Optimal Training for Movement Acquisition and Transfer: Does "Externally Focused" Visual Biofeedback Promote Implicit Motor Learning?

CONTEXT: Visual biofeedback has been shown to facilitate injury-resistant movement acquisition in adolescent athletes. Visual biofeedback is typically thought to foster implicit learning by stimulating athletes to focus attention externally (on movement outcome). However, biofeedback may also induce explicit learning if the athlete uses the visual information to consciously guide movement execution (via an internal focus). OBJECTIVE: To determine the degree to which athletes reported statements indicating implicit or explicit motor learning after engaging in a visual biofeedback intervention. DESIGN: Prospective cohort study. SETTING: Three-dimensional motion-analysis laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-five adolescent female soccer athletes (age = 15.0 ± 1.5 years, height = 165.7 ± 5.9 cm, mass = 59.4 ± 10.6 kg). INTERVENTIONS: Standard 6-week neuromuscular training intervention (three 90-minute sessions/wk), with added visual biofeedback sessions (2 sessions/wk). For the biofeedback training, participants performed squatting and jumping movements while interacting with a visual rectangular stimulus that mapped key parameters associated with injury risk. After the last biofeedback session in each week, participants answered open-ended questions to probe learning strategies. MAIN OUTCOME MEASURE(S): Responses to the open-ended questions were categorized as externally focused (ie, on movement outcome, suggestive of implicit learning), internally focused (ie, on movement itself, suggestive of explicit learning), mixed focus, or other. RESULTS: A total of 171 open-ended responses were collected. Most of the responses that could be categorized (39.2%) were externally focused (41.8%), followed by mixed (38.8%) and internally focused (19.4%). The frequency of externally focused statements increased from week 1 (18%) to week 6 (50%). CONCLUSIONS: Although most statements were externally focused (suggesting implicit learning), the relatively large proportion of internal- and mixed-focus statements suggested that many athletes also engaged in explicit motor learning, especially in early practice sessions. Therefore, biofeedback may affect motor learning through a mixture of implicit and explicit learning.

Randomized clinical trial of Fibromyalgia Integrative Training (FIT teens) for adolescents with juvenile fibromyalgia - Study design and protocol.

OBJECTIVE: Juvenile-onset fibromyalgia (JFM) is a chronic debilitating pain condition that negatively impacts physical, social and academic functioning. Cognitive-behavioral therapy (CBT) is beneficial in reducing functional disability among adolescents with JFM but has only a modest impact on pain reduction and does not improve physical exercise participation. This randomized controlled trial (RCT) aims to test whether a novel intervention that combines CBT with specialized neuromuscular exercise training (the Fibromyalgia Integrative Training program for Teens "FIT Teens") is superior to CBT alone or a graded aerobic exercise (GAE) program. DESIGN/METHODS: This 3-arm multi-site RCT will examine the efficacy of the FIT Teens intervention in reducing functional disability (primary outcome) and pain intensity (secondary outcome), relative to CBT or GAE. All interventions are 8-weeks (16 sessions) in duration and are delivered in small groups of 4-6 adolescents with JFM. A total of 420 participants are anticipated to be enrolled across seven sites with approximately equal allocation to each treatment arm. Functional disability and average pain intensity in the past week will be assessed at baseline, post-treatment and at 3-, 6-, 9- and 12-month follow-up. The 3-month follow-up is the primary endpoint to evaluate treatment efficacy; longitudinal assessments will determine maintenance of treatment gains. Changes in coping, fear of movement, biomechanical changes and physical fitness will also be evaluated. CONCLUSIONS: This multi-site RCT is designed to evaluate whether the combined FIT Teens intervention will have significantly greater effects on disability and pain reduction than CBT or GAE alone for youth with JFM. Clinical trials.gov registration: NCT03268421.

Real-time biofeedback integrated into neuromuscular training reduces high-risk knee biomechanics and increases functional brain connectivity: A preliminary longitudinal investigation.

Prospective evidence indicates that functional biomechanics and brain connectivity may predispose an athlete to an anterior cruciate ligament injury, revealing novel neural linkages for targeted neuromuscular training interventions. The purpose of this study was to determine the efficacy of a real-time biofeedback system for altering knee biomechanics and brain functional connectivity. Seventeen healthy, young, physically active female athletes completed 6 weeks of augmented neuromuscular training (aNMT) utilizing real-time, interactive visual biofeedback and 13 served as untrained controls. A drop vertical jump and resting state functional magnetic resonance imaging were separately completed at pre- and posttest time points to assess sensorimotor adaptation. The aNMT group had a significant reduction in peak knee abduction moment (pKAM) compared to controls (p = .03, d = 0.71). The aNMT group also exhibited a significant increase in functional connectivity between the right supplementary motor area and the left thalamus (p = .0473 after false discovery rate correction). Greater percent change in pKAM was also related to increased connectivity between the right cerebellum and right thalamus for the aNMT group (p = .0292 after false discovery rate correction, r2  = .62). No significant changes were observed for the controls (ps > .05). Our data provide preliminary evidence of potential neural mechanisms for aNMT-induced motor adaptations that reduce injury risk. Future research is warranted to understand the role of neuromuscular training alone and how each component of aNMT influences biomechanics and functional connectivity.

Preliminary Outcomes of a Cross-Site Cognitive-Behavioral and Neuromuscular Integrative Training Intervention for Juvenile Fibromyalgia.

OBJECTIVE: Cognitive-behavioral therapy (CBT) is effective in reducing disability among youth with juvenile fibromyalgia (FM); however, engagement in moderate to vigorous physical activity remains poor, even after CBT. The purpose of this study was to evaluate the feasibility and preliminary outcomes of an innovative program combining CBT with specialized neuromuscular exercise: the Fibromyalgia Integrative Training for Teens (FIT Teens) program. METHODS: Adolescents with juvenile FM (n = 22, all female, ages 12-18 years) from 2 urban children's hospitals participated in the 8-week FIT Teens intervention. Participants completed measures of pain intensity, functional disability, depressive symptoms, pain catastrophizing, fear of movement, and readiness to change at baseline and after the intervention. RESULTS: The feasibility of the intervention across 2 sites was documented, including high retention rates (80%). Participants showed significant decreases in functional disability (P < 0.05), depression (P < 0.001), fear of movement (P < 0.01), and pain catastrophizing (P < 0.001) from pre- to postintervention. Results of the readiness to change measure indicated a significant decrease in precontemplation (P < 0.01) and increase in action/maintenance scores (P < 0.001). All results demonstrated medium to large effect sizes. CONCLUSION: Adolescents with juvenile FM reported significant improvements in physical function and reduced fear of movement following the intervention. Improvement in physical function was achieved in a shorter time frame than in a prior trial of CBT without an exercise component. Further work is needed to compare the FIT Teens program with existing approaches and determine whether objective changes in exercise participation are achieved.