Brain Training with whole body agility training.

1. Brain Processes Generating Rapid Responses
to Changing Environmental Conditions
Gary B. Wilkerson, EdD, ATC
November 14, 2018Technology Driving the Mind-Body Connection

2. Injury Resistance vs. Susceptibility
2
■ Key factor: Capacity for rapid and precise execution of complex
muscle activation patterns (Reaction Time)
– Rapid movements for avoidance of collisions
– Rapid generation of limb stiffness to resist external load

3. ACL Tear – Effects on Brain
3
■ Loss of proprioception from ACL mechanoreceptors
– Decreased activity in somatosensory area of cerebral cortex
■ Quantifiable alterations in brain function
– Electroencephalography (EEG): Somatosensory Evoked Potentials (SEPs)
– Functional MRI (fMRI): Blood Oxygenation Level Dependent (BOLD) signal
– Transcranial Magnetic Stimulation (TMS) + Electromyography (EMG)
■ Increased reliance on visual input
– Increased activity in visual and movement preparation areas
■ Need for brain network reprogramming
– Excessive reliance on vision impairs feed-forward NM control
Valeriani et al, Brain. 1996
Baumeister et al, Scand J Med Sci Sports. 2008
Kapreli et al, Am J Sports Med. 2009
Grooms et al, J Orthop Sports Phys Ther. 2017

4. Concussion – MSK Injury Incidence
4
■ Herman et al, 2013, Clin J Sports Med
– College athletes with concussion Hx (n=49) vs. matched controls (n=90)
– 90-day period; LE sprain or strain; RR = 2.7
■ Nordström et al, 2014, Br J Sports Med
– Male soccer players with concussion Hx (n=66) vs. no concussion Hx (n=1599)
– 12-mo post-concussion surveillance; any MSK injury; RR = 2.2
■ Pietrosimone et al, 2015, Med Sci Sports Exerc
– Retired NFL football players (n=2429); LE MSK injury #
– Concussions 1 vs. 0: OR = 1.6; 2 vs. 0: OR = 2.3; 3 vs. 0: OR = 2.9
■ Brookes et al, 2016, Am J Sports Med
– College athletes with concussion Hx (n=75) vs. matched controls (n=182)
– Non-contact LE sprain or strain within 90-day period; OR = 2.5
■ Lynall et al, 2015, Med Sci Sports Exerc
– Concussion Hx (n=44) vs. matched controls (n=58);
– 13 Sports – Cases: 28 M/16 F; Controls: 39 M/19 F
– LE MSK injuries 1 year pre & post concussion occurrence
– Incidence rate per 1000 Athlete-Exposures:
■ Cases vs. Controls Post: 3.51 / 2.14 RR = 1.6
■ Cases Post vs. Cases Pre: 3.51 / 1.78 RR = 2.0

5. Neuromechanical Responsiveness
(or Perception-Action Coupling)
5
Interactions between neural, biomechanical and
environmental dynamics. Ting et al., Neuron, 2015
Neurocognitive + Biomechanical

6. Functional Connectivity of Brain Networks
6
A. Nodes defined (Regions of Interest)
B. Co-activation measured (BOLD signals)
C. Functional link between nodes
established by a predefined threshold
Van Den Heuvel MP, Pol HE. Exploring the brain network: a review on resting-state fMRI functional connectivity.
Eur Neuropsychopharmacol. 2010;20(8):519-34.
Temporal correlations of activation patterns between anatomically separated brain regions

7. https://openi.nlm.nih.gov/detailedresult.php?img=PMC4390556_EJPT-6-27313-g001&req=4

8. INS
pgACC
OFC
DLPFC
PPC
PCC
VMPFC
DMPFC
HippAmyg Hypo
PAG
NTSNA
RVLM
Prec
dACC
TPC
IPC
LTC
Interrelated Networks
Default Mode Network
Executive Control Network
Salience Network
Central Autonomic Network
Rostral Limbic System

9. Anterior Cingulate Cortex
9
Dorsal ACC: Cognition
Ventral ACC: Emotion
Key area involved in
decision-making that
determines Choice RT
Anterior Cingulate Cortex
Hypothalamus
Amygdala

10. Flanker Test: Anterior Cingulate Cortex Activation
10
Congruent:
>>>>>
OR
<<<<<
Incongruent:
>><>>
OR
<<><<
Blue-White: Deactivation of Default Mode Network
Yellow-Red: Activation of Task-Positive Attentional Network
Kelley AMC, et al. Competition between functional brain networks mediates behavioral variability.
Neuroimage. 2008;39(1):527-537.

11. rMFG: Right Middle Frontal Gyrus
rIFG: Right Inferior Frontal Gyrus
rIPC: Right Inferior Parietal Cortex
rSPC: Right Superior Parietal Cortex
TH: Thalamus
Erickson KI, et al. A structural equation
modeling analysis of attentional control: an
event-related fMRI study. Cogn Brain Res.
2005;22:349-357.
Flanker Test:
Functional connectivity strength
lateralized to Right Hemisphere

12. 12
483 ms
FAST
FAST SLOW
SLOW
73884% 16%
111558% 42%
No mTBI N = 45
Mean = 420
SD = 72
mTBI Hx N = 26
Mean = 457
SD = 86
mTBI Hx No mTBI
SLOW ≥ 483 ms 11 7
FAST < 483 ms 15 38
Total 26 45
Fisher’s Exact One-Sided P =.014
Sensitivity = 42% Specificity = 84%
Odds Ratio = 3.98 90% CI: 1.56 – 10.19
Last mTBI: 4.6 ±3.1 years
Range: 0.8 – 12.4 years
Median: 4.0 years
Spring 2017:
D-I FCS Football Players n=71

13. 13

14. Assessment of Visuomotor Reaction Time
and Whole-Body Reactive Agility
Age: 24.25 ±4.5 years
Sport Male Female Total
Wrestling 12 4 16
Boxing 6 1 7
Sledding 3 4 7
Figure Skating 4 3 7
Gymnastics 4 0 4
Multi-Event* 5 2 7
Total 34 14 48
* Includes Track & Field, Marathon, Pentathlon,
and Weightlifting
Self-Reported Concussion History:
mTBI Hx n=21
Last mTBI: 2.0 ±2.3 yrs
Median: 0.6 yrs (7 mo); Range: 0.02 – 7.5 yrs
No mTBI Hx n=27
Wilkerson et al. Detection of persisting
concussion effects on neuromechanical
responsiveness. Med Sci Sports Exer.
2018;50(9):1750-1756.

15. Dual-Task (Cognitive + Visuomotor RT) Performance
History No History
≥ 15 ms 15 7
< 15 ms 6 20
Total 21 27
Sensitivity = .71 +LR = 2.76
Specificity = .74 –LR = 0.39
RR = 2.96 OR = 7.14
90% CI: 2.44, 20.90
Flanker Test (Proactive Mode)
Left Avg. minus Right Avg.
(Positive Value: Slower Left – Faster Right )
≥ 15 ms
AUC = .747
Left – Right RT Diff.
Concussion

16. Dual-Task (Cognitive + Visuomotor RT) Performance
≥ 1.28
AUC = .675
Scrolling Text (Proactive Mode)
RTavg: Outer 2 Rings / Inner 3 Rings
History No History
≥ 1.28 17 13
< 1.28 4 14
Total 21 27
Sensitivity = .81 +LR = 1.68
Specificity = .52 –LR = 0.37
RR = 2.55 OR = 4.58
90% CI: 1.51, 13.92
Concussion

17. Whole-Body Reactive Agility (Side-Shuffle)
≥ 7.7%
AUC = .633
WBRA Speed (m/s) Asymmetry
(Right > Left OR Left > Right)
History No History
≥ 7.7% 12 6
< 7.7% 9 21
Total 21 27
Sensitivity = .57 +LR = 2.57
Specificity = .78 –LR = 0.55
RR = 2.22 OR = 4.67
90% CI: 1.63, 13.36
Concussion

18. Olympic Athletes
Self-Report of Concussion History
21/48=44% Prevalence
Optimal VMRT
0 or 1 Dual-Task Factor +
7/32=22% Prevalence
Optimal WBRA
Speed Asymmetry < 7.7%
2/21=10% Prevalence
Suboptimal WBRA
Speed Asymmetry ≥ 7.7%
5/11=46% Prevalence
Suboptimal VMRT
Both Dual-Task Factors +
14/16=88% Prevalence
Optimal WBRA
Speed Asymmetry < 7.7%
6/8=75% Prevalence
Suboptimal WBRA
Speed Asymmetry ≥ 7.7%
8/8=100% Prevalence

19. Lower Extremity Sprain or Strain
(Previous 12 Months)
WBRA Acceleration (m/s2) Asymmetry
(Right > Left OR Left > Right)
No Interaction Effect
WBRA Acceleration (m/s2) Asymmetry
(Right > Left OR Left > Right)
≥ 3.5%
AUC = .767
Injury No Injury
Positive Hx 17 4
Negative Hx 15 12
Total 32 16
Sensitivity = .53 +LR = 2.13
Specificity = .75 –LR = 0.63
RR = 1.46 OR = 3.40
90% CI: 1.12, 10.36
Self-Reported History of Concussion
Injury No Injury
≥ 3.5% 29 6
< 3.5% 3 10
Total 32 16
Sensitivity = .91 +LR = 2.42
Specificity = .63 –LR = 0.15
RR = 3.59 OR = 16.11
90% CI: 4.35, 59.72

20. Cohort Completing Performance Assessment
(n=35)
Age: 25.7 ±5.2 years
Subset Completing Training Program*
(n=22)
Age: 26.1 ±5.1 years
Athletes with concussion history (n=19)
Most Recent: 4.6 ±5.3 years; Median: 2.6 years; Range: 0.3 – 18.0 years
Athletes with concussion history (n=12)
Most Recent: 5.0 ±4.9 years; Median: 3.4 years; Range: 0.3 – 16.5 years
Elite Athlete Performance Assessment
* 60-second visual-cognitive-motor training sessions, 2-3 X per week over 4-week period

21. AUC = .868
AUC = .808
≥ .15
OR=11.7
≥ .15
OR=25.5
≥ .18
OR=18.0
Full Cohort Available for Screening n=35 (Concussion: 19/35)
Subset Completing Training Program n =22 (Concussion: 12/22)
≥ .14
OR=39.6
≥ .18
OR=19.6
≥ .20
OR=12.0
Avg Asym Yes No Prevalence
≥ .18 14 2 88%
< .18 5 14 36%
Total 19 16
Sensitivity 74% Specificity 88%
χ2(1)=13.10
1-Sided P<.001
OR=19.6
90% CI: 4.33 – 88.73
Avg Asym Yes No Prevalence
≥ .18 8 1 89%
< .18 4 9 31%
Total 12 10
Sensitivity 67% Specificity 90%
χ2(1)=7.25
1-Sided P=.010
OR=18.0
90% CI: 2.42 – 133.69
Avg Asym Yes No Prevalence
≥ .15 10 3 77%
< .15 2 7 22%
Total 12 10
Sensitivity 83% Specificity 70%
χ2(1)=6.42
1-Sided P=.017
OR=11.7
90% CI: 2.12 – 64.27
Avg Asym Yes No Prevalence
≥ .15 17 4 81%
< .15 2 12 14%
Total 19 16
Sensitivity 90% Specificity 75%
χ2(1)=15.04
1-Sided P<.001
OR=25.5
90% CI: 5.39 – 120.58

22. Neural Basis of Asymmetry
Temporal Retina: Direct connection to ipsilateral hemisphere
Nasal Retina: Direct connection to contralateral hemisphere

23. Concussion Hx Subset Completing Training Program n =12
Pre- to Post-Training Change in Whole-Body Reactive Agility Asymmetries
Variable Cut-Pt Pre Mean Post Mean Mean Change SRM % Change
Lateral RT Asym ≥ .22 .559 ±.670 .257 ±.191 – .301 ±.627 .48 54%
Lateral Speed Asym ≥ .10 .094 ±.096 .073 ±.050 – .021 ±.097 .22 22%
Lateral Acc Asym ≥ .03 .121 ±.076 .106 ±.069 – .015 ±.086 .17 12%
Lateral Dec Asym ≥ .14 .140 ±.126 .093 ±.113 –.047 ±.148 .32 34%
Diag/Back RT Asym ≥ .09 .334 ±.374 .383 ±.295 +.049 ±.480 (.13) (15%)
Diag/Back Spd Asym ≥ .17 .126 ±.082 .085±.052 – .041 ±.104 .40 33%
Diag/Back Acc Asym ≥ .12 .185 ±.108 .100 ±.107 – .085 ±.187 .45 46%
Diag/Back Dec Asym ≥ .24 .213 ±.145 .168 ±.133 – .046 ±.207 .22 22%
Diag/Front RT Asym ≥ .10 .351 ±.311 .445 ±.530 +.094 ±.625 (.15) (27%)
Diag/Front Spd Asym - .090 ±.037 .104 ±.087 +.013 ±.090 (.15) (15%)
Diag/Front Acc Asym ≥ .12 .161 ±.129 .090 ±.057 –.071 ±.120 .59 44%
Diag/Front Dec Asym ≥ .15 .196 ±.119 .125 ±.126 –.073 ±.179 .40 36%

24. Brain Information Processing
24
■ Embodied Predictive Interoceptive Coding (EPIC) –
Brain anticipates, rather than reacting to perceptions
– Response initiated before decision-making completed
■ Partial info used to prepare for probable action outcome
■ M1 conveys anticipated consequences of response to S1
■ Feed-forward anticipatory response
– Modulation of spinal reflexes during decision-making
■ Adjustment of kinetic chain stiffness
– Response adjusted on the basis of sensory input
■ Feedback used to correct for prediction error
■ Feedback influences future anticipatory actions
Barrett LF, Simmons WK. Interoceptive predictions in the brain. Nat Rev Neurosci. 2015
Selen LPJ, et al. Deliberation in the motor system. J Neurosci. 2012
Wolpert DM, et al. Principles of sensorimotor learning. Nat Rev Neurosci. 2015

25. Considerations for Brain Training
25
■ Perception and processing of visual and sensory inputs need to
be enhanced
– Both Reaction Time (RT) and Response Accuracy (RA)
– Integration of contextual information with expectations stored in memory
(recognition of patterns in a visual display)
■ Progressive increase in “cognitive load” imposed during
performance of dynamic movement patterns
– External focus of attention on changing environmental cues
– Motor control automaticity reduces demand on resources
Grooms D, et al. Neuroplasticity following anterior cruciate ligament injury. J Orthp Sports Phys Ther. 2015
North JS, et al. The relative importance of different perceptual-cognitive skills during anticipation. Hum Mov Sci. 2016
Smeeton NJ, et al. The relative effectiveness of various instructional approaches in developing anticipation skill. J Exp Psychol Appl. 2005
Ward P, Williams AM. Perceptual and cognitive skill development in soccer. J Sport Exerc Psychol. 2003

26. Considerations for Brain Training
26
■ Perception and Action are interdependent (coupled)
– Prediction accuracy and response speed are greatest when
executed during functional movement
■ Supraspinal processes determine kinetic chain stiffness
– Affect precision and speed of reactive responses
■ Attention/processing resources limited, but adaptable
– Selective attention limits visual field awareness
– Central-peripheral visual input integration can be improved
Farrow D, Abernathy B. Do expertise and the degree of perception-action coupling affect natural anticipatory performance? Perception. 2005
Nakata H, et al. Characteristics of the athlete’s brain. Brain Res Rev. 2010
Wolpert DM, et al. Principles of sensorimotor learning. Nat Rev Neurosci. 2011

27. Whole-Body Reactive Agility with Cognitive Demand
27
Lateral Side-Shuffle Agility Test
10 Left – 10 Right
Diagonal 4-Corner Agility Test
4 Left/Forward – 4 Right/Forward
4 Left/Backward – 4 Right/Backward
>>>>><<<<<
>><>> <<><<

28. Neuroplasticity – Network Reorganization
28
■ Change in structural connections among neurons
– Alteration in patterns of neural information flow
■ Interactions among widely separated regions of brain
■ Astrocytes interact with neurons (network-specific)
– Key role in synaptogenesis and synaptic transmission
Haim LB, Rowitch DH. Functional diversity of astrocytes in neural circuit regulation. Nat Rev Neurosci, 2017
Neurons that fire together, wire together
Neurons that fire out of sync, fail to link

29. NEUROMECHANICAL
RESPONSIVENESS TO
ENVIRONMENTAL CUES
& INJURY POTENTIAL
MULTI-
SEGMENTAL
ALIGNMENT
BRAIN
PROCESSING
OF NEURAL
INPUT
POSTURAL
BALANCE
MUSCLE
STRENGTH &
ENDURANCE
VISUOMOTOR
REACTION
TIME
REFLEXIVE
MUSCLE
RESPONSES

30. Summary
30
1. Accumulating evidence suggests long-term disruption of
normal brain network connectivity following concussion
2. Deficient neuromechanical coupling capabilities may persist
following concussion or MSK injury, elevating risk for re-injury
3. Visuomotor reaction time appears to be a highly modifiable
factor that may reduce injury risk and enhance performance
Gary-Wilkerson@utc.edu