Ep 190: Progressing the visual-cognitive control chaos continuum, with Dr Meredith Chaput (part 2)

[00:00:00] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the editor-in-chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. Welcome to part

[00:00:23] 2 of our chat with Dr Meredith Chaput about the visual-cognitive control chaos continuum. Last week we talked about how changes in the way that the nervous system works after injury or neuroplasticity can compensate for impairments like joint instability, pain and muscle inhibition.

[00:00:40] Dr Chaput also explained the five phases of the visual-cognitive control chaos continuum. Today we talk about how to assess for cognitive compensations and how to progressively load the visual-cognitive system during sports injury rehabilitation. Today's episode begins with a small confession.

[00:01:01] I am terrible at maths and whenever anyone asks me to count backwards from seven, I completely freak out. How do you handle that with athletes for whom they're individuals and some of these cognitive tasks might induce a lot of anxiety about accuracy? Something happens

[00:01:17] that you weren't expecting. How do you deal with that? That's just like one of the easiest examples we share. There are so many different cognitive paradigms that you could use. The stoop test is an example for those who don't know what

[00:01:31] that is. That would be like if you displayed the word red on a PowerPoint, but the word was actually in blue and you have the individual have to say the color of the word not the actual word. That's a psychological interference response inhibition paradigm.

[00:01:50] Another one is the flanker task. This is a task that has a set of five arrows and then the individual has to respond to what way the center arrow is directed. You could do

[00:02:02] stuff like that. We've done things where you have a circular array of letters and then you have either a line or a box that pops up in the spatial location of what a letter

[00:02:16] was and they have to recall what letter was in that spot. There's a lot of alternatives that you could use that aren't met. If the cognitive task that you're doing is going to improve the saliency of the intervention for the participant, then you probably need

[00:02:35] to adjust it and figure out something that's going to work best for them but still being able to scale it to a high level of difficulty. The other thing about adding the cognitive

[00:02:44] task and something that we tried to emphasize in the paper is that you have to be able to measure both a physical and cognitive out. If you do a dual task of sorts and you're still only measuring the physical component and the athlete knows you're only measuring

[00:03:00] the physical component, then they can use attention to just focus on the physical component and get all of your math questions wrong or serial seven subtraction if you're not going to focus and make that a priority. You have to instruct an athlete to do everything

[00:03:17] as quickly and accurately as possible so that they focus on both cognitive and physical outcomes. Athletes are going to keep track of both. Athletes are going to understand if they didn't do well on either. I think that's where education comes into play

[00:03:32] is if you allow somebody to consistently compensate and only focus on physical and not educated out and why cognition matters, then they're only going to focus on physical. That's my plug for measuring both cognition and physical performance. You want to know when I add this

[00:03:50] cognitive task, does it increase valgus at the knee during a lateral step down or something like that? A lot of the time as a clinician, you're naturally more engaged in the physical performance because we know that that's really important. It does become difficult to keep

[00:04:07] track of. If you can make it easier on the back end by having things pre-timed and pre-programmed, then it makes your documentation and keeping track of that significantly easier. I think this idea of measuring the cognitive and the physical outcomes gets us nicely to

[00:04:26] progressing. How do you judge when the athlete is ready to progress when you can change that cognitive task? If they're above that 70% error rate, I can probably make the cognitive or physical task harder. Clinically, I like error on this side of progressing physically

[00:04:46] first because I know I'm underloading them physically most of the time. That's really important for me is do it physically first. But if they're not able to, for whatever reason, progress physically, then if they are doing a performance of better than 70%, then

[00:05:05] I would say try to layer on another task or try something different. As you're preparing for a treatment session with a patient, I would also prepare that they might do the first set

[00:05:18] of an exercise using phase two. They might do it really well. Then I need to have something in phase three set up for them so that I can induce the amount of error for motor learning

[00:05:31] necessary. Then they might be able to do the next two sets at phase two. Then when they come in the next time, I can start them at phase three. When they come in the next time,

[00:05:43] they might be able to start at phase three. They might have to do another two sets. Then on set two, they get 10 out of 10, correct? For movement. Then it's like, okay, let's

[00:05:53] up them again. They might not stay in a phase very long. It might only take one set for them to figure that out. More so about trying to frame the mindset as a clinician that I need to induce

[00:06:06] error. I need to continually update my exercise to induce error. That's really helpful, I think, because some of these cognitive tasks that we're talking about are, I think one could argue, not really that sport relevant. Counting backwards by sevens or doing the stoop test or some of the

[00:06:26] cognitive examples you've given us are not things that an athlete is doing on the sporting field. I certainly, when we talk about physical tests, some people get really caught up in, I've got to make this as sport specific as possible. Of course, that's true at some point.

[00:06:44] How much of this is you simply have to challenge the system versus challenging the system in a very sport specific way? I love that you just brought that up. That's one of the number one questions that

[00:06:56] I get. This is my myth buster. It goes against all marketing of any of the companies that I just said to purchase their product. They all tell you that they're trying to train neuro cognition. They're trying to train reaction time. They're trying to train this element of visual

[00:07:16] attention. I am not trying to do that. What I'm trying to do is take away the neurologic compensation. If you reframe it in that mindset, I think the progression makes a lot more sense is I'm not trying to train somebody's visual attention ability to react to a stimuli

[00:07:36] because you do have to do sport for that. It should be sport specific. I'm trying to take away the neuro compensation of visual attention for motor control by using these dual tasks. Because if I

[00:07:49] let that compensation set in over the course of nine months of rehabilitation, that is like a pretty hardwired response. Now when they go onto the field or core or wherever they're returning to and now they can't use that compensation, you see deficits in neuro cognitive processing.

[00:08:11] You see deficits in physical. That's why we see when you dual task somebody and return to sport assessments. That's why I think you see so much compromise when you add a dual task onto a very

[00:08:24] simple hop test is because I didn't remove the neural compensation. I think maybe that's one of the reasons why we try to put so much neuro into this commentary was to sort of myth bust that I'm not training neuro cognition. I'm trying to train physical movement, implicit

[00:08:43] movement without the added compensation. How much homework are athletes getting? Is this something that only happens in the clinic or are you sending athletes back home to do some of these tasks on their own? Good question. I think that it all depends on whatever the

[00:09:02] theme or institutions like training model is. I'll be honest, my athletes, they enjoy doing the exercises with a dual task significantly more than just doing the training because most of them are already doing weight training or strength and conditioning, especially at the progression

[00:09:20] to on field. They're already doing a lot of physical stuff, so they enjoy the added cognitive challenges. There are ways where you can make your PowerPoints and you can export them as video files. If your athlete had smartphone virtual reality, they could do the dual task

[00:09:39] based off of the video file at home that you send them. I actually have a Google Drive folder that I have with PowerPoints pre-made that I'll just have a QR code and people can scan the QR

[00:09:52] code and use those files. I think that's one of the easier ways that I've noticed to implement it at home. I think one of the things I'll be honest about is we don't know yet how often

[00:10:07] they need to do this. A lot of the research from older adults, usually they compare two types of training groups. You have a traditional training group and then a training group that's

[00:10:18] augmented with dual tasks or just a dual task only group. The training that is done in the dual task nature that augments traditional therapy, they do far superior on physical and cognitive assessment. I think that's where we're going with the research and that's what

[00:10:37] our expectation is, is that we in no way want to replace traditional training and what that looks like for your home exercise program. Understanding that when we send somebody with a home exercise program and they're likely being underdosed or they don't have NMES at home, then this could

[00:10:59] easily be implemented at home as a surrogate. Then maybe you have to do less in the clinic. I don't know that we know the exact dosage, but I do know from clinical experience that athletes are more engaged and they're actually more compliant with their programs.

[00:11:15] Is there too much cognitive loading that you can do? I think there can be too much if it takes away from your ability to do the physical thing. So I don't think from a dosage perspective, I don't think it's harmful to do too much,

[00:11:32] but if you're going to prioritize cognitive load over getting knee extension range of motion back and getting quad strength back, I don't know that that is the route I would go. Some of our neural

[00:11:46] data does that with improvements in strength symmetry has maybe less change in these cross regions or premotor areas. There's a capacity of both cognitive and physical that has this tradeoff to it. I think it's our job as clinicians to try to maintain that balance of tradeoff,

[00:12:11] but if you're going to do too much cognitive load to where you have lost focus on getting quad strength back, then you're no longer practicing or augmenting traditional therapy. You're then replacing traditional therapy with this cognitive aspect, and that's not what I think we would advocate for.

[00:12:29] Now, Meredith, I can't let you go without a quick chat about what's coming up next for the research in this area. And you've touched a little bit on some of the open questions, the things that we're not sure about including things like dosing and the homework element to

[00:12:46] this. What are the important questions that you see coming up in the not too distant future in research? So something that I'm really passionate about is first off understanding what actually are like the dual task brain differences between somebody who's had an ACL reconstruction and healthy,

[00:13:05] because right now a lot of the MRI data, at least the tasks we do in the MRI are motor only, and then we sort of are inferring this information. And so first thing on my agenda is to get data

[00:13:17] for that. And then I'm also passionate about, well clinicians aren't able to measure or brain MRI everybody right to know like do you have this change? So is there a battery of functional and like return to sport assessments that then can help predict somebody who may or may

[00:13:37] not have more of this compensation that then applying dual task interventions could be more beneficial on than maybe somebody who doesn't have as much as this compensation. So that in general my like big area of interest, I think collectively between my lab at UCF and Ohio University and

[00:13:57] Emory and others were very interested from like the intervention, like if we apply dual task interventions, how does this actually change the brain? So that's one of the biggest questions that we get asked as well like do we know if applying in this is actually going to attack

[00:14:13] those regions theoretically it should. And I think in some of the other literature and other populations that does. And so we need to discover that in individuals who are recovering from ACL reconstruction. And then sort of the last area that I'm working on is understanding

[00:14:28] visual attention. And so I'm getting into eye tracking and trying to see if eye tracking can be used as like a surrogate for visual attention. There's only really one study that I know of at least that has looked at eye tracking in individuals with ACL reconstruction by Stephen

[00:14:47] Bobkin. And essentially individuals had differences in eye tracking, gaze accuracy, but they were able to preserve postural stability. And so this sort of corresponds with a paper by Dave Sherman that looked at response inhibition and EEG and individuals with ACL reconstruction

[00:15:10] compared to controls, basically they preserve reaction time and physical performance with differences in brain activation and ACL individuals also commit more cognitive accuracy errors. So I'm trying to see if there's a way that I can start to clinically use out some of this

[00:15:32] as a clinician. How can you understand if somebody might have this compensation and when to intervene on it? So sounds like plenty of work in progress, plenty that's coming up in future. Dr. Meredith Shappu, it's been so wonderful to have you bring the

[00:15:51] neurocognitive element into our physical rehabilitation today to share so many practical examples and practical ideas of things for people to try the next day they're back in the clinic. Dr. Meredith Shappu, thank you for joining me on JOSPT Insights. Thank you for having me.

[00:16:15] Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice subscribe to JOSPT Insights on Apple podcasts, Spotify, tune in, Stitcher, Google or your favorite podcast app. If you like JOSPT

[00:16:34] Insights help others find us tell your friends and colleagues and raid on reviewers. To keep up to date with all the latest JOSPT content be sure to follow us on Twitter we're at JOSPT and Facebook where JOSPT official talk with you next time.