Youth may be particularly responsive to motor learning training strategies that support injury-resistant movement mechanics in youth for prevention programs that reduce injury risk, injury rehabilitation, exercise performance, and play more generally (Optimizing Performance Through Intrinsic Motivation and Attention for Learning Prevention Rehabilitation Exercise Play; OPTIMAL PREP) One purpose of the present manuscript was to provide clinical applications and tangible examples of how to implement the proposed techniques derived from OPTIMAL theory into PREP strategies for youth. A secondary purpose was to review recent advances in technology that support the clinical application of OPTIMAL PREP strategies without extensive resources/programming knowledge to promote evidence-driven tools that will support practitioner feedback delivery. The majority of examples provided are within the context of anterior cruciate ligament (ACL) injury rehabilitation, but we emphasize the potential for OPTIMAL PREP strategies to be applied to a range of populations and training scenarios that will promote injury resistance and keep youth active and healthy.
Youth athletes are ideal candidates for novel therapeutic motor learning interventions that leverage the plasticity of the central nervous system to promote desirable biomechanical adaptions. We summarize the empirical data supporting the three pillars of the Optimizing Performance Through Intrinsic Motivation and Attention for Learning (OPTIMAL) theory of motor learning and expand on potential neurophysiologic mechanisms that will support enhanced movement mechanics in youth to optimize prevention programs for reduced injury risk, injury rehabilitation, exercise performance, and play (Prevention Rehabilitation Exercise Play; PREP). Specifically, we highlight the role of motivational factors to promote the release of dopamine that could accelerate motor performance and learning adaptations. Further, we detail the potential for an external focus of attention to shift attentional allocation and increase brain activity in regions important for sensorimotor integration to facilitate primary motor cortex efficiency. This manuscript serves to provide the most current data in support of the application of OPTIMAL PREP training strategies of the future.
There are numerous physical, social, and psychological benefits of exercise, sport and play for youth athletes. However, dynamic activities come with a risk of injury that has yet to be abated, warranting novel therapeutics to promote injuryresistance and to keep an active lifestyle throughout the lifespan. The purpose of the present manuscript was to summarize the extant literature and potential connecting framework regarding youth brain development and neuroplasticity associated with musculoskeletal injury. This review provides the foundation for our proposed framework that utilizes the OPTIMAL (Optimizing Performance Through Intrinsic Motivation and Attention for Learning) theory of motor learning to elicit desirable biomechanical adaptations to support injury prevention (injury risk reduction), rehabilitation strategies, and exercise performance for youth physical activity and play across all facets of sport (Prevention Rehabilitation Exercise Play; PREP). We conclude that both young male and females are ripe for OPTIMAL PREP strategies that promote desirable movement mechanics by leveraging a unique time window for which their heightened state of central nervous system plasticity is capable of enhanced adaptation through novel therapeutic interventions.
Anterior cruciate ligament (ACL) injury risk reduction strategies primarily focus on biomechanical factors related to frontal plane knee motion and loading. Although central nervous system processing has emerged as a contributor to injury risk, brain activity associated with the resultant ACL injury-risk biomechanics is limited. Thus, the purposes of this preliminary study were to determine the relationship between bilateral motor control brain activity and injury risk biomechanics and isolate differences in brain activity for those who demonstrate high versus low ACL injury risk. Thirty-one high school female athletes completed a novel, multi-joint leg press during brain functional magnetic resonance imaging (fMRI) to characterize bilateral motor control brain activity. Athletes also completed an established biomechanical assessment of ACL injury risk biomechanics within a 3D motion analysis laboratory. Knee abduction moments during landing were modelled as a covariate of interest within the fMRI analyses to identify directional relationships with brain activity and an injury-risk group classification analysis, based on established knee abduction moment cut-points. Greater landing knee abduction moments were associated with greater lingual gyrus, intracalcarine cortex, posterior cingulate cortex and precuneus activity when performing the bilateral leg press (all z > 3.1, p < .05; multiple comparison corrected). In the follow-up injury-risk classification analysis, those classified as high ACL injury-risk had greater activity in the lingual gyrus, parietal cortex and bilateral primary and secondary motor cortices relative to those classified as low ACL injury-risk (all z > 3.1, p < .05; multiple comparison corrected). In young female athletes, elevated brain activity for bilateral leg motor control in regions that integrate sensory, spatial, and attentional information were related to ACL injury-risk landing biomechanics. These data implicate crossmodal visual and proprioceptive integration brain activity and knee spatial awareness as potential neurotherapeutic targets to optimize ACL injury-risk reduction strategies.
Patellofemoral pain (PFP) is defined as retro‐ or peri‐patellar knee pain without a clear structural abnormality. Unfortunately, many current treatment approaches fail to provide long‐term pain relief, potentially due to an incomplete understanding of pain‐disrupted sensorimotor dysfunction within the central nervous system. The purposes of this study were to evaluate brain functional connectivity in participants with and without PFP, and to determine the relationship between altered brain functional connectivity in association with patient‐reported outcomes. Young female patients with PFP (n = 15; 14.3 ± 3.2 years) completed resting‐state functional magnetic resonance imaging (rs‐fMRI) and patient‐reported outcome measures. Each patient with PFP was matched with two controls (n = 30, 15.5 ± 1.4 years) who also completed identical rs‐fMRI testing. Six bilateral seeds important for pain and sensorimotor control were created, and seed‐to‐voxel analyses were conducted to compare functional connectivity between the two groups, as well as to determine the relationship between connectivity alterations and patient‐reported outcomes. Relative to controls, patients with PFP exhibited altered functional connectivity between regions important for pain, psychological functioning, and sensorimotor control, and the connectivity alterations were related to perceived disability, dysfunction, and kinesiophobia. The present results support emergent evidence that PFP is not localized to structural knee dysfunction, but may actually be resultant to altered central neural processes. Clinical significance: These data provide potential neuro‐therapeutic targets for novel therapies aimed to reorganize neural processes, improve neuromuscular function, and restore an active pain‐free lifestyle in young females with PFP.
Context: Neuromuscular training (NMT) facilitates the acquisition of new movement patterns that reduce ACL injury risk; however, the neural mechanisms underlying these changes are unknown. Objective: Determine the relationship between brain activation and biomechanical changes following NMT with biofeedback. Study Design: Controlled Laboratory Study Setting: Research laboratory Participants: Final analyses included twenty high school female soccer athletes (15.7±0.95 years; 1.68±0.05 m; 59.91±5.62 kg). Main Outcome Measures: Ten participants completed 6 weeks of NMT augmented with real-time biofeedback (aNMT) to reduce knee injury risk movements, and 10 participants completed no training. aNMT was implemented with visual biofeedback that responded in real-time to injury-risk biomechanical variables. A drop vertical jump with 3D motion capture was used to assess injury risk neuromuscular changes before and after the six-week intervention. Pre to post brain activation changes were measured using functional magnetic resonance imaging (fMRI) during unilateral knee and multi-joint motor tasks. Results: Following aNMT, sensory (precuneus), visual-spatial (lingual gyrus), and motor planning (pre-motor) brain activity increased for knee specific movement and sensorimotor cortex activity for multi-joint movement decreased. Knee abduction moment during landing also decreased (4.66±5.45 Nm; p=0.02; g=0.82) in the aNMT group with no change in the control group (p>0.05). The training-induced increased brain activity for isolated knee movement was associated with decreases in knee abduction moment (r=.67, p=.036) and sensorimotor cortex activity for multi-joint movement (r=.87, p=.001). No significant change in brain activity was observed in the control group (p>0.05). Conclusions: The relationship between neural changes observed across tasks and reduced knee abduction suggests that aNMT facilitates recruitment of sensory integration centers to support reduced injury risk mechanics and improve sensorimotor neural efficiency for multi-joint control. Further research is warranted to determine if this training related multimodal neuroplasticity enhances neuromuscular control during more complex sport-specific activities.
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