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Immersive virtual reality improves movement patterns in patients after ACL reconstruction: implications for enhanced criteria-based return-to-sport rehabilitation

Knee Surgery, Sports Traumatology, Arthroscopy volume 24, pages 2280–2286 (2016)Cite this article

Abstract

Purpose

The purpose of this study was to evaluate the influence of immersion in a virtual reality environment on knee biomechanics in patients after ACL reconstruction (ACLR). It was hypothesized that virtual reality techniques aimed to change attentional focus would influence altered knee flexion angle, knee extension moment and peak vertical ground reaction force (vGRF) in patients following ACLR.

Methods

Twenty athletes following ACLR and 20 healthy controls (CTRL) performed a step-down task in both a non-virtual reality environment and a virtual reality environment displaying a pedestrian traffic scene. A motion analysis system and force plates were used to measure kinematics and kinetics during a step-down task to analyse each single-leg landing.

Results

A significant main effect was found for environment for knee flexion excursion (P = n.s.). Significant interaction differences were found between environment and groups for vGRF (P = 0.004), knee moment (P < 0.001), knee angle at peak vGRF (P = 0.01) and knee flexion excursion (P = 0.03). There was larger effect of virtual reality environment on knee biomechanics in patients after ACLR compared with controls.

Conclusion

Patients after ACLR immersed in virtual reality environment demonstrated knee joint biomechanics that approximate those of CTRL. The results of this study indicate that a realistic virtual reality scenario may distract patients after ACLR from conscious motor control. Application of clinically available technology may aid in current rehabilitation programmes to target altered movement patterns after ACLR.

Level of evidence

Diagnostic study, Level III.

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Fig. 1

References

  1. Adamovich SV, Fluet GG, Tunik E, Merians AS (2009) Sensorimotor training in virtual reality: a review. NeuroRehabilitation 25(1):29–44

    PubMed  PubMed Central  Google Scholar 

  2. Arnason SM, Birnir B, Guethmundsson TE, Guethnason G, Briem K (2014) Medial hamstring muscle activation patterns are affected 1-6 years after ACL reconstruction using hamstring autograft. Knee Surg Sports Traumatol Arthrosc 22(5):1024–1029

    Article  PubMed  Google Scholar 

  3. Baltaci G, Harput G, Haksever B, Ulusoy B, Ozer H (2013) Comparison between Nintendo Wii Fit and conventional rehabilitation on functional performance outcomes after hamstring anterior cruciate ligament reconstruction: prospective, randomized, controlled, double-blind clinical trial. Knee Surg Sports Traumatol Arthrosc 21(4):880–887

    Article  PubMed  Google Scholar 

  4. Benjaminse A, Welling W, Otten B, Gokeler A (2014) Novel methods of instruction in ACL injury prevention programs, a systematic review. Phys Ther Sport. doi:10.1016/j.ptsp.2014.06.003

    Google Scholar 

  5. Castanharo R, da Luz BS, Bitar AC, D’Elia CO, Castropil W, Duarte M (2011) Males still have limb asymmetries in multijoint movement tasks more than 2 years following anterior cruciate ligament reconstruction. J Orthop Sci 16(5):531–535

    Article  PubMed  Google Scholar 

  6. Cordeiro N, Cortes N, Fernandes O, Diniz A, Pezarat-Correia P (2014) Dynamic knee stability and ballistic knee movement after ACL reconstruction: an application on instep soccer kick. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-014-2894-8

    PubMed  Google Scholar 

  7. Cortes N, Blount E, Ringleb S, Onate JA (2011) Soccer-specific video simulation for improving movement assessment. Sports Biomech 10(1):22–34

    Article  PubMed  Google Scholar 

  8. de Bruin ED, Schoene D, Pichierri G, Smith ST (2010) Use of virtual reality technique for the training of motor control in the elderly. Some theoretical considerations. Z Gerontol Geriatr 43(4):229–234

    Article  PubMed  Google Scholar 

  9. Fitts PM, Possner MI (1967) Human performance. Brooks and Cole, Oxford

    Google Scholar 

  10. Ford KR, Myer GD, Hewett TE (2007) Reliability of landing 3D motion analysis: implications for longitudinal analyses. Med Sci Sports Exerc 39(11):2021–2028

    Article  PubMed  Google Scholar 

  11. Fung J, Richards CL, Malouin F, McFadyen BJ, Lamontagne A (2006) A treadmill and motion coupled virtual reality system for gait training post-stroke. Cyberpsychol Behav 9(2):157–162

    Article  PubMed  Google Scholar 

  12. Gardinier ES, Manal K, Buchanan TS, Snyder-Mackler L (2012) Gait and neuromuscular asymmetries after acute anterior cruciate ligament rupture. Med Sci Sports Exerc 44(8):1490–1496

    Article  PubMed  PubMed Central  Google Scholar 

  13. Gokeler A, Benjaminse A, Hewett TE, Paterno MV, Ford KR, Otten E, Myer GD (2013) Feedback techniques to target functional deficits following anterior cruciate ligament reconstruction: implications for motor control and reduction of second injury risk. Sports Med 43(11):1065–1074

    Article  PubMed  PubMed Central  Google Scholar 

  14. Gokeler A, Benjaminse A, van Eck CF, Webster KE, Schot L, Otten E (2013) Return of normal gait as an outcome measurement in ACL-reconstructed patients: a systematic review. Int J Sports Phys Ther 8(4):441–451

    CAS  PubMed  PubMed Central  Google Scholar 

  15. Gokeler A, Benjaminse A, Welling W, Alferink M, Eppinga P, Otten B (2014) The effects of attentional focus on jump performance and knee joint kinematics in patients after ACL reconstruction. Phys Ther Sport. doi:10.1016/j.ptsp.2014.06.002

    Google Scholar 

  16. Gokeler A, Hof AL, Arnold MP, Dijkstra PU, Postema K, Otten E (2010) Abnormal landing strategies after ACL reconstruction. Scand J Med Sci Sports 20(1):e12–e19

    CAS  Article  PubMed  Google Scholar 

  17. Hewett TE, Di Stasi SL, Myer GD (2013) Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction. Am J Sports Med 41(1):216–224

    Article  PubMed  Google Scholar 

  18. Hooper DM, Morrissey MC, Drechsler WI, Clark NC, Coutts FJ, McAuliffe TB (2002) Gait analysis 6 and 12 months after anterior cruciate ligament reconstruction surgery. Clin Orthop Relat Res 403:168–178

    Article  PubMed  Google Scholar 

  19. Lewek MD, Feasel J, Wentz E, Brooks FP Jr, Whitton MC (2012) Use of visual and proprioceptive feedback to improve gait speed and spatiotemporal symmetry following chronic stroke: a case series. Phys Ther 92(5):748–756

    Article  PubMed  PubMed Central  Google Scholar 

  20. Magdalon EC, Michaelsen SM, Quevedo AA, Levin MF (2011) Comparison of grasping movements made by healthy subjects in a 3-dimensional immersive virtual versus physical environment. Acta Psychol 138(1):126–134

    Article  Google Scholar 

  21. Marx RG, Jones EC, Angel M, Wickiewicz TL, Warren RF (2003) Beliefs and attitudes of members of the American Academy of Orthopaedic Surgeons regarding the treatment of anterior cruciate ligament injury. Arthroscopy 19(7):762–770

    Article  PubMed  Google Scholar 

  22. Mestre DR, Ewald M, Maiano C (2011) Virtual reality and exercise: behavioral and psychological effects of visual feedback. Stud Health Technol Inform 167:122–127

    PubMed  Google Scholar 

  23. Mirelman A, Bonato P, Deutsch JE (2009) Effects of training with a robot-virtual reality system compared with a robot alone on the gait of individuals after stroke. Stroke 40(1):169–174

    Article  PubMed  Google Scholar 

  24. Myer GD, Martin L Jr, Ford KR, Paterno MV, Schmitt LC, Heidt RS Jr, Colosimo A, Hewett TE (2012) No association of time from surgery with functional deficits in athletes after anterior cruciate ligament reconstruction: evidence for objective return-to-sport criteria. Am J Sports Med 40(10):2256–2263

    Article  PubMed  PubMed Central  Google Scholar 

  25. Myer GD, Schmitt LC, Brent JL, Ford KR, Barber Foss KD, Scherer BJ, Heidt RS Jr, Divine JG, Hewett TE (2011) Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL reconstruction. J Orthop Sports Phys Ther 41(6):377–387

    Article  PubMed  PubMed Central  Google Scholar 

  26. Ortiz A, Olson S, Trudelle-Jackson E, Rosario M, Venegas HL (2011) Landing mechanics during side hopping and crossover hopping maneuvers in noninjured women and women with anterior cruciate ligament reconstruction. PM & R 3(1):13–20

    Article  Google Scholar 

  27. Paterno MV, Schmitt LC, Ford KR, Rauh MJ, Myer GD, Huang B, Hewett TE (2010) Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med 38(10):1968–1978

    Article  PubMed  PubMed Central  Google Scholar 

  28. Porter JM, Nolan RP, Ostrowski EJ, Wulf G (2010) Directing attention externally enhances agility performance: a qualitative and quantitative analysis of the efficacy of using verbal instructions to focus attention. Front Psychol 1:216

    Article  PubMed  PubMed Central  Google Scholar 

  29. Risberg MA, Holm I (2009) The long-term effect of 2 postoperative rehabilitation programs after anterior cruciate ligament reconstruction a randomized controlled clinical trial with 2 years of follow-up. Am J Sports Med 37(10):1958–1966

    Article  PubMed  Google Scholar 

  30. Simoneau GG, Wilk KE (2012) The challenge of return to sports for patients post-ACL reconstruction. J Orthop Sports Phys Ther 42(4):300–301

    Article  PubMed  Google Scholar 

  31. Wulf G, McNevin N, Shea CH (2001) The automaticity of complex motor skill learning as a function of attentional focus. Quart J Exp Psychol 54(4):1143–1154

    CAS  Article  Google Scholar 

  32. Wulf G, Shea C, Lewthwaite R (2010) Motor skill learning and performance: a review of influential factors. Med Educ 44(1):75–84

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors gratefully acknowledge the assistance of Adam Kiefer for editing the manuscript and providing critical comments.

Conflict of interest

The authors have no conflicts of interest that are directly relevant to the content of this article.

Author information

Affiliations

  1. Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

    Alli Gokeler, Marsha Bisschop, Anne Benjaminse, Helco G. van Keeken & Egbert Otten

  2. Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics and Orthopaedic Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA

    Gregory D. Myer

  3. School of Sport Studies, Hanze University Groningen, Groningen, The Netherlands

    Anne Benjaminse

  4. Department of Oral and Maxillofacial Surgery, Center for Rehabilitation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

    Pieter U. Dijkstra

  5. Department of Orthopedic Surgery, Martini Hospital, Groningen, The Netherlands

    Jos J. A. M. van Raay

  6. Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

    Johannes G. M. Burgerhof

Authors
  1. Alli Gokeler
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  2. Marsha Bisschop
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  3. Gregory D. Myer
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  4. Anne Benjaminse
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  5. Pieter U. Dijkstra
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  6. Helco G. van Keeken
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  7. Jos J. A. M. van Raay
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  8. Johannes G. M. Burgerhof
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  9. Egbert Otten
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Correspondence to Alli Gokeler.

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Gokeler, A., Bisschop, M., Myer, G.D. et al. Immersive virtual reality improves movement patterns in patients after ACL reconstruction: implications for enhanced criteria-based return-to-sport rehabilitation. Knee Surg Sports Traumatol Arthrosc 24, 2280–2286 (2016). https://doi.org/10.1007/s00167-014-3374-x

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  • DOI: https://doi.org/10.1007/s00167-014-3374-x

Keywords

  • Anterior cruciate ligament
  • Motor learning
  • External focus
  • Knee biomechanics