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Tendon Neuroplastic Training – An approach we can utilize in Esports Rehab

Hello fellow physical therapists and healthcare practitioners! Today I will be reviewing an article and approach we have to consider when treating injuries in esports. As we have mentioned several times before, there is a high prevalence of tendon injuries in gaming/esports due to the poor load capacity that results from excessive use without proper conditioning. While most protocols directly target the load capacity of tendons – we have to consider our pain system and motor control when addressing tendon rehab to facilitate a full return to play with both chronic and acute injuries.

With this being said, this article I reviewed was a narrative review from Rio et al. 2015 which describes the tendon neuroplastic training (TNT) approach with tendon rehabilitation. Because this study was a review instead of a RCT we will be reviewing the major concepts described in the study and provide an update about the evidence among these concepts.

Motor Control & Tendinopathy

Rio et al begins by reviewing tendon research and its heavily bias into investigating muscle strength as represented by MVC. Rio et al outlines that there are countless studies out there looking into muscle strength yet have now shown any convincing association between strength & the presence of tendinopathy. For example, athletes with rotator cuff tendinopathy have been shown to be 15% stronger in measures of abduction on their asymptomatic side than controls (and comparable strength to controls on their symptomatic side). This has also been seen in lateral epicondylalgia and i’m sure many of us in the clinic have likely also seen an increase in the muscle strength with pain continuing to linger.

This leads Rio et al to review studies of what they believe many of us are missing with rehab – motor control or the influence of cortical inhibition/excitability on tendinopathy. It becomes overwhelmingly clear through the body of studies the team reviews that changes in motor control & cortical inhibition/excitability have a clear role in the rehabilitation of those with tendinopathy.

Rio et al then goes onto provide some rationale for while motor control changes occur. For most of us it should make sense as to why:

PROTECTION

We change how we move to protect certain parts our body and in the case of tendinopathy Rio et al shows changes in movement patterns, muscle recruitment, activation patterns occur as a way to limit load or strain on the tissue. She brings up an important mistake many of us make in the orthopedic setting: Focusing on only treating the impairments themselves. We need to realize people alter their movement patterns and have a reduction of motor drive to protect their tissues and as a result WE HAVE TO RETRAIN THEIR MOVEMENT AND RESOLVE CHANGES IN CORTICAL EXCITABILITY/INHIBITION.

We often forget to address motor coordination impairments in tendon rehabilitation. Taken from Rio’s presentation at Sportsfisio 2017 Conference

After addressing any strength or flexibility impairments it is imperative we COMPLETE movement training and motor control interventions on our patients to ensure FULL return to prior level of activity. This section in the narrative review basically states that current tendon rehab fails to address the multitude of contributing factors to altered motor control.

As a part of this section Rio et al also underlines the presence of bilateral motor control changes. It is important for us to consider not only the local site of tendinopathy but the increased risk of development at other sites as a result of the injury. This is likely due to the motor control changes which occur bilaterally/systemically as Rio et. al states there is an increasing body of evidence multiple sites are affected with tendinopathy. The bottom line for treatment is we have to address changes in motor control for both sides to prevent the development of tendinopathy on the unaffected side.

We have to consider motor drive in our assessment of impairments or contributing factors leading to the increased stress on tendons

What happens first? Pain or Changes in Muscle Control?

Rio et al. proceeds to discuss the important question of whether pain or the change in motor control occurs first. Based on the current body of research present – it is still inconclusive however there are a limited amount of studies which provide support for the idea that muscle activity changes occur AFTER the presence of pain as a way to protect the tissue.

This is consistent with many of our other theories regarding pain and movement in that many of the resulting impairments we find are again about… PROTECTION.

How we move is often the major threat to the tissue which is why motor control adaptations occur in order to limit continued load on our tendons. Rio et al. provides a study to support this notion indicating hyperexcitability of the quadriceps in athletes with patellar tendon is correlated with the length of time in symptoms (with the same being found for RC tendinopathy and chronicity). For a basketball player who may be moving incorrectly he or she may feel some pain at the patellar tendon (PT) and may be experiencing these gradual changes in motor control as a way to limit the stress on their PT.

Rio et al continues to provide evidence for this belief highlighting a study which looked at the agonist/antagonist activity of patients with PT.

“The pain adaptation model proposes that agonist activity is reduced and the antagonist activity is increased with pain. This may be the case in PT as there were no differences in MVC between athletes with PT and controls (Rio et al, accepted). However, in a separate study, following isometric exercise that reduced their pain, the MVC of the quadriceps of athletes with PT increased by 18.7%, implying their agonist activity (the quadriceps) was in fact inhibited (reduced) prior to isometric exercise.”

The bottom line is again we need to review and consider interventions to address motor control in tendinopathy.

Resistance Training & Motor Control

Rio et. al begins to introduce concepts of training motor control in which she contrasts self-paced resistance training with external timing cues (visual and auditory). External timing cues meaning using a metronome or a video to guide the athlete on the tempo of each of the reps for a given resistance exercise. External pacing has been shown increases in excitability in both skill (visuomotor tracking) and short-term resistance training – meaning external pacing can increase excitability and release inhibition in both train/untrained limbs. Rio et al. underlines the importance of this evidence and its potential role in tendinopathy rehabilitation.

Taken from Rio’s Presentation at Sportsfisio Conference 2017

Current Tendon Rehabilitation and the TNT Approach

As many of us know the focus of most tendon rehab is to appropriately load the tendon to restore tendon & muscle properties. There are a variety of approaches and paradigms with most of the evidence favoring

1. Eccentric-only

2. Heavy slow resistance (concentric/eccentric)

3. Strength Training

While these paradigms have absolutely been able to help improve pain and function – they are mostly self-paced as patients are provided guidance of sets, reps and load but not provided the tempo (for motor control impairments). Rio et al. believes the high recurrence rate is due to this lack of motor-control specific exercise intervention.

Rio et al. then goes through a case study they designed to assess the effect of TNT and Isometric protocols for pain reduction and motor drive on patients with PT in a 4 week period (as they were more concerned about addressing motor drive than changing strength). Here are the most important takeaways

1. Test either isometric or TNT intervention for 1 week to determine which protocol will be most effective for your patient (1 week mean change in NRS moderately correlated with change in VISA-P at 4 weeks)

2. It takes about 4 weeks to normalize corticospinal excitability

3. Isometric Protocol (4x/week): 5×45”

4. Isotonic Protocol (60 BPM) (4x/week): Slightly Longer Eccentric Component, 4×8, 3” con, 4” ecc

The studies the Rio et al performed provide rationale and support for the use of external pacing over self-pacing in targeting primary motor cortex .

Conclusion & Considerations

The big three findings Rio et. al found from this study are the following

  1. Tendinopathy may be associated with changes in motor control; these changes may be bilateral and persistent despite rehabilitation

  2. Current rehabilitation may not adequately address motor control issues as self-paced strength training (the mainstay of the treatment) does not alter corticospinal drive to the muscle—this may contribute to recalcitrance and recurrence of tendinopathy.

  3. Tendon neuroplastic training proposes a concept of strength-based loading that is an important stimulus for tendon and muscle, but with strategies known to optimise neuroplasticity of the motor cortex and drive to the muscle. It needs to be tested in a wide range of anatomical locations as it is unclear whether findings for the patellar tendon are applicable to all tendinopathies.

Understanding motor control as a major impairment to be treated with tendinopathies is crucial for healthcare practitioners to understand with rehabilitation, especially in esports. I believe however we have to consider more than load capacity (strength impairment) and motor drive (coordination impairment) in esports. Due to the perception of importance and larger homunculus representation of the hand in the primary motor cortex – there is an increased likelihood of centralized sensitivity which likely contributes to chronicity of injuries in esports.

We have to consider pain science (lorimer moseley’s paradigm) and how beliefs in addition to “pain system” adaptations tend to also prevent progress with tendon rehab (often when it is chronic). We need to help our patients understand how our nervous system makes adaptations that do not accurately represent our tissue capacity or status with healing. These thoughts need to be addressed in concurrence with interventions targeting the motor coordination/strength impairments as listed above. In this way we can more holistically treat our patients and ensure an efficiency recovery.

Hope you guys were able to learn something! Don’t forget to share this with any of your fellow colleagues in esports. Thanks for the support

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