think this comes in handy
honestly even in cases where you're being
(29:44):
being underdosed or I always say when like
physiologically they like aren't ready to progress
or go to the next level it's like not let's
keep doing the same thing or let's just like keep adding weight if I'm already
strong how else can I challenge the body to prepare it for what it needs to
return to and that's this and so I mean that's that's my take is it's always
(30:09):
been and always will be an adjunct to therapy,
not like the solution on its own.
But I think a lot of therapists underdose exercise.
And so if you're already chronically underdosing and then you allow people to
compensate neurologically with cognition, that to me is just like a disaster when we get on -field.
(30:36):
And so I think that's where this can come into play.
So I kind of hijacked Scott's question there. I think, you know,
to spin what I said back into that, that integration of those kind of traditional
rehab philosophies with.
The kind of neurocognitive training that you're talking about,
how do you implement that and integrate that into your session?
And especially when it comes to a home exercise program, we do a lot,
(30:59):
we do a lot at Shelbourne eCenter on trying to minimize the amount of times
we have to have the patients come to the office and then only come into the office.
Only if you absolutely have something that we need to do, do we need to do testing?
Do we need to make measurements? Do we need to start a progression?
Do we need to teach you a new concept? And if not, we don't need to bring you to the office.
So as someone like us that are trying to minimize visits, that's one of the
(31:20):
things that I've always wondered is when you're doing things like this,
how do you integrate that into a more minimalist type of program as part of
a home exercise program, et cetera?
That's where the minimal technology in this paper probably works out really well for you guys.
Because nowadays, everybody's got a tablet, smartphone, or computer.
You can make a a pre-timed PowerPoint, pre-timed slides, and you know within
(31:45):
that PowerPoint that you create for somebody how many repetitions are congruent
versus incongruent or like even odd.
So you know about the dose based off of this dual task that you're providing
them that they should be able to do or that they will be doing when they watch
that for that specific exercise.
So I would create a library of PowerPoint for starters.
(32:10):
Other tools that you can use.
I don't know. I am not supported by Switched On at all, but I really like their
app and it's super useful.
There's a subscription, but there's also like a free version and it just has
dual tasks literally programmed into your phone for things that you already do in rehab.
(32:35):
And so that is like super useful, I think.
So I think it also depends on phase of rehab and what your training goal is.
So like if your session for the day, if you're like, this is hypertrophy,
like I'm lifting at 80%, my one rep max.
(32:57):
I do not expect a high chaos intervention to be applied on top of that.
I think we need to respect performance and...
Integrate it appropriately, but also understanding that when we participate
in sport, we operate at like a pretty sub max load with births of max effort.
(33:19):
So anything that is honestly like sub max for that person based on like what
they're doing at that time, you could probably apply this.
Now, how about the really late stage? And we're talking like the graded functional
progression as, let's say, a soccer player starts to get back into varsity soccer.
They're either working with you or they're working with their athletic trainer
that you're in contact with.
(33:40):
Is it your hope that what you've gone through the previous months to work on
these things has done its job to the point where they're ready for that?
Are you still having them do some of these visual cognitive tasks,
even when they're 100% doing some type of footwork drill or something of that nature?
I think this actually significantly helps the transition to on-field because
(34:06):
most people who are doing the on-field rehab are already doing a sport-specific version of this.
And they're using colors, different colored soccer balls to simulate like response
inhibition and stuff during like small-sided games or constrained practice sort of drill scenarios.
Scenarios and so if you do this
thing earlier they already understand the concepts
(34:29):
that you're trying to integrate later on those high level drills and so honestly
the organization that does this really well is isokinetic i watched some awesome
on-field rehab when i was in italy this past spring and they are like seamlessly
integrating these concepts.
(34:49):
So I think it overall augments both from like the athlete, but also like the therapist.
I don't know if you, do you guys have different people who like do early versus
late stage therapy for you?
Is it like one therapist that would like take everybody through it?
We, no, we don't. We are a very monogamous office.
(35:09):
When Scott becomes your therapist, Scott is your therapist until the end of time.
And no, but, and it's, it's funny. And I'll give our therapist a little bit
of a hard time that if Scott used to, when Scott was doing PT,
if one of our other therapists would see him, I don't even know this person,
what's going on with them. What's their emotion?
Like, what's their strength? Like, what have they been doing?
What sports are they doing?
And I'm like, you know, sometimes I would give them a hard time.
(35:29):
Like, you know, it's going to be okay.
Like, I know you're seeing somebody that you don't see every single time,
but we'll, we'll get through this together, you know?
So no, we don't have people that are focused on early stage versus late stage.
We have one of the real kind of bedrock principles of how we run our offices.
You may have me or Dr. Shelbourne as your doctor, but your therapist is really
(35:51):
the person that has even more of a primary connection with you on a regular
basis. They're your therapist forever.
They see you when you come for your initial visit. They take you back to the
room. They get your x-rays. They get your history.
They enter all your information, do your documentation. They present it to me.
We go in, see the patient together.
They immediately start rehab with the therapist. if they want to call about
(36:11):
their MRI results, if they want to see when they're going to have their next
appointment, why does my incision look like this after surgery?
Where should I be at rehab? The therapist is their primary connection to the office.
So no, it's a completely different way of looking at it.
And we like that personal connection part of it, but we're always trying to
get better on how we can make those concepts better.
(36:34):
So they're really taking them through the entirety of the process.
I think with that sort of model, something like this would be easier then because you have control,
right, about how you want to and you know exactly what you've done throughout
that versus like going from provider at early care who has their way of implementing
(36:55):
these things to, okay, now strength and conditioning on field.
Meredith told me I was going to do this. Scott, you're telling me I need to
do this? Yeah. She told me that.
Yeah. No, exactly. I think it would be.
I agree with you. I think it would, you know, if we were to find something that
this would kind of work with our patients, it would be not as much of a challenge
(37:16):
to implement because it is the same therapist and you're carrying it through the initial concepts.
Remember, we talked about this back at the two-week visit that eventually we're
going to be doing this for this reason.
That's why we laid the groundwork at two weeks doing this to be able to do this.
I think the biggest thing that would be maybe challenging in that is I would
see that it would be easy to fall into the motor learning model because it would be easy to say, well,
(37:42):
like, we're just going to do this group of exercises and then progress them
like one stage at a time together.
And that sort of defeats the purpose of like providing variability.
Like we talked about in the paper, like you need error.
Enter an interview with Meredith. That's why we're talking to you tonight,
just to learn about this kind of stuff is for that specific reason.
(38:03):
I think this is something we could get, we could specifically get better at
with our, with our patients.
Yeah. You need air to learn. And I think we, as therapists try so hard to like
put people in this like box of perfect and it's out of like our best heart because
we just want them to do so well.
But it's like, I need you to mess up.
I need you to like, not be perfect. And if you are perfect, then I'm not challenging you enough.
(38:28):
And so that's where I can do something like this to make it more challenging.
We see in our hop tests, this is a fun fact, we just tested a girl today,
that single leg hop, nailed them. Triple hop, nailed them.
Cognitive dual task, hop. On her uninjured limb, she had two physical misses,
(38:49):
but on her injured leg, she had six.
She had a decent deficit in hop distance, but it took her eight tries to get three good trials.
Like, that's important information that should get documented, right?
So, like, she's hopping the same distance, but she's not able to do it in the
(39:11):
same way or at the same quality because it takes her so many different tries to do it.
We definitely see patients like that all the time where they've tested on the
isokinetic testing dead on.
They test on their leg press dead on they have great
range of motion they have no swelling they try to hop and land and
they just can't do it and vice versa that that people
that are you know 30 percent strength deficit on
(39:32):
quads 30 percent straight deficit on overall and we're thinking gosh they're
just forever for coming back and then they hop and stick it like what that was
nothing i'm ready to go play sports well hell i guess yeah go ahead and play
i guess i don't you know they're they're they're the all these things have to
fit together and but they're but and we try to to fit them together,
that as your strength improves.
As your motion improves, as your swelling goes down, as your confidence builds,
(39:55):
then that hop and landing and the more functional things will come along.
And the vast majority of patients, that's the case. But there is a patient every
once in a while, like, I don't know why the hell this is happening this way.
But, you know, she says that she is practicing every day. She gets no swelling.
She doesn't hurt. She feels normal.
And her strength is a 30% deficit when we do the objective testing.
(40:16):
We don't really know why. So, you know, and then that leads into kind of the
last question I think we have for you.
We've talked a lot about what things you've integrated so far into your practice,
what we've learned so far.
Where's this headed in the future and what do you think the next 10,
20 years looks like with all these concepts?
That's a good question. I think we're just now like dipping our toes into the
(40:41):
world of dual task and there's a lot more to come.
There's a lot more on what is the brain actually doing during dual tasks, right?
And are these different between patient populations, greater difficulties in dual tasks, right?
How do I, a big challenge that I get or that I see is like, how do I know I'm
(41:04):
challenging somebody to the appropriate level of dual task difficulty?
We need to figure out better ways to approach that problem.
And then I think the biggest question is like, we need clinical trials that
say like, okay, if I implement this, what actually happens, right?
Is there a reduced second injury risk?
That's obviously like the big thing. Is there their higher return to sport rates,
(41:27):
because they reduce second entry risk.
And so, I mean, we did the same hop tests and whatever for 30 some odd years.
So hopefully we can get to that a little bit faster here.
But that's where I think this is going to head. And there's a lot of good direction.
Yeah, I'm hopeful for and excited to hear all this.
(41:48):
You know, we just bring it back to the clinical context, Ronnie,
we always, we see these patients at, you know, nine months and.
We see, just to give you a quick background, Meredith, we see patients back
for research at one year and two years after an ACL reconstruction.
So we get a chance to talk to these patients afterwards. And,
you know, we get to talk to them and say, hey, how was your football season?
How was your soccer season? They say, oh, yeah, I played, but I sucked.
(42:09):
You know, I was just, I wasn't good. I wasn't as fast as I used to be.
And we always just say, oh, you know, it's just first year back after an ACL
reconstruction can be hard.
They were testing off the charts well. It's just, hey, it's one of those things
where the second season is going to be better than the first.
And, you know, when I read this paper, I was thinking about that scenario a
lot and just wonder, you know, what was the, was everything just happening too
(42:30):
fast in terms of the game around them was too fast because the processing was down.
And I read this and I thought, well, you know, what, what are these,
the patients that you see that put an emphasis on this visual cognitive theory,
and if they're able to almost process the sport and have better performance when they get back.
So it's, it's, it's, it's interesting stuff. It's fascinating stuff.
And like I said, I'm excited to hear what you guys are up to next with this. That's fascinating.
(42:54):
Actually, that's a fascinating observation because you always have this like
speed accuracy tradeoff of cognition, physical performance.
And so the goal is like to perform both of those really high, right? In sport.
But like if somebody has a cognitive compensation, right, maybe they feel like
they're not as fast because they have to slow down the physical side of things
(43:17):
so that they can keep up cognitively because they have that compensation. Ligamentization.
So maybe what they're describing to you is like the physiologic phenomenon that
we're trying to get out with research. Yeah.
That's one of those classic, it's seeing you, but I'm not seeing it.
You know, it's just, like you say, we chalk it up to,
you know, ligamentization hasn't taken place yet, or just the fact that you've
(43:38):
been out of your sport for X amount of months, but, you know,
talking about this and looking at this visual cognitive theories makes that,
makes that process a little more interesting. Yeah.
Well, thanks again for joining us tonight, Meredith. We really enjoyed this
discussion as we kind of put a bow on this at the end.
What do you think are some kind of take-home points and final thoughts before
we leave our listeners tonight?
(43:58):
The big one is do the basics well. You have to get range of motion and strength back.
And then these adjuncts are just that. They're additive ways that you can challenge your patients.
And it should start very early in rehab. we can't
wait until end stage of rehab to start implementing
these because likely the compensation has already
(44:20):
set in all right merida thanks again for for joining us and we'll make sure
to look you up next time we're at a meeting and discuss this some more absolutely
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(44:43):
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Music.
Music.
(00:12):
This is Dr. Benner, and I'm here with our co-host, Scott Bauman,
again tonight for another episode of the Shelburne East Center Podcast.
If you want to see us on social media, you can find us on Instagram and Twitter at the SKC Podcast.
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Our last episode, episode 45, we had Hassan Gomraoui from the University of
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And that was a really interesting discussion, a little bit about health policy
(00:55):
and health economics in that one. So make sure to go check that one out and
all of our previous content.
Tonight, we have another great episode. We have a great guest.
We have Meredith Chaput from the University of Central Florida.
She's a physical therapist and a pretty remarkable educational background,
and we're going to discuss with her the visual cognitive progression during
recovery from ACL reconstruction, specifically a recent paper that she had published
(01:18):
in JOSPT earlier this year.
Meredith is, like I said, a physical therapist and PhD researcher.
She got her DPT from Creighton, went on from there and did a sports residency
at Vanderbilt Orthopedics in Nashville, as well as Belmont University.
She is SCS certified. from there she went
and got her PhD in translational biomedical science from Ohio
University and she's currently involved in the
(01:38):
APTA specifically the educational lead for the sports
performance SIG through the APTA and her current position
is assistant professor of PT in the School of Kinesiology and Rehabilitation
Science at the University of Central Florida and specifically her research is
involved with compensatory nervous system plasticity after lower extremity musculoskeletal
injury which is really what we're
(01:59):
looking to talk with her about today and obviously being an e-podcast,
this is specific to the ACL and post-op after ACL reconstruction.
So we want to get all the details about this specific topic and we will eventually
hit the paper that she wrote in JOSPT as well.
So before we get started, Meredith, thanks for joining us on the podcast.
Thanks for having me. I'm really excited for the discussion today.
(02:22):
So before we get started, Meredith, if you could just kind of introduce yourself.
I know we gave you more of the educational background, but just tell us a little
bit about yourself and your path and how you got into PT and specifically orthopedics.
Yeah. So I am originally from Minnesota. I did my undergraduate at the University
of Minnesota, Duluth in exercise science.
And before I got there, I was actually college basketball hopeful.
(02:48):
Studying elementary education.
And I wanted to be a basketball coach and elementary educator.
And then I had a history of three knee surgeries and a broken leg that led me
into a lot of physical therapy and decided not to play basketball anymore.
And my mom actually convinced me to try physical therapy.
(03:12):
She was like, you've been through enough of it. Don't you think you would be good at helping people?
And I was like, well, maybe, but it's kind of boring is what I thought.
I didn't like my physical therapy I went through.
And then she was like, why don't you just say you You didn't like your physical therapist.
No, Dave was great. Dave and Big Stone Therapy is awesome.
(03:34):
But she was really the one that sort of inspired me to like go for it.
And then once I actually switched my major from elementary education to exercise
science, I really realized like, oh, I love exercise and I love physiology,
learning about it and working with people.
And so it was through my own experiences and then through my mom's help and
(03:55):
education that That sort of pushed me down the road of PT, specifically ortho.
Now, once you got into PT school and figured out that was going to be your career,
you know, now that you're in orthopedics, and I went to physical therapy school
as well, so I know that you're going to go through two different tracks.
There's the neuro track and there's the orthopedic track. And if you're anything
like me, you are not a fan of the nervous system. But obviously,
(04:16):
that's what you're doing now.
You've kind of mixed the two, which is, I wouldn't say it's the most common
thing in physical therapy, especially orthopedics.
Everything is usually joint specific. And that's why I find your research so fascinating.
And we chatted before we got online. I've heard you speak at many conferences
and followed you on Twitter and things.
And one of your co-authors is Dustin Grooms.
And I know he's big into the nervous system as it relates to post-op ACL as
(04:39):
well. So I really find this stuff fascinating.
But we talked about your path into PT and orthopedics. What got you interested
in this specific realm of PT in that it's dealing with the nervous system?
Yeah. Yeah, I actually at Creighton, I was mentored by Terry Grindstaff and
he is a sports physical therapist.
But one of the best pieces of advice he gave me actually as a curious student,
(05:03):
I told him I wanted to be a PT in the NFL.
And his advice to me as I picked my clinicals was, well, do a neuro rotation. Okay.
Don't shy away from doing an outpatient neural rotation. And I didn't really
understand like the, the reason why behind that until I was on my rotation and
(05:25):
I would just have discussions with him.
And I realized like, oh, everything in ortho comes back to the nervous system.
And so from a, I would say like an early part in my education with him,
we were able to have pretty in-depth conversations.
And I was able to ask pretty in-depth questions to him about like the neurophysiologic
(05:45):
differences after knee injury.
And it all sort of started with arthrogenic muscle inhibition.
And then it expanded out from there. And then it wasn't until I was in residency
that I found Dustin Grooms' research.
And so it was like one of his first clinical commentaries in JOSBT on visual perturbation.
(06:06):
And it was the first time I really read anything about sensory reweighting.
I read it. I immediately started implementing with my patients and just sort
of like using them as my research subjects, right, for this.
And I saw like an immediate anecdotal change.
And it started with actually like psychological readiness and like just willingness
to participate in activity that they might have shied away from before.
(06:31):
And then I ended up down the neuro rabbit hole for good. And that's how I ended up with him for my PhD.
You mentioned your own experience having knee injuries and multiple lower extremity surgeries,
once you started to learn about that, it had to be an interesting Pandora's
box to open and it had to all of a sudden, I can imagine, take you back to the
(06:51):
time when you were going through that and think, well, wow, I never really thought
about this and all these things that I'm reading about.
Maybe that's why this went this way and that went that way when I was going through it myself.
So talk to us a little bit about that, how once you started to get into that
realm of the cognitive progression during recovery, all that kind of stuff,
how you related that back to your own experience and, you know,
(07:11):
really grew to love this topic.
I don't think that I ever had like the rigor, honestly, of like sports rehab
that I needed to like play the elite level basketball that I wanted to.
And but I was provided at the time, you know, and so I think that really stuck
with me throughout my education.
(07:32):
And I always felt like something was missing, but I didn't know what.
Like I as an athlete, I always felt like my mind was always ahead of where my
body could be. and like always constantly saying to myself, I could do this before.
Why can't I do it now? Like I'm lifting weights, I'm running,
I'm doing all of the things.
I never struggled with like psychological readiness, but I think,
(07:53):
I think the gap was honestly a lot of this nervous system research that's coming out now.
So I experienced that as athlete. And so I think I was not as resistant as a
clinician to like, just try.
I think a lot of the times you figure out what works well for you and you're
(08:15):
like, Hey, my athletes get like strong.
They get their full range of motion back. They get back to sport and you get
used to a routine and it's more difficult to change that routine.
And so then we come in and we're like, Hey, add dual tasks into your ortho rehab.
And it sort of shakes things up a little bit, but I think overall,
I've always been somebody that I just try to like find the gap in something.
(08:39):
And for me, I felt it. And so I never intervened on myself with this stuff,
but I did with my athletes and I saw immediate changes.
So anecdotally, that was enough for me. You said something pretty interesting
when you were going through it yourself.
You said that your mind was really ahead of your body. And I'm sure you've I've
(09:00):
seen patients that are similar, but also the complete opposite.
You've had patients that you swear up and down, they're ready to go back and
they say, I don't know what to tell you. I'm just not ready.
Something's going on, whether it's a fear, whether it's something in the nervous system.
I don't know. And that's why we're here to see if we can pick your brain on.
But I find it fascinating that there's just such a wide variety of those cases.
(09:23):
You can have an ACL reconstruction, but they can present at six,
nine months, two very different ways, similar to how you were.
And then, like I said, the opposite where your brain almost seems behind.
So knowing there is that wide variety and knowing this is one of your specialties,
what does the current literature say?
You mentioned gaps and things. And is there a general consensus as to what the
(09:44):
literature is saying as it relates to the central nervous system and the role
it has specifically with ACL reconstruction? Yeah.
Yeah, that's a loaded question. So in general... You got five minutes, go.
There's a lot that goes into central nervous system plasticity, right?
Like I study whole brain using brain MRI and specifically my specialty area
(10:06):
is cognition and attention.
But there's a lot of factors that
go into play of like how somebody might compensate at a whole brain level.
And it could start with arthrogenic muscle inhibition.
So we know from a very early phase in recovery that inhibition of your quad
(10:30):
leads to alterations in gait mechanics.
If that persists for a long time, that's going to instill a different motor
pattern than you had before.
And so I think what's really challenging,
honestly, about studying the central nervous system is there's so many factors
that compound together over the course of nine months that I can't say like
(10:51):
this is like only because of the injury.
It's the injury, surgery, and then all of these other factors and the setbacks
that we know so well as clinicians, you know, as patients that then compound
into this whole brain change right at the time of return to sport.
And so something that I think we're still trying to figure out, honestly,
(11:13):
is like, what does regular exercise do to that research is being done right
now by like Greg Myers group at Emory in partnership with Ohio University and
Dustin Grooms, just from like an injury prevention training perspective.
Perspective, what happens to the whole brain after these prevention programs,
all the way to, we still don't know necessarily.
(11:34):
Like, okay, if I implement this perfect dual-task training program.
Does it have the same impact or does it compound impact for a better benefit
compared to standard training?
I think we theorize a lot of things, but that's like the direction that the
research is headed, in my opinion. Yeah.
Let's dig into the actual study that brought us here tonight,
(11:56):
your study in JOSPT that was recently published that talks a lot about visual
cognitive progression during recovery from ACL reconstruction.
I'll be honest with you, as a bone doctor like myself who doesn't know what
lots of these big words meant,
it was a lot of flashbacks to my neurophysiology training way back in medical
(12:17):
school about 8,000 years ago when I was a medical student.
And it was an interesting read, but it It was a tall order for me to read this
paper and try to make heads or tails of this.
So I'm just interested in explaining those concepts to somebody like me who
used to think about this stuff back when I absolutely had to,
but doesn't necessarily think about it on an everyday basis.
(12:39):
Kind of dig in on some of those concepts.
The first one we had down here on our little outline was cross-modal brain regions
being affected following musculoskeletal injury, specifically in the ACL.
Let's ask a simple, what the hell does that mean?
I love that. These are my favorite brain regions.
And they're not usually talked about like when you learn neuroanatomy, right?
(13:01):
You learn like frontal cortex, working memory, primary motor cortex,
parietal cortex, sensory.
And so you learn everything just like ortho in physical therapy.
You learn everything very segmented
and it's rare that you learn learn how everything comes together.
And so cross-modal brain regions are situated basically at the anatomical junctions
(13:25):
of all of these like primary motor sensory regions.
And essentially what they do is they try to map together multiple sensations.
So the ones after ACL injury that are are most impacted are those that map together
proprioception and vision to then produce quality and accurate motor control.
(13:49):
Now, your cerebellum and your basal ganglia are also impacted,
and they also help do that.
But this cross-modal plasticity or increased activation in cross-modal regions
is not specific to ACL injury.
It actually occurs in individuals who have severe visual impairment,
(14:10):
sensory neural hearing loss, aging, like the list goes on.
And the similarity between
all of these regions is that they're highly
connected or related to attention and so
attention is super powerful i can choose to attend to something and i can choose
(14:31):
to actively ignore other things and attention regulates these regions so that's
why dual tasking we think can be used to help sort of modulate what's going on.
So these regions, this comes from some of Dustin's work that they're working
on now, they're not necessarily increased until later on in rehab.
(14:57):
So sort of the shift in brain activity goes from like being prefrontal cortex
or working memory driven, you have increased activation in cognitive processing
regions, all the way to cross-modal plasticity at end-stage rehab.
And that's tough. That means that this is probably like a really ingrained pattern by that time.
(15:19):
I really thought it was interesting when you gave the analogy in the paper about
a corner kick, about how there are kind of two different ways of looking at
the reactions and the kind of athletic participation things that you actually
have to do when you're actually playing sports.
You know, we spend a lot lot of time talking about getting your range of
motion back getting your strength back doing things in the weight room doing
(15:39):
things in the training room but obviously then you're trying to take
that and put it into into into practice on the
field in which you have to respond to a lot of different stimuli and a lot of
different external factors that aren't really related directly to any of those
things that we really focus on from a rehab perspective one part of the paper
where you talked about when there's a corner kick if you're a striker in the
(16:01):
down in the scoring zone,
you're thinking about, all right, when this ball gets in the air,
who am I going to have to react to?
Where's the ball going to be? What am I going to have to jump?
What am I going to have to do? And you're thinking about that and planning for it before it happens.
And then somebody else who's maybe two or three players down from you is just
reacting to what, what is happening.
Maybe the ball goes in the air and that first person goes and does what they plan on doing.
(16:24):
Then the ball ricochets towards them. And all of a sudden something unexpected expect that happens.
And there's a whole different region of the brain, a whole different neuropathway
that's involved in that reactionary period and how to link those together.
I thought that was pretty fascinating.
So as we relate that now to ACL rehab, you know, how do we integrate concepts like that?
And how does that play in specifically to ACL rehab? And how does it differ early versus late?
(16:49):
I think, honestly, it goes straight into our interventions.
So which was like the whole purpose of the paper was I was very passionate about providing clinicians,
hopefully an easy resource that had like a flow to follow of how do I implement
dual tasks progressively with the exception of I've seen a lot just on social media,
(17:15):
even about just like you can implement any dual task.
You can't because every dual
task the way that you implement it is going to have a different like
neural source let's say so like
if i implement just a divided attention task like serial seven subtraction that's
working memory that's like primarily prefrontal cortex that's not going to target
(17:38):
these cross-modal brain regions necessarily so that's what like the purpose
of this framework work is,
is to, like, ground these interventions in neurophysiology and appropriate progression.
So it starts with divided attention, where...
(17:58):
You are just basically following direction or you're doing two things at once.
So I can't remember exactly what we say in the paper, but a simple example of
this that I show videos of a lot is like if you're going to do like a three-way lunge to cones,
you might have three different colored cones out and then you might have a light
(18:20):
or a PowerPoint screen on your computer that flashes the colors,
and now the patient just lunges to the cone that matches the color.
That's very different than just
like the patient self-selecting their own exercise or their own direction.
And so that just starts at a very basic level to introduce, to then imply motor control,
(18:47):
which is what's needed in sport, all the way up to like the high chaos level,
which is like the highest one where you're actually trying to do what you described,
like you might have physical perturbation plus responding to,
you know, a visual stimuli.
And that's what sport is. That's what the corner kick situation is.
And so I think our overall, we're trying to advocate for integrating this early,
(19:12):
which is also why we use the examples of like quad sets and straight leg raises
and very early interventions because this likely sets in very early.
And so it's important that we intervene early.
And that's sort of a side, that's sort of a side tangent. I don't know how you want to go down there.
(19:33):
Well, but before we get too far into the progression, my surface level question
is when you, I have two questions.
First one is when you're attacking this, are you under the impression that you're
preventing decline? decline or are you treating a deficit or both?
Or does it depend? So,
I am working to almost mitigate the compensation that could set in neurologically
(20:01):
or that will set in by just like concentrating on movement.
And so I think that's also like a huge myth buster is like in sports performance,
you hear like, I'm going to improve neurocognitive processing with whatever intervention.
I don't think by doing a dual task with math, I'm going to make you better on
the soccer pitch per se neurocognitively. But what I do think is I can use that
(20:24):
intervention to dissociate cognitive processing and motor control.
Because what we see is that those two things come together.
They like for very simple knee movement, you're engaged in these cognitive and
visual regions that when you return to sport, they have to be scanning your
environment, making decisions.
They can't help you maintain neuromuscular control of your joint.
(20:46):
And so by implementing these early on, my goal is to mitigate that neural compensation.
Now, take this with a grain of salt because I'm very orthopedics-based here
and not central nervous system-based.
But when you're talking general orthopedics, if somebody's weak,
you strength test. And if somebody feels loose, you do a Lachman.
(21:06):
There's always these tests you treat. And then for the strength example,
you can retest. And so you're able to measure how effective was my intervention
of strength because I can just easily measure their strength again to see what's working.
So with this type of treatment, when you're doing more visual cognitive things,
first question is, how do you assess initially that somebody needs this?
(21:29):
And is there any type of retesting them to see, hey, is what we're doing helping
what we're trying to accomplish? Sure.
That's a good question. And I think you've identified maybe another gap that
we need more research on.
And I think we're trying to figure that out. So there's a good body of literature
that's now supporting that if somebody scores lower on like a computerized assessment
(21:53):
of neurocognitive function, like an impact test,
then like a healthy person that's never been injured, they might have like an
at-risk neural profile or a biomechanical profile file for ACL injury.
And so that literature is there.
I don't know if I would put my eggs in that basket.
(22:15):
I would actually put my eggs in more of like the functional dual task basket.
So this work, the one study that I'm thinking of right now off the top of my
head was done by Dave Sherman and Grant Norte.
And what they did is they measured EEG and they had individuals after ACL reconstruction
(22:37):
kick to like a soccer player paradigm.
And it was a go, no-go task where you had to kick based off of what side the soccer ball was on.
But then also if it was like a teammate or an opponent journey or jersey,
you kicked versus you didn't have to kick.
And what's interesting about ACL individuals is that when they do this response
(22:59):
inhibition task, they have the same exact reaction time, but they make more
errors, cognitive errors.
So in order to preserve physical performance, which in this case was reaction
time, they committed more errors, which isn't good when you think about,
okay, this person's returning to sport, right?
They're just like willing to give up cognitive accuracy for performance.
(23:22):
And I think that's sort of what we're doing when we put our people back into the field of play.
So I would err more towards using dual task assessments.
And you can calculate what we call like a dual task effect or dual task cost,
which just means you take the change in performance between doing the normal
(23:42):
task and something with a dual task and seeing how much does performance drop.
In our preliminary data, it should be about less than 10% in almost every one
of our assessments that we've done it in so far, a healthy person.
Our ACL individuals, it's between like 10 to 20% deficit sometimes that we see
(24:03):
when we dual task them. We actually had a COPR case.
She, on our dual task hop test, she only had like a 9% deficit on her COPR classification visit.
She went through nine months of pretty standard rehab that was like focused on strength training.
She passes basically every return to sport outcome, psychological readiness,
(24:27):
strength, all of the traditional hops.
And at the time of return to of sport, her final assessment,
the one thing she didn't pass was her dual task hop.
And now she had a 20% performance drop on her involved limb when dual tasked.
So that's what I would do.
So now you're talking about these tests and you recognize deficits or even just
(24:48):
trying to prevent further decline of this.
You mentioned in your paper, the visual cognitive control chaos continuum.
Can you describe what that is and how that progression or what that progression
looks like, especially as it pertains to patients following ACL reconstruction?
So the goal of this is to just progress from your regular activity or exercise
(25:12):
or intervention that you're doing in high eye control across four graded stages
of dual task progression.
And so moderate control, and this goes from moderate control being phase two
is just like a divided attention task, and then switching into visual selective attention,
(25:34):
which is really the cognitive process that you're engaging a lot in, in sport.
These processes, like they occur together, But I think...
The progressive nature of the dual task is important.
And so the goal is similar to motor learning.
We tend to categorize people into motor learning categories,
(25:57):
like you're in the cognitive phase of learning or the autonomous phase of learning.
The goal of this continuum is that like in any one rehab session,
you might use four to, you might use all five of these phases depending on stage
of recovery and what challenge that patient needs.
(26:18):
And so let's say all of your table type exercises,
you have progressed to moderate or high chaos, but now you're starting to introduce
maybe, I don't know, like an isometric lunge or something like that.
And it's the first time the patient has done it.
You would start back down at high control for that, but you might only need,
(26:38):
if they understand the goal of the task and they're able to complete it with
like little cueing, then in order to take away cognitive compensation,
you might go up to moderate control where you just have them repeat back a Stroop
test or a Flanker task to you while they do it.
And so the goal is that this is like very flexible based off of the standard
(27:00):
of care that you're already providing.
Now with the standard care that you're already providing and whatever your frequency
and duration may be for that particular stage, how do you integrate this type
of therapy into that standard of care?
Is this something you're doing every single time you see the athlete or patient?
And when it comes to exercises at home, do you even mess with this when it comes
(27:26):
to the home exercise program, or do you just do that in the clinic?
I think it depends on your goal. So I'll be the first to say that if you don't
get range of motion back and you don't get strength back, like those two things are more important.
Thank you for that. Agreed. And we have like we have neural data that shows
like these changes are more pronounced when you don't recover strength as quickly.
(27:52):
And so those things matter.
And I think, yeah, I'm very cautious of that. do the basics well,
and then this augments what you're doing.
I don't mean to cut you off, but I couldn't agree more.
I think, unfortunately, when I hear people talk about these topics,
it's as if we're trying to figure out which one can negate the other,
rather than trying to figure out how can these complement each other?
(28:14):
How can we do the right things in this realm?
But when we're doing the right things there, don't forget about this.
And to me, that's where the biggest gap is. And honestly, why we were anxious
to talk to you is because I think at Shelbourne E-Center, I think we do a tremendous
job at the first two months of rehabilitation and that our patients look so good at two months,
full extension, nearly full flexion,
(28:37):
approaching symmetry on strength.
And then what do we do from month two to month four or five?
And we're starting to talk about letting people go back to sport.
When I think about early rehab.
A lot of the times, right, people are using NMES and like other modalities and such.
And I always say that like, if I'm using NMES and I'm using the approach where
like I'm having my patient contract with it, or even if I guess if you're using it passively,
(29:01):
like they don't have to think about contracting that, right?
They already have the cue to contract.
So like, it does me no good to stare at my quad and like do that more when I
can, I can easily put on a dual task for that.
That's why like post-op week one easily implementable while
you're on the table and because i would
(29:23):
argue that like physiologically they're still
being underdosed like in early rehab and that's
why late strength training is so hard to like
if you don't get it early right it's just like harder as you go and
so i think this comes in handy
honestly even in cases where you're being
(29:44):
being underdosed or I always say when like
physiologically they like aren't ready to progress
or go to the next level it's like not let's
keep doing the same thing or let's just like keep adding weight if I'm already
strong how else can I challenge the body to prepare it for what it needs to
return to and that's this and so I mean that's that's my take is it's always
(30:09):
been and always will be an adjunct to therapy,
not like the solution on its own.
But I think a lot of therapists underdose exercise.
And so if you're already chronically underdosing and then you allow people to
compensate neurologically with cognition, that to me is just like a disaster when we get on -field.
(30:36):
And so I think that's where this can come into play.
So I kind of hijacked Scott's question there. I think, you know,
to spin what I said back into that, that integration of those kind of traditional
rehab philosophies with.
The kind of neurocognitive training that you're talking about,
how do you implement that and integrate that into your session?
And especially when it comes to a home exercise program, we do a lot,
(30:59):
we do a lot at Shelbourne eCenter on trying to minimize the amount of times
we have to have the patients come to the office and then only come into the office.
Only if you absolutely have something that we need to do, do we need to do testing?
Do we need to make measurements? Do we need to start a progression?
Do we need to teach you a new concept? And if not, we don't need to bring you to the office.
So as someone like us that are trying to minimize visits, that's one of the
(31:20):
things that I've always wondered is when you're doing things like this,
how do you integrate that into a more minimalist type of program as part of
a home exercise program, et cetera?
That's where the minimal technology in this paper probably works out really well for you guys.
Because nowadays, everybody's got a tablet, smartphone, or computer.
You can make a a pre-timed PowerPoint, pre-timed slides, and you know within
(31:45):
that PowerPoint that you create for somebody how many repetitions are congruent
versus incongruent or like even odd.
So you know about the dose based off of this dual task that you're providing
them that they should be able to do or that they will be doing when they watch
that for that specific exercise.
So I would create a library of PowerPoint for starters.
(32:10):
Other tools that you can use.
I don't know. I am not supported by Switched On at all, but I really like their
app and it's super useful.
There's a subscription, but there's also like a free version and it just has
dual tasks literally programmed into your phone for things that you already do in rehab.
(32:35):
And so that is like super useful, I think.
So I think it also depends on phase of rehab and what your training goal is.
So like if your session for the day, if you're like, this is hypertrophy,
like I'm lifting at 80%, my one rep max.
(32:57):
I do not expect a high chaos intervention to be applied on top of that.
I think we need to respect performance and...
Integrate it appropriately, but also understanding that when we participate
in sport, we operate at like a pretty sub max load with births of max effort.
(33:19):
So anything that is honestly like sub max for that person based on like what
they're doing at that time, you could probably apply this.
Now, how about the really late stage? And we're talking like the graded functional
progression as, let's say, a soccer player starts to get back into varsity soccer.
They're either working with you or they're working with their athletic trainer
that you're in contact with.
(33:40):
Is it your hope that what you've gone through the previous months to work on
these things has done its job to the point where they're ready for that?
Are you still having them do some of these visual cognitive tasks,
even when they're 100% doing some type of footwork drill or something of that nature?
I think this actually significantly helps the transition to on-field because
(34:06):
most people who are doing the on-field rehab are already doing a sport-specific version of this.
And they're using colors, different colored soccer balls to simulate like response
inhibition and stuff during like small-sided games or constrained practice sort of drill scenarios.
Scenarios and so if you do this
thing earlier they already understand the concepts
(34:29):
that you're trying to integrate later on those high level drills and so honestly
the organization that does this really well is isokinetic i watched some awesome
on-field rehab when i was in italy this past spring and they are like seamlessly
integrating these concepts.
(34:49):
So I think it overall augments both from like the athlete, but also like the therapist.
I don't know if you, do you guys have different people who like do early versus
late stage therapy for you?
Is it like one therapist that would like take everybody through it?
We, no, we don't. We are a very monogamous office.
(35:09):
When Scott becomes your therapist, Scott is your therapist until the end of time.
And no, but, and it's, it's funny. And I'll give our therapist a little bit
of a hard time that if Scott used to, when Scott was doing PT,
if one of our other therapists would see him, I don't even know this person,
what's going on with them. What's their emotion?
Like, what's their strength? Like, what have they been doing?
What sports are they doing?
And I'm like, you know, sometimes I would give them a hard time.
(35:29):
Like, you know, it's going to be okay.
Like, I know you're seeing somebody that you don't see every single time,
but we'll, we'll get through this together, you know?
So no, we don't have people that are focused on early stage versus late stage.
We have one of the real kind of bedrock principles of how we run our offices.
You may have me or Dr. Shelbourne as your doctor, but your therapist is really
(35:51):
the person that has even more of a primary connection with you on a regular
basis. They're your therapist forever.
They see you when you come for your initial visit. They take you back to the
room. They get your x-rays. They get your history.
They enter all your information, do your documentation. They present it to me.
We go in, see the patient together.
They immediately start rehab with the therapist. if they want to call about
(36:11):
their MRI results, if they want to see when they're going to have their next
appointment, why does my incision look like this after surgery?
Where should I be at rehab? The therapist is their primary connection to the office.
So no, it's a completely different way of looking at it.
And we like that personal connection part of it, but we're always trying to
get better on how we can make those concepts better.
(36:34):
So they're really taking them through the entirety of the process.
I think with that sort of model, something like this would be easier then because you have control,
right, about how you want to and you know exactly what you've done throughout
that versus like going from provider at early care who has their way of implementing
(36:55):
these things to, okay, now strength and conditioning on field.
Meredith told me I was going to do this. Scott, you're telling me I need to
do this? Yeah. She told me that.
Yeah. No, exactly. I think it would be.
I agree with you. I think it would, you know, if we were to find something that
this would kind of work with our patients, it would be not as much of a challenge
(37:16):
to implement because it is the same therapist and you're carrying it through the initial concepts.
Remember, we talked about this back at the two-week visit that eventually we're
going to be doing this for this reason.
That's why we laid the groundwork at two weeks doing this to be able to do this.
I think the biggest thing that would be maybe challenging in that is I would
see that it would be easy to fall into the motor learning model because it would be easy to say, well,
(37:42):
like, we're just going to do this group of exercises and then progress them
like one stage at a time together.
And that sort of defeats the purpose of like providing variability.
Like we talked about in the paper, like you need error.
Enter an interview with Meredith. That's why we're talking to you tonight,
just to learn about this kind of stuff is for that specific reason.
(38:03):
I think this is something we could get, we could specifically get better at
with our, with our patients.
Yeah. You need air to learn. And I think we, as therapists try so hard to like
put people in this like box of perfect and it's out of like our best heart because
we just want them to do so well.
But it's like, I need you to mess up.
I need you to like, not be perfect. And if you are perfect, then I'm not challenging you enough.
(38:28):
And so that's where I can do something like this to make it more challenging.
We see in our hop tests, this is a fun fact, we just tested a girl today,
that single leg hop, nailed them. Triple hop, nailed them.
Cognitive dual task, hop. On her uninjured limb, she had two physical misses,
(38:49):
but on her injured leg, she had six.
She had a decent deficit in hop distance, but it took her eight tries to get three good trials.
Like, that's important information that should get documented, right?
So, like, she's hopping the same distance, but she's not able to do it in the
(39:11):
same way or at the same quality because it takes her so many different tries to do it.
We definitely see patients like that all the time where they've tested on the
isokinetic testing dead on.
They test on their leg press dead on they have great
range of motion they have no swelling they try to hop and land and
they just can't do it and vice versa that that people
that are you know 30 percent strength deficit on
(39:32):
quads 30 percent straight deficit on overall and we're thinking gosh they're
just forever for coming back and then they hop and stick it like what that was
nothing i'm ready to go play sports well hell i guess yeah go ahead and play
i guess i don't you know they're they're they're the all these things have to
fit together and but they're but and we try to to fit them together,
that as your strength improves.
As your motion improves, as your swelling goes down, as your confidence builds,
(39:55):
then that hop and landing and the more functional things will come along.
And the vast majority of patients, that's the case. But there is a patient every
once in a while, like, I don't know why the hell this is happening this way.
But, you know, she says that she is practicing every day. She gets no swelling.
She doesn't hurt. She feels normal.
And her strength is a 30% deficit when we do the objective testing.
(40:16):
We don't really know why. So, you know, and then that leads into kind of the
last question I think we have for you.
We've talked a lot about what things you've integrated so far into your practice,
what we've learned so far.
Where's this headed in the future and what do you think the next 10,
20 years looks like with all these concepts?
That's a good question. I think we're just now like dipping our toes into the
(40:41):
world of dual task and there's a lot more to come.
There's a lot more on what is the brain actually doing during dual tasks, right?
And are these different between patient populations, greater difficulties in dual tasks, right?
How do I, a big challenge that I get or that I see is like, how do I know I'm
(41:04):
challenging somebody to the appropriate level of dual task difficulty?
We need to figure out better ways to approach that problem.
And then I think the biggest question is like, we need clinical trials that
say like, okay, if I implement this, what actually happens, right?
Is there a reduced second injury risk?
That's obviously like the big thing. Is there their higher return to sport rates,
(41:27):
because they reduce second entry risk.
And so, I mean, we did the same hop tests and whatever for 30 some odd years.
So hopefully we can get to that a little bit faster here.
But that's where I think this is going to head. And there's a lot of good direction.
Yeah, I'm hopeful for and excited to hear all this.
(41:48):
You know, we just bring it back to the clinical context, Ronnie,
we always, we see these patients at, you know, nine months and.
We see, just to give you a quick background, Meredith, we see patients back
for research at one year and two years after an ACL reconstruction.
So we get a chance to talk to these patients afterwards. And,
you know, we get to talk to them and say, hey, how was your football season?
How was your soccer season? They say, oh, yeah, I played, but I sucked.
(42:09):
You know, I was just, I wasn't good. I wasn't as fast as I used to be.
And we always just say, oh, you know, it's just first year back after an ACL
reconstruction can be hard.
They were testing off the charts well. It's just, hey, it's one of those things
where the second season is going to be better than the first.
And, you know, when I read this paper, I was thinking about that scenario a
lot and just wonder, you know, what was the, was everything just happening too
(42:30):
fast in terms of the game around them was too fast because the processing was down.
And I read this and I thought, well, you know, what, what are these,
the patients that you see that put an emphasis on this visual cognitive theory,
and if they're able to almost process the sport and have better performance when they get back.
So it's, it's, it's, it's interesting stuff. It's fascinating stuff.
And like I said, I'm excited to hear what you guys are up to next with this. That's fascinating.
(42:54):
Actually, that's a fascinating observation because you always have this like
speed accuracy tradeoff of cognition, physical performance.
And so the goal is like to perform both of those really high, right? In sport.
But like if somebody has a cognitive compensation, right, maybe they feel like
they're not as fast because they have to slow down the physical side of things
(43:17):
so that they can keep up cognitively because they have that compensation. Ligamentization.
So maybe what they're describing to you is like the physiologic phenomenon that
we're trying to get out with research. Yeah.
That's one of those classic, it's seeing you, but I'm not seeing it.
You know, it's just, like you say, we chalk it up to,
you know, ligamentization hasn't taken place yet, or just the fact that you've
(43:38):
been out of your sport for X amount of months, but, you know,
talking about this and looking at this visual cognitive theories makes that,
makes that process a little more interesting. Yeah.
Well, thanks again for joining us tonight, Meredith. We really enjoyed this
discussion as we kind of put a bow on this at the end.
What do you think are some kind of take-home points and final thoughts before
we leave our listeners tonight?
(43:58):
The big one is do the basics well. You have to get range of motion and strength back.
And then these adjuncts are just that. They're additive ways that you can challenge your patients.
And it should start very early in rehab. we can't
wait until end stage of rehab to start implementing
these because likely the compensation has already
(44:20):
set in all right merida thanks again for for joining us and we'll make sure
to look you up next time we're at a meeting and discuss this some more absolutely
as we talked about before if you want to find us on social media you can find
us at the skc podcast on face on twitter and instagram you can find our facebook
and youtube pages the shelbourne e-center podcast podcast,
you can email us at the SKC podcast at gmail.com.
(44:43):
If you haven't followed already, don't miss any of our subsequent content and
be able to go back and get our previous content on all podcast,
podcast avenues that you get your, get your content from.
So thank you for joining us and we will see you again next time.
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