Treatment for orthopedic injuries has primarily been concerned with musculoskeletal health and recovery. Range of motion, strength, posture, PNS, soft tissue healing, structure, movement patterns, and biomechanics have taken top priority. These are helpful factors in rehabilitation, however current research is calling for a much more whole systems approach to physical therapy. In my opinion, this is largely overdue and I’m fully on board with it.
Other systems which Physical therapists could include for a more well rounded treatment approach are psychological factors, social factors, contextual factors, and the central nervous system including the eyes and the mind.
The Stroop task is a cognitive task meaning it brings the brain into play by adding in decision making, processing speed, inhibition, and attention. Adding in a brain game (like the Stroop Task) during a physical challenge brings two systems on board: the musculoskeletal system and the central nervous system. This type of activity is called dual tasking by requiring the patient to perform two complex tasks simultaneously.
Dual tasking has been implemented in pediatric physical therapy, occupational therapy, and physical therapy for neurologic disorders and concussion, but has been left out of orthopedics. Perhaps this is due to our near-sightedness in postural, structural, and biomechanical constructs.
Watch the Stroop Task video then read below for how to implement it with your orthopedic patients.
As a PT when you watch your patient perform a dual task, two things could happen that are equally valuable and give you information:
- The physical task is performed with more quality, speed, coordination, and/or control
- The physical task is performed with less quality, speed, coordination, and/or control
In the first case, the physical task could look better because the patient is distracted by an external focus of attention and away from the body. This would be beneficial in regards to painful movement, kinesiophobia, and hypervigilence on pain.
If the dual task is more challenging then perhaps this patient relies heavily on their visual system for motor control and balance. This is found to be true in many athletes after a musculoskeletal injury. Vision is only one aspect of balance. Patients also needs vestibular and somatosensory input for balance.
Perhaps this patient fatigues easily after cognitive tasks as in the case with post concussion. Athletes need to be able to make decision in game time speed so adding in a cognitive dual task can help the PT to see if they are ready for return to sport. Return to sport should challenge the athlete mentally and physically since that is what happens in real time play.
“Research has shown that people with chronic pain have difficulty directing their attention away from pain. A mental strategy that incorporates focused attention and distraction has been found to modulate the perception of pain intensity.”
The Stroop task is one strategy to reduce pain perception, not the only way. It is fun and challenging for people and gives them something else to think about besides the difficulty of the movement.
Think of it as a down-regulation strategy to help lessen pain. The clinical relevance being that performing a highly demanding task might distract attention from pain. The visual system, auditory system, and somatosensory are commonly used to initiate distraction.
Telling someone not to think about their pain doesn’t work, but allowing their attention to be focused elsewhere can be more motivating. Focused attention has been regarded as a better strategy than distraction for pain modulation.
A few key reminders:
- Give the patient autonomy in the dual task. For example, let them choose between a couple different physical tasks or choose the speed at which they move. And don’t step in to cue them on the movement!
- The physical task should be challenging but not overwhelming. It also needs to represent the goals for that particular patient. If it’s a runner, have them doing single leg hopping or running in place, provided their body can handle load and impact. The more personal, the more motivating.
- It is called dual task for a reason. Not triple task or quadruple task. Don’t overcomplicate it for you or your patient.
For return to sport rehab, dual tasks are an assessment paradigm to identify performance deficits. In this regard, the Stroop task allows you to see how well the athlete can tolerate a cognitive task when combined with a sport specific physical task. It has been shown in research to have high reliability and is “beneficial if incorporated into the evaluation of physical and mental function of athletes.”
Dual tasks can allow you to screen for motor performance and also train the patient in a well rounded way.
After an injury, one’s attention is visually and cognitively directed to the injured body part. Then in PT we affirm this attention as a means for more control and stability. Having the patient dual task by occupying the mind with memory tasks, can increase the neural demand of neuromuscular training strategies.
If balance and motor control rely heavily on the visual system for feedback then adding a cognitive task like Stroop can bring the visual field elsewhere and off the body part.
Studies show when vision was perturbed, patients with ACL injuries performed significantly worse (e.g., increased postural sway, failure in task completion). Therefore, these types of “neurocognitive” (term from Dr. Dustin Grooms) tasks are highly beneficial for neural processing and confidence with return to sport.
For our athletes we need to mimic their sport specific environment as much as possible. This doesn’t just mean aesthetically, but in paying attention to the visual, cognitive, vestibular, and somatosensory just as much as the musculoskeletal.
For an example of how to use the Stroop Task with movement go here