Review Article

Functional Brain Plasticity Associated with ACL Injury: A Scoping Review of Current Evidence

Table 1

Summary of the techniques used to measure brain activity and clinical interpretations in ACL injury.

TechniqueMeasurementInterpretation

EEGSomatosensory-evoked potentials (SEPs)Peaks of activity are measured by electroencephalography (EEG) electrodes in the somatosensory cortex after an external stimulus is delivered to the common peroneal nerve or to the ACL (i.e., via arthroscopy)The ascending stimulus to the somatosensory cortex, following common peroneal nerve stimulation, is detected as P27 component which provides information about the afferent system. Literature shows contradictory information regarding the ability to reproduce SEPs in people with ACL deficiency or reconstruction
Spectral analysisEEG signals are measured during a movement (i.e., joint angle or force reproduction). The mean absolute EEG spectral power is divided into different frequencies: delta (0–4 Hz), theta (4.75–6.75 Hz), alpha 1 (7–9.5 Hz), alpha 2 (9.75–12.5 Hz), beta (12.75–18.5 Hz), and gamma (30–80 Hz), corresponding to different levels of activity in different areas of the cortexIt has been suggested that differences in theta power in the frontal cortex may be linked to differences in working memory and focused attention, whereas alpha power is typically inversely related to the neuronal activation. As such, increased alpha power recorded over parietal cortical areas may be interpreted as a deactivation of the somatosensory cortical areas

TMSMotor-evoked potentials (MEPs)Muscle response (measured by electromyography), following a transcranial magnetic stimulus (TMS) delivered at the motor cortex travelling down the motor pathwaysDecreased MEPs represent less information travelling in the motor pathways to the target muscle
Motor thresholdMinimum transcranial magnetic stimulation (TMS) intensity necessary to cause a response (MEP) in the target muscle—it is a measure of motor cortex excitability and can be measured at rest (i.e., resting motor threshold), or during an activity (i.e., active motor threshold (AMT))Motor threshold is inversely related to motor cortex excitability, meaning that people with reduced corticomotor excitability would have a higher motor threshold. A reduction in motor cortex excitability may affect motor output
Intracortical inhibition (SICI and LICI)Paired TMS pulses (first, a conditioning subthreshold pulse, followed by a suprathreshold testing pulse) are delivered with varying interstimulus intervals. Short intervals (<5 ms) produce short-interval intracortical inhibition (SICI), while longer intervals (>50 ms) produce long-interval intracortical inhibition (LICI)SICI is associated with GABAa activity, while LICI is associated with GABAb activity. Higher levels of intracortical inhibition may be associated to lower cortical excitability
Cortical silent period (CSP)The cortical silent period (CSP) corresponds to an interruption in voluntary electromyography (time from MEP onset to EMG activity resumption) in the target muscle following TMS. CSP is mediated by GABAb activity at a cortical levelLonger CSP represent higher levels of inhibition, which may lead to muscle inhibition. However, a link between CSP and MEP changes has not been established
Intracortical facilitationSimilar to intracortical inhibition measurements, paired TMS pulses are used for measuring intracortical facilitation. In this case, a 7 to 30 ms interval between the conditioning and testing pulses is usedCortical facilitation is mediated by neurotransmitter glutamate onto non-N-methyl-D-aspartate receptors. There is conflicting evidence on whether ICF is changed in people with ACL injury or reconstruction

MRIFunctional MRI during a taskThe blood oxygen level-dependent signal is quantified through the blood hemodynamics during a specific task (e.g., knee flexion-extension cycles)An increased BOLD signal is associated to a higher activity of the respective brain area, which may be associated to reduced efficiency of these cortical regions, in people with ACL injury