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282 | 10 Common NMES Mistakes in ACL Rehab - Part 1 · The ACL Athlete Podcast

• 0:18
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:22
  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.
• 0:31
  SPEAKER_00: I'm your host, Dr.
• 0:32
  SPEAKER_00: Robbie Patel, performance physical therapist and coach.
• 0:36
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:43
  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.
• 0:54
  SPEAKER_00: Thanks for joining.
• 0:55
  SPEAKER_00: Now let's dive into today's episode.
• 1:01
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:07
  SPEAKER_00: So today we are kicking off a two-part series on one of my favorite tools in ACL rehab.
• 1:13
  SPEAKER_00: That is NMES or Neuromuscular Electrical Stimulation.
• 1:20
  SPEAKER_00: And so this is something that I have talked about in previous podcast episodes, and it's one of the earlier episodes that I touched on, covering the research, the specific parameters, even some of the devices.
• 1:33
  SPEAKER_00: So that is something that you can easily search, go to our website and look at the blog or look at the podcast and search NMES, and those episodes will come up.
• 1:43
  SPEAKER_00: But today I want to talk a little bit more on NMES and revisit this, but more so from things that I've observed, things that I want to share that are some mistakes that I see, but then things that we have seen in practice that are effective, what the research shows, and things to just squeeze out every little bit of using this tool and this modality as much as we can.
• 2:09
  SPEAKER_00: Whether you're an ACLer, a clinician listening to this, maybe a parent helping your athlete with this, whoever you may be, like this is something that I think there are some things that we can tackle with this that we can make sure we get the most out of our quads.
• 2:26
  SPEAKER_00: And the thing that is always just still so surprising to me, even after all these years, as much as you might see NMES talked about in the social media space or whatever it may be, it's still very common to hear of people not using it.
• 2:44
  SPEAKER_00: And there are people I talk to still every single week who are like, yeah, I don't know what that is.
• 2:49
  SPEAKER_00: We never use that, or oh yeah, we use that, but we only used it for a couple weeks.
• 2:54
  SPEAKER_00: Their quad started to fire, or their PT was like, Oh, we could see your quad.
• 2:59
  SPEAKER_00: So we just need to stop it and move on to the next thing, which you know, context is important in this, and that'll be something really important in this entire episode and the series in general, because you can't just blanketly apply everything, but it will allow you to essentially pull some things from this that I think will be so, so valuable for you.
• 3:22
  SPEAKER_00: And the thing that we just want to make sure is that just because the quads start firing doesn't mean that we are done with this, right?
• 3:30
  SPEAKER_00: There's a lot more to get out of it.
• 3:32
  SPEAKER_00: So, across two episodes, we're gonna cover 10 of the most common NMES mistakes I see athletes and honestly clinicians as well making through this process and just things that I'm hoping that we could talk through in part one, the big picture stuff around whether you're using it correctly, when you're using it, how often, the intensities, and then part two next week gets into the setup and execution details, more specific on pad placement, size, the cycles that are used, skin contact, batteries, and then also just some other parameters that can help with getting this thing dialed in.
• 4:10
  SPEAKER_00: But before I get into these, I do want to share something that was the whole reason behind making this episode series.
• 4:19
  SPEAKER_00: And one of the things that I think needs to be clearly stated is that NMES should be the standard of care for any postoperative knee case.
• 4:28
  SPEAKER_00: I really don't think it should be optional.
• 4:30
  SPEAKER_00: When we think about how much the knee is impacted, whether you have a minor menisectomy or a meniscus procedure or whatever it might be that is not nearly as invasive as maybe an ACL reconstruction, but especially a total joint replacement, I just don't see how it doesn't make sense to use NMES, especially when we see the research shows there is very strong outcomes in quad activation, regaining extension, and all the things that is beneficial in SY is also a superior type modality compared to other things we might see in the research.
• 5:10
  SPEAKER_00: It shouldn't be just one of these things where, oh, if your PT happens to have a unit at the clinic, you get it.
• 5:15
  SPEAKER_00: It should be a requirement across the board.
• 5:17
  SPEAKER_00: And that goes for ACL reconstructions, quad tendon repairs, patellar tendons, meniscus, you name it.
• 5:24
  SPEAKER_00: Any knee surgery where the quad might be inhibited, aka any knee surgery, especially if there's swelling and pain involved, then we need to use it.
• 5:33
  SPEAKER_00: And as I shared, we talk with ACL athletes all the time who aren't using it.
• 5:38
  SPEAKER_00: Or, like I said, they were doing it very temporarily and they're no longer doing it anymore.
• 5:44
  SPEAKER_00: And I do get it, right?
• 5:46
  SPEAKER_00: Like I think that sometimes PTs they'll see the quad activate and they'll say, okay, it's working.
• 5:51
  SPEAKER_00: We don't necessarily need it anymore.
• 5:53
  SPEAKER_00: But it's a bit of a subjective thing, right?
• 5:56
  SPEAKER_00: Like, yes, we can get extension, yes, the quads are active, but I think we are still undershooting what the total benefit of NMES is.
• 6:05
  SPEAKER_00: And I think sometimes it's like, oh, okay, let's wake the muscle up, but it's actually let's squeeze out of this the most that we can because there is some sort of neurological disconnect as well, not only locally, but from the brain to the quad itself, both bidirectional.
• 6:23
  SPEAKER_00: The afferent pathways and the motor pathways are both impacted.
• 6:29
  SPEAKER_00: That means the sensory going in, the motor going out, those are impacted.
• 6:33
  SPEAKER_00: And so then, therefore, we need to do everything we can until we essentially get ourselves to a good place where this quad is doing its thing.
• 6:41
  SPEAKER_00: You're talking about 80, 90% symmetry, good torque to body weight.
• 6:45
  SPEAKER_00: Like these are things that we need to keep tapping into, especially for the cases where it feels like the quad is taking a long time to recover.
• 6:54
  SPEAKER_00: And so I'm excited to dive into this today.
• 6:57
  SPEAKER_00: I think that it's something that we need to make sure that it's a tool that we can utilize.
• 7:04
  SPEAKER_00: I want to make sure it's not something that we underuse, that it's something that we just kind of abandoned too early, um, and it's something that we can just kind of create more of as a standard.
• 7:15
  SPEAKER_00: And the other thing that I'm just gonna tag along with this is that a lot of times people will spend a lot of time, you know, spending a hundred bucks, two hundred bucks, or whatever you may call it.
• 7:25
  SPEAKER_00: They may like load up on all the items, if you will, for post op.
• 7:28
  SPEAKER_00: And it might be the fancy ice machine, you know, the elevated pillows and all these other things that you might use super temporarily.
• 7:37
  SPEAKER_00: And don't get me wrong, get a good ice machine, you know, but at the end of the day, like whenever you're looking at what is gonna move the needle in this process, it's not gonna be that amazing ice machine that you got.
• 7:48
  SPEAKER_00: It's gonna be the NMES unit you get.
• 7:52
  SPEAKER_00: And in my opinion, I think blood flow restriction training is also should be a part of majority of ACL rehab, especially post op.
• 7:59
  SPEAKER_00: But with that said, like NMES is a non-negotiable for us.
• 8:02
  SPEAKER_00: And it should be that operating standard and it should be where we put you know an investment in versus maybe some of the other kind of tertiary stuff that sometimes people will will buy, right?
• 8:14
  SPEAKER_00: And that is something I want to help understand as we walk through this a little bit more and through this list of things, because I think it's important for you to know.
• 8:23
  SPEAKER_00: And what I go through in this podcast series, you know, I don't want this to be something that are like technically things that you need to go and run to your PT or start spiraling because you didn't do these things or are not doing these things, because some of these will apply to you directly and some may not.
• 8:42
  SPEAKER_00: And if you're approaching using the NMES or post op, then it is something that you can keep in mind and make sure you are tapping into, but especially anyone who is in this process, hopefully you're using it.
• 8:54
  SPEAKER_00: And if you're continuing to use it, you can still get the most out of it, right?
• 8:59
  SPEAKER_00: But there could be a legitimate reason in your care, your team might not necessarily be using it at this point.
• 9:05
  SPEAKER_00: Not every single one of our athletes are using NMES throughout the entire course of their rehab.
• 9:10
  SPEAKER_00: There are certain situations where it might not be warranted based on how they are progressing, the way things are showing up, their numbers that they're looking at, the graph types, maybe access.
• 9:20
  SPEAKER_00: So there are a number of things.
• 9:21
  SPEAKER_00: So we're not here to try and blow up any type of program or what you're doing or not doing.
• 9:26
  SPEAKER_00: The goal is to give you knowledge to ask better questions as always, understand what you're doing and why, and optimize where you have the room to do that.
• 9:34
  SPEAKER_00: So it might just be picking one or two things to be like, oh, I didn't think about that.
• 9:38
  SPEAKER_00: Maybe I could put that in play.
• 9:39
  SPEAKER_00: Or if you're a clinician using this, then it's something that hopefully you can apply to your athletes and get more out of this.
• 9:47
  SPEAKER_00: And if we get more out of this, we can get people moving along better, functioning better, getting back to strength better, back to their activities better, and that's the goal, right?
• 9:56
  SPEAKER_00: So I want to make sure that this has a compounding effect for you to be able to improve over the time that you do this rehab.
• 10:03
  SPEAKER_00: And so as we go into it, when we're talking about NMES, especially if you're a brand new to this and you're like, whoa, Rob, you're coming in with a he.
• 10:12
  SPEAKER_00: What is NMES?
• 10:13
  SPEAKER_00: These four letters I know, I don't know what you were saying.
• 10:16
  SPEAKER_00: So here's the 30-second version.
• 10:18
  SPEAKER_00: After an ACL injury or a significant knee injury, something called orthogenic muscle inhibition kicks in, AMI in short.
• 10:26
  SPEAKER_00: The joint sends a distress signal to the nervous system.
• 10:30
  SPEAKER_00: The nervous system responds by partially shutting down voluntary activation of the quadriceps, the amount that you can activate essentially.
• 10:38
  SPEAKER_00: This is not a conscious decision.
• 10:40
  SPEAKER_00: It is a protective neurological response that we get.
• 10:44
  SPEAKER_00: And it is one of the primary reasons quad atrophies and there's weakness are also so persistent after ACL injury and reconstruction, and sometimes can last often more than just you know a few months.
• 10:58
  SPEAKER_00: It could be months into years that we have some people who might deal with this.
• 11:03
  SPEAKER_00: So it's really important for us to recognize this, and especially the subset who really, really struggle with getting their quads back online.
• 11:10
  SPEAKER_00: And so the best analogy to this is if you think about a Christmas tree and you think about the lights on a Christmas tree.
• 11:19
  SPEAKER_00: Well, if all of the lights are working, then great, you plug it in and all the lights light up.
• 11:24
  SPEAKER_00: That's a normal functioning quad.
• 11:26
  SPEAKER_00: When we have an ACL injury and a surgery, imagine plugging in that Christmas tree, but only 50% of the lights turn on.
• 11:35
  SPEAKER_00: And that's essentially what happens after this ACL injury in the surgery is that the motor output is not the same.
• 11:43
  SPEAKER_00: So it takes a lot more effort to get the same amount of stimulus or the same amount of strength in that quad.
• 11:50
  SPEAKER_00: So the motor unit recruitment is not great, and the neurological disconnect is there.
• 11:54
  SPEAKER_00: So this is something that is hard to really grasp, and is something that we're still continuing to try and understand in the ACL world itself.
• 12:04
  SPEAKER_00: There are people who are leading the front in this that we really appreciate who are sharing more information about this, but we still have as many questions as we do answers.
• 12:13
  SPEAKER_00: But we're doing whatever we can based on the research and based on what we see with athletes to give you our best to make sure you are not the person lagging behind and you're the person who's getting the most out of this.
• 12:25
  SPEAKER_00: Now, this is where NMES comes in neuromuscular electrical stimulation.
• 12:30
  SPEAKER_00: It bypasses that inhibited pathway.
• 12:32
  SPEAKER_00: It uses electrical current to directly stimulate the muscle and force a contraction of your quadricep, regardless of what the nervous system is or is not doing voluntarily.
• 12:41
  SPEAKER_00: It's not some magic.
• 12:43
  SPEAKER_00: Um, it's a tool that works with essentially your human anatomy, your physiology, and what is happening in the knee after that injury and surgery.
• 12:53
  SPEAKER_00: And the research behind it is very strong.
• 12:56
  SPEAKER_00: It's not just, you know, one study here.
• 12:59
  SPEAKER_00: Hogger and colleagues posted a study in 2017 showing NMES is effective for quad strengthening post-ACL surgery.
• 13:06
  SPEAKER_00: Kim and colleagues published a systematic review in JOSPT in 2010 showing NMES showing improvements in strength, function, and patient reported outcome measures.
• 13:16
  SPEAKER_00: Toth and colleagues published a randomized sham-controlled blinded trial in 2020 showing NMES preserved quad muscle fiber size and contractility after ACL injury and reconstruction.
• 13:29
  SPEAKER_00: Many more other studies in addition to that.
• 13:32
  SPEAKER_00: So let's dive into these mistakes that we typically see in this.
• 13:36
  SPEAKER_00: Mistake number one: only use an NMES in the early post op phase.
• 13:41
  SPEAKER_00: This is probably the most common mistake I see very often.
• 13:45
  SPEAKER_00: The pattern looks like this athlete goes to PT for the first few weeks after surgery, gets STEM hooked up, and the quads start firing again.
• 13:52
  SPEAKER_00: Swelling comes down, the NMES disappears from the program.
• 13:55
  SPEAKER_00: Done and we're moving on.
• 13:57
  SPEAKER_00: The problem is that we don't have to necessarily stop there.
• 14:01
  SPEAKER_00: We see benefits up to even 80% limb symmetry index on the involved limb.
• 14:07
  SPEAKER_00: And for most athletes, especially those going through this process, 80% is not something they're hitting in the first few weeks.
• 14:14
  SPEAKER_00: A lot of athletes are still working towards that benchmark for months and months and months, you know, four, five, six, nine months out, they're still working to get there.
• 14:23
  SPEAKER_00: And the piece that is really important here, the quad inhibition does not just exist in the immediate post-op phase.
• 14:30
  SPEAKER_00: AMI or that orthogenic muscle inhibition can persist long after the joint looks and feels better.
• 14:37
  SPEAKER_00: And so that subjective sense of just your quads are activating is not the same as your nervous system fully firing and doing that voluntary recruitment.
• 14:48
  SPEAKER_00: And that gap is exactly where NMES can be super helpful.
• 14:52
  SPEAKER_00: So if you're someone who pulled NMES out of your program because things were feeling better and your quad was visibly contracting, it's something that you can consider in this process to still have in the mix.
• 15:02
  SPEAKER_00: Maybe you don't need to do it every single day.
• 15:05
  SPEAKER_00: Maybe it's something you do a few times a week just to get a little bit more out of it.
• 15:09
  SPEAKER_00: I think that there could be still value in this.
• 15:11
  SPEAKER_00: And there are certain athletes that we still have in even mid and late stages where they're still trying to close this gap, maybe some of the more harder cases that we might still continue to utilize past just, you know, the first early post-op period.
• 15:26
  SPEAKER_00: Now, again, it will be context dependent in terms of who we are saying, hey, you need to be doing this versus not.
• 15:33
  SPEAKER_00: But I think that this is something that we need to just still consider versus the common theme that we see is just doing it early post op.
• 15:43
  SPEAKER_00: Mistake number two, using a TENS unit instead of an MES unit.
• 15:47
  SPEAKER_00: And this is one that when I talk to people and ask them, have you ever heard of this?
• 15:52
  SPEAKER_00: And they're like, Well, I got a TENS unit.
• 15:54
  SPEAKER_00: Or they might be like, Well, my dad has a TENS unit, or you know, my husband has one.
• 15:59
  SPEAKER_00: For some reason, I'm referencing the males who probably need the help.
• 16:02
  SPEAKER_00: Um, the TENS unit is essentially a little different.
• 16:05
  SPEAKER_00: It looks very similar to an NMES unit, but it's different.
• 16:10
  SPEAKER_00: TENS is transcutaneous electrical nerve stimulation.
• 16:14
  SPEAKER_00: This works on the sensory nerve fibers and in general, it is for pain modulation.
• 16:20
  SPEAKER_00: It is not doing anything for the motor output.
• 16:23
  SPEAKER_00: The thing about NMES is that it is targeting motor neurons.
• 16:27
  SPEAKER_00: Its job is to produce a strong visible muscle contraction.
• 16:31
  SPEAKER_00: So it is intentionally built towards that.
• 16:34
  SPEAKER_00: So if you hook it up and your quad is not visibly and strongly contracting, you're not getting the benefit you're looking for, especially if it's just kind of constantly pulsating at a low intensity.
• 16:44
  SPEAKER_00: And so this is one of the things that we want to make sure it's not a tens unit.
• 16:48
  SPEAKER_00: Sometimes they're combo units, but we want to make sure the parameters and the machine itself can be an enemy S unit, sometimes also coined as like a EMS unit, but we want to make sure that the parameters fit and it's not just a tens unit.
• 17:05
  SPEAKER_00: Mistake number three, not using it frequently enough.
• 17:09
  SPEAKER_00: And this might be the highest leverage mistake that I see on the list that I'm sharing with you, because the math is very interesting whenever I actually wrote this out.
• 17:19
  SPEAKER_00: So if you're going to physical therapy twice a week in person, getting NMES hooked up during those sessions, you're probably only doing it for maybe 10 minutes per session.
• 17:29
  SPEAKER_00: So let's say you get 20 minutes of exposure of NMES throughout the entire week.
• 17:34
  SPEAKER_00: 20 minutes, that's it.
• 17:36
  SPEAKER_00: For a muscle that has been, you know, neurologically inhibited since you've had this injury, since the surgery, you're only getting 20 minutes.
• 17:44
  SPEAKER_00: And we have all of our athletes get their own NMES devices.
• 17:49
  SPEAKER_00: And before it sounds like, oh, well, that seems expensive, there are affordable units out there that get the job done.
• 17:54
  SPEAKER_00: It's not the fanciest and it's not the most powerful clinical unit that plugs into the wall, but it gives athletes access to using this tool some input and an NMES device every single day.
• 18:07
  SPEAKER_00: And I'm gonna share that device info in the show notes.
• 18:11
  SPEAKER_00: It's something that we do really have our athletes use very consistently every day, usually.
• 18:17
  SPEAKER_00: And in some cases, it might be even twice a day, depending on their bandwidth, how they're tolerating things, just to get the most out of that thing.
• 18:24
  SPEAKER_00: And so if we do the math on that, let's say you're doing it 10 minutes per session once a day.
• 18:30
  SPEAKER_00: That's 70 minutes, right?
• 18:32
  SPEAKER_00: And then let's say you're doing it twice a day for let's just say a week, but let's say some days it's just once a day, and then some days it's twice a day.
• 18:42
  SPEAKER_00: That could be up to a maximum of 140 minutes in the week.
• 18:46
  SPEAKER_00: So you compare that of 20 minutes from in-person PT for those two visits, 10 minutes each, versus 70 to 140 minutes of total NMES.
• 18:58
  SPEAKER_00: That's a at least sevenfold difference in stimulus at minimum.
• 19:04
  SPEAKER_00: Massive, especially when we're talking about the quads being shut down, when we're talking about this is the pathway and the gateway to getting your walking back, to getting back to functionality, to getting back to the longer stage stuff like running, jumping, cutting, the sport, the activities.
• 19:20
  SPEAKER_00: The quad is the biggest domino effect that will impact your ACL rehab by far.
• 19:27
  SPEAKER_00: There's not a single thing other than getting that quad back online and getting it stronger that will impact and have the biggest impact throughout your entire recovery.
• 19:37
  SPEAKER_00: Now, this is not necessarily replacing what you're doing in PT.
• 19:41
  SPEAKER_00: It's just about increasing the dosage of being able to get some input.
• 19:45
  SPEAKER_00: So even with people who, you know, they are working with in-person PT, I might just tell them, hey, get an NMES device to use at home.
• 19:53
  SPEAKER_00: And it might be something that they could just squeeze a little bit more out of in order to get the most out of their units, out of their quads, and make the most of the time that they're doing their rehab.
• 20:04
  SPEAKER_00: Mistake number four, the intensity is too low.
• 20:08
  SPEAKER_00: And this is the one I see a lot where athletes hold back.
• 20:10
  SPEAKER_00: And I get it, don't get me wrong.
• 20:12
  SPEAKER_00: NMES can be uncomfortable.
• 20:14
  SPEAKER_00: I've been through two ACL rehabs and I have done plenty of NMES in my life.
• 20:19
  SPEAKER_00: I promise you that.
• 20:35
  SPEAKER_00: The research benchmark is a contraction force greater than or equal to 50% of your maximal voluntary isometric contraction, MVIC.
• 20:45
  SPEAKER_00: In clinic, with the right testing equipment, or you can use a knee extension machine, we can actually measure this.
• 20:51
  SPEAKER_00: At home, it's a little bit harder.
• 20:54
  SPEAKER_00: And so I'm not gonna bog you guys down in needing to get that 50% of your MVIC because as long as you make this thing super freaking strong that is tolerable within the duration that you have it without being in agonizing pain, you're probably gonna tap into that.
• 21:11
  SPEAKER_00: So then, therefore, as you turn it up as high as you can with the practical version of this, you want to get to a max tolerable intensity.
• 21:20
  SPEAKER_00: That is the goal.
• 21:21
  SPEAKER_00: Max tolerable intensity, almost to the verge of intolerable, but maximum tolerable intensity.
• 21:28
  SPEAKER_00: You should be in some discomfort when the unit is active and you're contracting your quad with that unit.
• 23:40
  SPEAKER_00: Not pain in a harmful sense, and I want y'all to know that.
• 23:43
  SPEAKER_00: But this is not supposed to be some cakewalk or just like chilling, talking to your friends while it's contracting.
• 23:49
  SPEAKER_00: I like to kind of think of this as a one repetition maximum to some degree.
• 23:53
  SPEAKER_00: Like you're hitting that thing and then you're resting.
• 23:55
  SPEAKER_00: Like you're not gonna be just casually talking to your friends when you're hitting a one rep max on a squat or some sort of movement, right?
• 24:01
  SPEAKER_00: Like you are going to be trying to get the most out of your own.
• 24:03
  SPEAKER_00: Out of it.
• 24:04
  SPEAKER_00: So this is something that I think is very underestimated.
• 24:10
  SPEAKER_00: And so this is something that we want to make sure that you're not just chilling watching TV and you know it's just turning on and off and you barely register it and you're just going through the motions.
• 24:20
  SPEAKER_00: That means the intensity is not high enough and you're not getting out of it the stimulus that you want.
• 24:25
  SPEAKER_00: It's like sitting on a knee extension machine.
• 24:27
  SPEAKER_00: You could do 100 pounds, but you choose to do only like 20 pounds of it, right?
• 24:32
  SPEAKER_00: You're not really going to get anything from it, and it's not going to be that much of a takeaway or the adaptation you need.
• 24:39
  SPEAKER_00: So most people can tolerate more than they initially think, especially when you first start working with it.
• 24:45
  SPEAKER_00: The first few minutes at a new intensity level feels like a lot, but after a few minutes, your nervous system starts to acclimate to that sensation and that intensity.
• 24:55
  SPEAKER_00: And you typically can turn it up further.
• 24:57
  SPEAKER_00: So make sure you are doing that.
• 24:59
  SPEAKER_00: Start your session, get a few contractions in, then check if you can push the intensity higher.
• 25:04
  SPEAKER_00: In most cases, you can.
• 25:06
  SPEAKER_00: So ramp up gradually when you are new to the NMES or coming back to it.
• 25:10
  SPEAKER_00: But once you know the device and you know your tolerance, you get used to the flow of it, push that intensity.
• 25:17
  SPEAKER_00: The research is consistent on this.
• 25:19
  SPEAKER_00: The higher intensity means the more motor unit activation, more force that we can create, and more muscle fiber recruitment.
• 25:27
  SPEAKER_00: All of this is amazing in the sense of getting our quads to join the party.
• 25:32
  SPEAKER_00: The discomfort is the point of this, not a sign you were doing something wrong.
• 25:36
  SPEAKER_00: So just know that.
• 25:38
  SPEAKER_00: And then the last point that I'm going to bring up here, the mistake number five, not using NMES when the quads hit a plateau.
• 25:45
  SPEAKER_00: This is the last one that's a little different from others because it is a little less about early setup errors and more about missed application later in rehab.
• 25:54
  SPEAKER_00: And this is something that we see fairly regularly, I would say.
• 25:58
  SPEAKER_00: And athlete is deep in their recovery, they're doing the work, they're loading their quad as consistently as they can.
• 26:05
  SPEAKER_00: But sometimes the numbers are stalling.
• 26:08
  SPEAKER_00: And the LSI is maybe stuck in the, let's just say 60s to 80s, right?
• 26:16
  SPEAKER_00: Torque to body weight ratios are not necessarily moving as much as we would want.
• 26:20
  SPEAKER_00: And we are talking about that, you know, 3.0 newton meters per kg benchmark or just getting 100% torque to body weight on the involved side.
• 26:29
  SPEAKER_00: Or the quad just feels off compared to the other side in ways that does not fully explain itself through just training load alone.
• 26:37
  SPEAKER_00: Just the response to it, the soreness, or even just people feeling that quad more.
• 26:42
  SPEAKER_00: There's the sensation that they just don't feel the same as the other side.
• 26:46
  SPEAKER_00: And when we see that plateau, in unique cases, we will go back to NMES.
• 26:51
  SPEAKER_00: Not all cases.
• 26:52
  SPEAKER_00: Again, don't go running back to your PT because there might be a reason why they're not necessarily using this.
• 26:58
  SPEAKER_00: So understand, ask questions first before you're like, we need to throw NMES into this.
• 27:03
  SPEAKER_00: It's not necessarily a sign of failure going backwards if you reintroduce it, but it could be something that we can introduce to target some neurological drive as well for additional motor unit recruitment, potentially tap into more strength gains when traditional loading is not necessarily moving the needle.
• 27:20
  SPEAKER_00: And again, we have to make sure we are maximizing the traditional loading as well, because if we're not doing that, then that's probably the issue, anyways.
• 27:28
  SPEAKER_00: But if we are doing everything our due diligence, sticking a good strength and conditioning principles and loading up well, then yeah, this can be something that we potentially introduce and see if is going to be helpful even in the mid and late stages when there could be a plateau in play.
• 27:45
  SPEAKER_00: But the the thing is the the plateaus do happen.
• 27:48
  SPEAKER_00: And as much as we want this to be linear, there are plenty of people who get stuck.
• 27:51
  SPEAKER_00: And I would say often that people will get stuck in those 60 to 80% ranges for a little bit because the initial newbie gains might come through again, and then they make a breakthrough, and then eventually they get into the 60s, 70s, 80s.
• 28:08
  SPEAKER_00: You know, the programming gets a little bit more um intense, if you will.
• 28:12
  SPEAKER_00: They're doing more things, more dynamic things, more in the gym things.
• 28:16
  SPEAKER_00: And then they're also having life continue to go on.
• 28:20
  SPEAKER_00: So then it could be something that just takes more time to get there, especially even people in our 80s, right?
• 28:27
  SPEAKER_00: They might be in the 80 percentile, but they might still not be at the criteria we want for them to be able to return to sport and activities and full performance.
• 28:37
  SPEAKER_00: And so it might be something that they kind of linger in that 80 percentile for a bit, but that is something that we need to explore further, right?
• 28:45
  SPEAKER_00: And so sometimes this can actually just be addressing some underlying inhibition, doing some more rate of force development work alongside it with some peak strength work, usually is the thing that we're gonna be tapping into.
• 28:59
  SPEAKER_00: But the NMES can re-enter the picture even at the late stage of rehab.
• 29:04
  SPEAKER_00: If your quads are taking their time getting to where they need to be and strength gains have slowed down, it could be something worth entertaining.
• 29:12
  SPEAKER_00: And I'm especially gonna say this for my quad tendons because we just noticed that the strength coming back takes longer, but then also the rate, how quickly we could tap into those high amounts of force takes longer.
• 29:26
  SPEAKER_00: So this could be something that helps us to put the AMI at bay, but then also maybe squeeze a bit more out of it for those longer rehabs where it might take longer and the quads get hit a little bit harder as well.
• 29:40
  SPEAKER_00: So, all right, those are five that I wanted to share here in terms of this part one, recap them really fast.
• 29:49
  SPEAKER_00: Number one, only using NMES in early post-op phase.
• 29:53
  SPEAKER_00: The research supports it could be in later phases up to even 80% LSI.
• 29:58
  SPEAKER_00: Don't try to get rid of it early, even if the quads feel like they are working.
• 30:04
  SPEAKER_00: Number two, using a TENS unit instead of an NMES unit.
• 30:08
  SPEAKER_00: Make sure you have the right device.
• 30:09
  SPEAKER_00: Number three, not using it frequently enough.
• 30:12
  SPEAKER_00: I don't think that two times a week is enough.
• 30:15
  SPEAKER_00: Honestly, for something that is shut down and neurologically inhibited, that's 20 minutes a week versus if you get your own unit and try to use it once or twice daily, it could be up to 70 to you know 140 minutes in a week.
• 30:28
  SPEAKER_00: 7x fold on an increase of what you were doing.
• 30:32
  SPEAKER_00: Number four, intensity too low, it should not be comfortable.
• 30:36
  SPEAKER_00: Max tolerable intensity when you find that threshold, try to push it up even a little bit more.
• 30:41
  SPEAKER_00: Number five, not using NMES when the quads hit a plateau.
• 30:46
  SPEAKER_00: This tool is not just for early rehab.
• 30:48
  SPEAKER_00: If your strength numbers are stalling, it could be something that we could tap into.
• 30:52
  SPEAKER_00: Maybe you have a complex case and the quads are just not responding in the way it should.
• 30:58
  SPEAKER_00: And you're further along.
• 30:59
  SPEAKER_00: Couldn't hurt to bring it back in to squeeze out as much as we can.
• 31:03
  SPEAKER_00: Next week in part two, we're gonna get into the setup, execution, some duty cycle, pad placement, pad size, skin contact batteries, some parameters, things that are a little bit more nuanced that we see that are helping our athletes and things that we are seeing.
• 31:19
  SPEAKER_00: It's gonna be really useful from a practical application, especially if you are already using the NMES and want to make sure you get everything out of every single session and make it as effective as possible.
• 31:29
  SPEAKER_00: The device recommendations and any research references I mentioned today are in the show notes.
• 31:34
  SPEAKER_00: If you're navigating your ACL recovery and need some help, please reach out to us.
• 31:39
  SPEAKER_00: We are here to help.
• 31:40
  SPEAKER_00: We can help you put in this NMES into play, be able to audit what you are doing, be able to give you a specific roadmap, and we are here to help in any way that we can.
• 31:50
  SPEAKER_00: Thanks for being here, y'all.
• 31:51
  SPEAKER_00: See you next week.
• 31:52
  SPEAKER_00: This is your host, Ravi Patel, signing off.