Latest / The ACL Athlete Podcast / 037 | Get the Most Out of Your Quads with Neuromuscular Electrical Stimulation (NMES)

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037 | Get the Most Out of Your Quads with Neuromuscular Electrical Stimulation (NMES) · The ACL Athlete Podcast

• 0:19
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:23
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:33
  SPEAKER_00: I'm your host, Dr.
• 0:34
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:38
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:46
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:57
  SPEAKER_00: Thanks for joining.
• 0:58
  SPEAKER_00: Now let's dive into today's episode.
• 1:04
  SPEAKER_00: What's up guys, and welcome back to another episode on the ACL Athlete Podcast.
• 1:10
  SPEAKER_00: Today is episode number 37, and we are talking about NMES, Neuromuscular Electrical Stimulation for Your Quads in ACL rehab.
• 1:22
  SPEAKER_00: And before we dive into this, I just want to put a disclaimer that you need to consult with your medical provider, PT, whoever it is you're working with, before using NMES.
• 1:34
  SPEAKER_00: And today is purely just educational.
• 1:37
  SPEAKER_00: And what I want you to do is make sure it's right for your specific case, and hopefully it applies so that way you can get the most out of your quad and out of your ACL rehab.
• 1:49
  SPEAKER_00: Alright, so what is NMES?
• 1:52
  SPEAKER_00: Neuromuscular electrical stimulation.
• 1:55
  SPEAKER_00: So exactly kind of what it says.
• 1:57
  SPEAKER_00: So neuromuscular, so we're trying to impact the nerves and the muscle unit.
• 2:02
  SPEAKER_00: So for this example, we're talking about the quads and the femoral nerve, and we are using electrical stimulation to help kick that thing on, to help it fire.
• 2:13
  SPEAKER_00: And what you typically see is this early in rehab, and it is these sticky gel pads that you'll see, some on the thighs, and the muscle is pulsating, and it'll pulsate and then it'll go to a strong contraction and then it'll relax, and then uh you'll go through a sequence of these different contract relax to get the quad to fire, and it's all safe as long as you are abiding by the right parameters and that you've consulted with a medical provider to make sure that this is right.
• 2:46
  SPEAKER_00: But I see this get missed all the time early in ACL rehab, and it's such a huge benefit with athletes to be able to utilize NMES, and it's tough because it really depends on if the physical therapist that you're working with has the equipment and is able to utilize it.
• 3:06
  SPEAKER_00: But guess what?
• 3:07
  SPEAKER_00: There are affordable options that you can use in your own home.
• 3:11
  SPEAKER_00: So don't just be limited by what you have at the clinic and make sure that you're using it appropriately.
• 3:18
  SPEAKER_00: And as you see, as I go through this today and tell you about it, you're gonna be like, Well, this is something that I need to add to my regimen, obviously, depending on where you're at in the process.
• 3:29
  SPEAKER_00: So, why should we use it?
• 3:31
  SPEAKER_00: And I'm gonna start with stating the quads, the quadriceps are the most important muscle in your ACL rehab process, recovery all the way through, and it's the one that we see the biggest deficits that translate over to functional outcomes, uh performances, pain, arthritis, all these things down the road.
• 3:53
  SPEAKER_00: There are a list of factors, but quadriceps weakness is one of the biggest ones up there.
• 3:59
  SPEAKER_00: And if we try to reverse engineer, well, how can we maximize this process as soon as the ACL injury happens?
• 4:06
  SPEAKER_00: And then also after surgery, then we can make sure that your outcomes are as best as possible, and that includes having NMES in this process, especially early.
• 4:19
  SPEAKER_00: And the quadriceps is at its weakest right after surgery due to just the deconditioning, it's hard to activate.
• 4:28
  SPEAKER_00: Well, you just had surgery, so there's been trauma to the knee.
• 4:32
  SPEAKER_00: Usually, this is accompanied by a nerve block that's done either at the femoral nerve or the adductor nerve.
• 4:39
  SPEAKER_00: There's pain, there's swelling, there is this term that's called orthogenic muscle inhibition, which is a very complicated mess of all these combinations.
• 4:50
  SPEAKER_00: You'll hear it referred to as AMI, and one of the things that is impacted are the neural pathways and the activation, and this can go all the way up towards the brain, to the spinal cord, into those nerves that branch out to help activate your quad muscle.
• 5:09
  SPEAKER_00: So these are all being impacted, and one of our goals early on in ACL rehab, as you've heard me say in the past, is we got to get that quad activated and contracting by your own nature, and that's what's most important.
• 5:24
  SPEAKER_00: So we call that volitional quad contraction.
• 5:27
  SPEAKER_00: You're doing it on your own volition, and we need that to happen.
• 5:31
  SPEAKER_00: And NMES is shown to help with this and improve the activation of the quads, and could be used to help augment quadriceps strengthening work that we're doing in a positive way, and has been shown to improve outcomes for quadriceps strength, self-reported function, and functional performance down the road.
• 5:52
  SPEAKER_00: And this is from research studies.
• 5:54
  SPEAKER_00: A really good one is effects of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction on quadriceps strength, function, and patient-oriented outcomes.
• 6:06
  SPEAKER_00: A systematic review.
• 6:08
  SPEAKER_00: That's a lot of words.
• 6:09
  SPEAKER_00: But this is a systematic review by Kim in 2010 that shows a very positive outcome with using NMES in your ACL rehab to help benefit your quads.
• 6:22
  SPEAKER_00: And one of the giants and research, Lynn Snyder Mackler, she's done some research dating back to 1994, 1995, where East End was beneficial for the studies that she did, and we've seen that repeatedly.
• 6:38
  SPEAKER_00: And these were done so early.
• 6:40
  SPEAKER_00: I mean, 1994, 1995.
• 6:43
  SPEAKER_00: We've known this for 20 plus years now.
• 6:46
  SPEAKER_00: So this should be something that is just normal and a part of the process, and we should integrate it.
• 6:53
  SPEAKER_00: Now, that's not to say every single person has to do it or needs to.
• 6:57
  SPEAKER_00: We could still get by without doing it, but it's just an added benefit to this process.
• 7:03
  SPEAKER_00: And some other articles just for you to be able to look at Turan Dodge 2013, hopefully I said that right, Hauger 2017 with Mike Ryman on that, and then Toth in 2020.
• 7:17
  SPEAKER_00: They all show different populations and the benefits of NMES compared to control groups.
• 7:23
  SPEAKER_00: And what NMES does, it directly recruits the motor neurons.
• 7:28
  SPEAKER_00: So we're talking about the motor part of your femoral nerve to produce a better quadriceps contraction and for better strength gains than just doing voluntary exercises alone.
• 7:41
  SPEAKER_00: And this has led to better functional outcomes with activation and strength.
• 7:47
  SPEAKER_00: And that was a study done with Palmyri Smith 2008.
• 7:52
  SPEAKER_00: So there are a lot of studies that support this.
• 7:56
  SPEAKER_00: Now, as time goes on, sure this could be refuted, but as of the collective body of research, it seems weird that we would not use this to help with our ACL rehab process.
• 8:08
  SPEAKER_00: And if I'm even just using my own anecdote, whenever I used NMES for my ACL rehabs, it was huge.
• 8:16
  SPEAKER_00: It was a huge game changer.
• 8:17
  SPEAKER_00: I had difficulty activating my quads, and this NMES helped me to put that mind muscle type connection and to be able to help fire, and it helps to also visually see it.
• 8:30
  SPEAKER_00: And then you're trying to work really hard to hit that quad set or whatever movement you're doing to be able to continue to build that neural pathway back up.
• 8:40
  SPEAKER_00: And so that's something that I remember was very beneficial, and I use it with both of mine, and I loved it.
• 8:46
  SPEAKER_00: And now working with ACL athletes, whether it's remote or whether it's in person, it's one of the things that I recommend, unless there might be some sort of contraindication as to why they shouldn't do it.
• 8:59
  SPEAKER_00: But it's a very rare instance where you're not supposed to be doing it.
• 9:03
  SPEAKER_00: So this is something that I like to personally pair up with blood flow restriction training early on in the process to reduce that muscle atrophy and to help build that quad back and to feel that thing kick on again.
• 9:18
  SPEAKER_00: So now let's get into how we should use it.
• 9:21
  SPEAKER_00: And again, make sure you're consulting with someone who is a medical provider to know how to utilize it in your specific case.
• 9:30
  SPEAKER_00: But the parameters, so these can vary a lot based on the device, your own tolerance, if you have the option to change these settings.
• 9:39
  SPEAKER_00: But here is just a general overview.
• 9:42
  SPEAKER_00: So the wavelength can be anywhere from 300 to 1,000 microseconds, the frequency can be 50 Hertz, the ramp up time is two seconds, the on time is 10 to 15 seconds, the off time is 50 seconds, and typically the total time that you will do that work is 10 minutes.
• 10:06
  SPEAKER_00: The intensity itself, so the dial that you'll turn up, is at max tolerable.
• 10:12
  SPEAKER_00: So you want this as strong and as high as possible, but you don't want to be sitting there in misery or a ton of pain, but we want to be able to see what we call a titanic contraction.
• 10:22
  SPEAKER_00: So we want it to be visible and we can hold it, and this is a way to gauge that intensity, and sometimes you just need to build into it.
• 10:32
  SPEAKER_00: And in terms of the pad size, so the east end pad size and the placement, one mistake you'll see is that they're too small.
• 10:41
  SPEAKER_00: You'll use these small little squares, and they don't cover as much surface area, so we don't get to contact as much of the quad as we want, and therefore the impulse would not be nearly as strong as compared to getting those bigger rectangular ones or the oval ones that cover up a little bit more surface area, so we can get that good contraction and impulse to make sure we are utilizing as much of the quad as possible.
• 11:10
  SPEAKER_00: In terms of pad placement location, you're gonna have one at the VMO, the vastus medialis obliqueus.
• 11:18
  SPEAKER_00: So that's where that teardrop is.
• 11:20
  SPEAKER_00: Just think on the inside of the knee, and then on the other end, you're gonna have one closer up towards the hip.
• 11:29
  SPEAKER_00: Think about where your pocket typically is, and that's going to be on your vastus lateralis.
• 11:35
  SPEAKER_00: So you still need to make sure that it's on your quads and you don't hit like your TFL or your hip flexor, or you're too far below the knee or your adductor.
• 11:44
  SPEAKER_00: So this is where pad placement is important to make sure you have the entire muscle belly of the quad kind of covered from as far down near the VMO to the vastus lateralis up near the hip.
• 11:58
  SPEAKER_00: But just make sure they're both on the quads.
• 12:01
  SPEAKER_00: In terms of position with what you're doing, most times you'll see this in supine or laying on your back with things like quad sets, which is great early on because you know your knee is limited and you can't really do that much.
• 12:14
  SPEAKER_00: So having a straight leg, you know, you're just kind of firing that quad with quad sets and having the NMES on there.
• 12:21
  SPEAKER_00: And then you can kind of build towards, depending on if you're weight bearing or where you're at in the process early, you can do it with TKEs, terminal knee extensions, uh, or short short arc quads.
• 12:33
  SPEAKER_00: I like to do it with TKEs because we're kind of getting into the gait pattern, so then we can start working on that terminal knee extension where we have heel contact in our walking pattern, and we're trying to fire up the quads and get that extension back.
• 12:48
  SPEAKER_00: So I like that position a lot to build towards once it's tolerated.
• 12:52
  SPEAKER_00: There are a number of different exercises like that where we could isolate the quad.
• 12:57
  SPEAKER_00: But one that I think can get missed that is actually a really good position that we try to train a lot actually, and where the isokinetic testing is done and isometric testing, but doing this in a 60-degree to 90-degree knee extension position.
• 13:14
  SPEAKER_00: So imagine you're sitting in a leg extension machine.
• 13:17
  SPEAKER_00: Let's say you're able to just max out the weight on it.
• 13:21
  SPEAKER_00: So let's say it's like two or three hundred, that way it's kind of an immovable force.
• 13:26
  SPEAKER_00: And you can also do it with a strap that's hooked to a bench, or even something where you're like seated up against a wall and you're kind of kicking into the wall with your foot.
• 13:36
  SPEAKER_00: Something that's immovable essentially, and you want to aim for that 60 degree, and you can work in various positions depending on the tolerance of your knee and the flexion range and comfort you're in.
• 13:49
  SPEAKER_00: But try doing it this way.
• 13:50
  SPEAKER_00: So you're seated and you are kicking into the wall and or the knee extension machine at 60 degrees, and you're using the NMES for that 10 to 15 seconds on, and then resting.
• 14:03
  SPEAKER_00: And this is a great position because this is also where we produce our max peak torque of our knee and our quadriceps.
• 14:10
  SPEAKER_00: So it's a good place to train this position once you can tolerate it with the NMES and with producing force.
• 14:18
  SPEAKER_00: And this will come back also to the type of tendon you have and the graft and all the pain and comfort that you will have or discomfort you'll have in this process.
• 14:29
  SPEAKER_00: So make sure you're gauging that.
• 14:31
  SPEAKER_00: So typically starting quad sets into maybe TKEs or short arc quads.
• 14:36
  SPEAKER_00: Uh, but I get my athletes pretty early into the knee extension isometric at 90 to 60 degrees with this.
• 14:45
  SPEAKER_00: And so now you're probably wondering when to start it and how often in a week do we do it?
• 14:50
  SPEAKER_00: So this is gonna vary a lot, and it's gonna depend on your specific case.
• 14:55
  SPEAKER_00: But some research starts at three days post-op and they do it anywhere from four to twelve weeks.
• 15:01
  SPEAKER_00: On average, what you will see is six weeks of duration, and some will do it three times per week, some say do it every day, and some did it three times per day.
• 15:14
  SPEAKER_00: So there's a lot of variation in terms of the different protocols to use it.
• 15:19
  SPEAKER_00: My personal recommendation is to do it early and do it often.
• 15:24
  SPEAKER_00: So start it as early as you can post op or post-injury, see how the knee tolerates it by doing it one time, see how it feels the next day, and if it tolerates it well, then maybe you can bump it to every day.
• 15:40
  SPEAKER_00: And depending on your specific case, it can't even be multiple times a day.
• 15:46
  SPEAKER_00: But as a rule of thumb, at least one time per day should be enough for you to be able to get the most out of this.
• 15:53
  SPEAKER_00: And remember, this is a stress recovery balance process, so you don't want to just crush it all the time with ESTEM or neuromuscular electrical stimulation and just constantly crush it.
• 16:06
  SPEAKER_00: And you want to make sure that you balance the recovery process with this.
• 16:09
  SPEAKER_00: So think about it as doing it early and often.
• 16:12
  SPEAKER_00: Start off with one time, see how your knee responds, and if you get a good response from it, and then just continue to kind of weave it into the process.
• 16:22
  SPEAKER_00: Most importantly, work with your PT and see what they personally recommend.
• 16:27
  SPEAKER_00: I would say even three times a week is a very effective dose to get the most out of NMES.
• 16:34
  SPEAKER_00: Now you're probably wondering how the heck do I get my hands on a device?
• 16:39
  SPEAKER_00: And now there are some brands that can get pretty expensive and they're fancy and they have the name like Compex or PowerDot.
• 16:47
  SPEAKER_00: I don't have any financial obligations with any of these companies, but those are the ones that you'll hear.
• 16:53
  SPEAKER_00: In all honesty, a cheap and effective unit on Amazon for about 50 bucks is the Belego EMS Digital Neuromuscular NMES stimulator.
• 17:04
  SPEAKER_00: That one's really great.
• 17:06
  SPEAKER_00: I've used it myself.
• 17:08
  SPEAKER_00: I have athletes who are using it, and it gets the job done, it's effective, and it also doesn't break the bank.
• 17:15
  SPEAKER_00: And that is something that you can kind of check out.
• 17:17
  SPEAKER_00: I'll even put a link in the show notes.
• 17:19
  SPEAKER_00: Again, no financial uh affiliation here.
• 17:23
  SPEAKER_00: Just want you guys to have an option if you're going through this process.
• 17:27
  SPEAKER_00: And I know it's hard to kind of filter through to be able to figure that out.
• 17:31
  SPEAKER_00: So I'll put that link in the show notes, but just make sure that it is an NMES device and not a tens unit.
• 17:39
  SPEAKER_00: There will be cheaper ones that are just for pain modulation, which are tens units.
• 17:44
  SPEAKER_00: We want NMES because it can put in a certain burst as well as a certain current that we need to get the most out of your quads.
• 17:53
  SPEAKER_00: Alright, so big takeaway from today if you are early in your process or you have difficulty firing your quad, get some NMES going, do it early, and do it often.
• 18:06
  SPEAKER_00: Alright, guys, that does it for today.
• 18:08
  SPEAKER_00: Thank you all so much for listening.
• 18:11
  SPEAKER_00: This is your host, Ravi Patel, signing off.