From Control to Chaos: Visual-Cognitive Progression During Recovery from ACL Reconstruction

BACKGROUND: Anterior cruciate ligament tear is a serious knee injury with implications for central nervous system (CNS) plasticity. To perform simple knee movements, people with a history of ACL reconstruction (ACL-R) engage cross-modal brain regions and when challenged with cognitive-motor dual-tasks, physical performance deteriorates. Therefore, people with ACL-R may increase visual-cognitive neural processes for motor control. CLINICAL QUESTION: What components of CNS plasticity should the rehabilitation practitioner target with interventions, and how can practitioners augment rehabilitation exercises to target injury associated plasticity? KEY RESULTS: This clinical commentary (1) describes the neurophysiological foundation for visual-cognitive compensation after ACL-R, (2) provides a theoretical rationale for implementing visual-cognitive challenges throughout the return to sport (RTS) continuum, and (3) presents a framework for implementing visual-cognitive challenges from the acute phases of rehabilitation. The 'Visual-Cognitive Control Chaos Continuum (VC-CCC) framework consists of five training difficulties that progress visual-cognitive challenges from high control to high chaos, to better represent the demands of sport. CLINICAL APPLICATION: The VC-CCC framework augments traditional rehabilitation so that each exercise can progress to increase difficulty and promote sensorimotor and visual-cognitive adaptation after ACL-R.