Associations Between Cognitive Function and ACL Injury-Related Biomechanics: A Systematic Review

Abstract

Context: Does lower baseline cognitive function predispose athletes to ACL injury risk, especially when performing unplanned or dual-task movements? Objective: To evaluate the association between cognitive function and biomechanics related to ACL injuries during cognitively challenging sports movements. Data Sources: PubMed (MEDLINE), Web of Science, Scopus, and SciELO databases were searched; additional hand searching was also conducted. Study Selection: The following inclusion criteria had to be met: participants completed (1) a neurocognitive test, (2) a cognitively challenging sport-related task involving lower limbs, and (3) a biomechanical analysis. The following criteria determined exclusion from the review: studies involving participants with (1) recent or current musculoskeletal injuries; (2) recent or current concussion; (3) ACL surgical reconstruction, reviews of the literature, commentary or opinion articles, and case studies. Study Design: Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement and registered at the International Prospective Register of Systematic Reviews (PROSPERO). Level of Evidence: Level 3. Data Extraction: Two of authors independently extracted data and assessed the methodological quality of the articles with the Downs and Black and ROBINS-I checklists, to assess methodological quality and risk of bias, respectively. Results: Six studies with different methodologies and confounding factors were included in this review. Of these 6 studies, 3 were ranked as high-quality, 3 demonstrated a low risk of bias, 2 a moderate risk, and 1 a severe risk. Five studies found a cognitive-motor relationship, with worse cognitive performance associated with increased injury risk, with 1 study reporting the opposite directionality for 1 variable. One study did not identify any interaction between cognitive function and biomechanical outcomes. Conclusion: Worse cognitive performance is associated with an increased injury risk profile during cognitively challenging movements.

Influence of Fatigue on Cognitive-Motor Function During Unanticipated Landings

“…Furthermore, several studies have indicated a possible relationship between decreased RT and harmful lower limb mechanics (ie, higher peak GRF, peak proximal anterior tibial shear force, knee abduction angle/moment and reduced knee flexion angle). 4,8,25,28,41 Our results corroborate this evidence and extend it by showing that worse baseline RT scores corresponded to increased harmful knee mechanics in the frontal plane throughout the fatigue progression. This finding suggests that lower performance in this neurocognitive domain may potentially decrease athletes’ ability to integrate stimuli and safely plan movements in dynamic sports environments, and this relationship could be influenced by fatigue incurred during competition.…”

“…These cognitive abilities were targeted because of their proposed relevance to musculoskeletal injuries. 4,8,12,28,39,43…”

“…These cognitive abilities were targeted because of their proposed relevance to musculoskeletal injuries. 4,8,12,29,40,44 Simple and choice tests assessed RT. For the simple RT test, the participants looked at a computer screen and were asked to press a button on the keyboard as fast as possible upon the presentation of an image on the screen.…”

“…43,44 In the context of sports, cognitive performance has been collectively defined as an athlete's ability to perform tasks related to the fundamental domains of functioning such as visual attention, self-monitoring, processing speed, reaction time, and dual-tasking. 8,28 As poor baseline neurocognitive performance is associated with harmful movements, deficits in cognitive subdomains such as sensory integration or attentional processing may lead to postural coordination errors and compromised lower limb patterns that pose an increased injury risk for athletes. 4,8,27,42 Added decision-making and divided attention challenges have also shown to result in deleterious effects on injury-relevant knee mechanics.…”

“…8,28 As poor baseline neurocognitive performance is associated with harmful movements, deficits in cognitive subdomains such as sensory integration or attentional processing may lead to postural coordination errors and compromised lower limb patterns that pose an increased injury risk for athletes. 4,8,27,42 Added decision-making and divided attention challenges have also shown to result in deleterious effects on injury-relevant knee mechanics. 1,2,27,30 Additionally, the combined effects of fatigue and cognitive loading on lower limb mechanics during cognitive-challenging sports-relevant movements (eg, perceptual-cognitive task or unplanned conditions) may represent a worst-case scenario in terms of the ACL injury risk.…”