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283 | 10 Common NMES Mistakes in ACL Rehab - Part 2 · 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: Ravi 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.
• 1:02
  SPEAKER_00: What is up everyone?
• 1:04
  SPEAKER_00: Today we are diving into part two of the NMES series.
• 1:08
  SPEAKER_00: And if you have not listened to part one yet, go back and start there.
• 1:12
  SPEAKER_00: We covered the big picture mistakes that we commonly see in this process using NMES.
• 1:18
  SPEAKER_00: Whether you're actually using it, when you're using it, how often, at what intensity.
• 1:23
  SPEAKER_00: These are very foundational to this process, and today is going to build on top of that.
• 1:29
  SPEAKER_00: Part two today is about what happens inside of each of these sessions, right?
• 1:34
  SPEAKER_00: The setup, looking at execution, the details that most people either do not necessarily know about or don't think matter as much.
• 1:43
  SPEAKER_00: Um, there's nuances to some of these things that we can get a lot out of.
• 1:48
  SPEAKER_00: And these details really matter just with any other thing that we are doing in this process.
• 1:54
  SPEAKER_00: The details are really important.
• 1:56
  SPEAKER_00: We're closing out with a rapid fire parameters block that I'll kind of share with you guys at the end that'll just kind of talk through some technical specifics just for you to get a little bit more out of it.
• 2:07
  SPEAKER_00: But the same framing as last week applies here, these mistakes are not all going to apply to every single person.
• 2:14
  SPEAKER_00: There could be legit reasons, your setup looks different for a certain reason, whether you are in your recovery or what your PTS prescribed, the goal is not to overwhelm you or have you go running to fix everything at once or thinking you need NMES in general, right?
• 2:34
  SPEAKER_00: I always want to provide the information to educate you guys, understand the information.
• 2:39
  SPEAKER_00: And then that allows you to ask better questions, if especially if things don't feel like they're adding up, or if you're like, hey, maybe this is something I can tap into that is a blind spot, or maybe my physical therapist is not thinking of, or it's something that maybe we can introduce to just get a little bit more out, right?
• 2:58
  SPEAKER_00: And it doesn't mean you need to apply every single thing, all 10 things that I share here.
• 3:02
  SPEAKER_00: It might be one thing, it might be two things, but it's just something that I want to make sure that you're not just blowing up your rehab and being like, you did this all wrong, especially if you're later in this process and you are not using an MES, right?
• 3:17
  SPEAKER_00: It's always going to be very context dependent.
• 3:19
  SPEAKER_00: And as I shared with our athletes, there are many athletes who are not necessarily using this in their rehab, even though they're maybe post-early stages.
• 3:30
  SPEAKER_00: Now, I will say if you're post-op and you're one of our athletes, there is a very rare chance that you're not using this.
• 3:37
  SPEAKER_00: Otherwise, every athlete is being recommended to use this, especially post-op.
• 3:41
  SPEAKER_00: And we continue to use it for a good bit.
• 3:43
  SPEAKER_00: But again, like the nuances are gonna be very important of how long we use it, where we pivot, or potentially not use it anymore.
• 3:50
  SPEAKER_00: So I want to make sure I give you the information here to maximize that use.
• 3:55
  SPEAKER_00: So let's go ahead and dive into the second half of these common mistakes that we'll typically see.
• 4:02
  SPEAKER_00: So I'm gonna start with number six here, since we went through one through five on the first one.
• 4:07
  SPEAKER_00: So mistake number six is rushing through what we call the duty cycle.
• 4:12
  SPEAKER_00: And the duty cycle is the ratio of the on and off time during the NMES session.
• 4:16
  SPEAKER_00: And most of the research supports approximately like a one to five ratio, roughly, let's say, like a 10 seconds to 50 seconds of rest.
• 4:26
  SPEAKER_00: Sometimes it might be 12 seconds, sometimes it might be 15 seconds, but it'll be roughly a one to five ratio when you look across the research using NMES, especially for quadriceps and especially for ACL.
• 4:39
  SPEAKER_00: So this is something that's important.
• 4:42
  SPEAKER_00: What we see is that sometimes athletes will shorten that rest period and they will do maybe 10 seconds on and 20 seconds off because it feels like they can get more repetitions, or they're just kind of waiting too long in between, move through the sessions faster.
• 4:56
  SPEAKER_00: That's a big one we see.
• 4:58
  SPEAKER_00: Where they're like, oh well, if I can do the 10 minutes that I need to do within the five minutes, that just saves me more time, more agony.
• 5:05
  SPEAKER_00: I get through it quicker.
• 5:07
  SPEAKER_00: Or they might just try to do more within the same time window.
• 5:12
  SPEAKER_00: And I understand the logic, but here is why it doesn't work.
• 5:17
  SPEAKER_00: NMES preferentially targets fast switch muscle fibers, the same fibers that fatigue the quickest.
• 5:25
  SPEAKER_00: And you're applying this to a quad that already has some level of inhibition working against it, especially post-op, post-injury.
• 5:34
  SPEAKER_00: It is not a muscle that is functioning at full capacity, so you gotta know that it's not its maximal ability to contract and fire.
• 5:42
  SPEAKER_00: You're already fighting the uphill battle of orthogenic muscle inhibition, AMI, on top of the post-surgical weakness.
• 5:50
  SPEAKER_00: So that's something that we just kind of need to factor into this.
• 5:55
  SPEAKER_00: Think about it like this enemies is not necessarily like a hit workout.
• 5:59
  SPEAKER_00: And so this was just something I was trying to think of is like people try to get through it, like sprint, the high intensity, especially are like people who really need a sweat, people who really like to exercise like intensely, like they just want to go at it and they want to hit it hard.
• 6:13
  SPEAKER_00: And sometimes people view it as that, as like a hit workout.
• 6:17
  SPEAKER_00: But this is not necessarily getting through as many contractions as possible.
• 6:22
  SPEAKER_00: This is about thinking about quality, and I think this is something that gets missed sometimes.
• 6:27
  SPEAKER_00: High effort output followed by full recovery.
• 6:30
  SPEAKER_00: The analogy I use in training, think about it like a one-rep max.
• 6:35
  SPEAKER_00: You wouldn't want to cut your rest short on a heavy lift because you know the quality of that next attempt depends entirely on how the recovered you are.
• 6:44
  SPEAKER_00: The same principle applies here.
• 6:46
  SPEAKER_00: You want each contraction to be as strong and as complete as possible.
• 6:50
  SPEAKER_00: That only happens when the muscle has adequate rest between efforts.
• 6:54
  SPEAKER_00: So keep the ratio around one to five and then aim for roughly 10 to 15 seconds on and 50-ish seconds off.
• 7:04
  SPEAKER_00: Let the rest be the rest.
• 7:06
  SPEAKER_00: And I think that is something that some people will just kind of try and power through and try to get through a lot of reps.
• 7:14
  SPEAKER_00: And yeah, you may even be able to do another repetition in between where you're contracting the quads, but the enemy s might not be on.
• 7:21
  SPEAKER_00: But I would say just give it that 10 seconds of intense work, turn that enemy us up as much as you can tolerate, squeeze the crap out of it, and then allow it to rest for the duration that it needs to rest.
• 7:34
  SPEAKER_00: And so this is something that I think can be really helpful to just get a little bit more out of an already fatigued quad and give it that rest it needs to be able to bounce back for that next repetition.
• 7:46
  SPEAKER_00: Now, are there certain situations you might speed it up more frequently?
• 7:50
  SPEAKER_00: Yes, maybe you're cut short on time, maybe you only have five minutes just based on the constraints of your life.
• 7:56
  SPEAKER_00: Then yeah, let's speed it up, get some more repetition, some work in.
• 7:59
  SPEAKER_00: But if you have the time to do it, then give yourself that full 10, 15 minutes of working on it, 10 on, 50 off, or whatever kind of ratio you're using, and be able to give it that max time because you're gonna get more out of it.
• 8:12
  SPEAKER_00: And plus, that is what the research says.
• 8:15
  SPEAKER_00: And we're gonna go based on data as a guide here.
• 8:18
  SPEAKER_00: Mistake number seven, wrong pad placement.
• 8:21
  SPEAKER_00: This one has a big impact on both the effectiveness of your sessions and your comfort during them.
• 8:28
  SPEAKER_00: And it is one of the most commonly skipped parts of the setup.
• 8:32
  SPEAKER_00: And I'll see this all the time where people are like, oh, I'm using NMES, and they'll show the setup of things, and there are a number of things that factor into this, but I'll see just like wrong pad placement.
• 8:41
  SPEAKER_00: They'll put it just randomly on the quad somewhere, randomly on the other part of the quad.
• 8:46
  SPEAKER_00: And yeah, it contracts, but are we getting the most out of this?
• 8:49
  SPEAKER_00: And the reason this is so valuable is because it's going to layer into a lot of things, it's going to help with like being placed over the motor points, and it's not just randomly stuck on the quad because it just kind of looks like the right general area, and that's important.
• 9:06
  SPEAKER_00: What is a motor point?
• 9:09
  SPEAKER_00: It is the location where a motor nerve enters the muscle tissue.
• 9:13
  SPEAKER_00: At that point, less current is required to excite that motor axons and produce a contraction.
• 9:21
  SPEAKER_00: When you place your pads over the motor points, you get more efficient stimulation, a stronger contraction at a lower intensity, and meaningfully less discomfort.
• 9:32
  SPEAKER_00: And so the most common places that we use them based on these motor points and the mapping, one pad on the VMO, which is that kind of teardrop muscle on the inside of your quad, and one pad near the hip on the vasus lateralis on the outer portion of the upper thigh.
• 9:49
  SPEAKER_00: Now, this is super important to make sure you're not also tagging in your TFL.
• 9:54
  SPEAKER_00: Your TFL, your tensor fascia lata, is another muscle that serves as a hip flexor and internal rotator.
• 10:01
  SPEAKER_00: So there's a lot of times people might get too high up on that hip and they might start contracting that a little bit.
• 10:06
  SPEAKER_00: So that is why it's really important to know anatomy and being able to be shown this correctly.
• 10:12
  SPEAKER_00: We send pictures to our athletes and they have videos to be able to see this.
• 10:15
  SPEAKER_00: And then we also check these as well to make sure we are covering the max distance.
• 10:19
  SPEAKER_00: So in theory, if you have those two pads, then it's gonna be a diagonal from think about where your pocket sits on, let's say it's your right leg where your right pocket sits, and it's also going to be a diagonal straight to the inner side of your quad.
• 10:36
  SPEAKER_00: So that's gonna be something that's very important from a pad placement standpoint.
• 10:42
  SPEAKER_00: Um, and that's gonna help us be able to get the most surface area across the quadriceps and give you the best chance at max output across the whole muscle group and hit those motor points.
• 10:54
  SPEAKER_00: So this is not some random, just like throw it on there and hope for best.
• 10:57
  SPEAKER_00: It's very intentional and very important.
• 10:59
  SPEAKER_00: And the the difference here on the motor points versus placing them on the random spots, it can influence the quality of the contraction you produce and also how much of the session it might actually hurt.
• 11:13
  SPEAKER_00: And so this is something that I've also provided two research papers and visual guides in the show notes so you can see those for the motor point placements.
• 11:24
  SPEAKER_00: If you're not sure where your pads are going, you can take a look at that.
• 11:28
  SPEAKER_00: So there are two of those linked in the show notes to help you out with that.
• 11:32
  SPEAKER_00: There are other points that you can put depending on your NMES device, but I would say the most common one is going to be that diagonal pattern from the inside of your knee near the patella, that VMO area, and then also on the vasus lateralis, all the way up on the upper part of the thigh.
• 11:50
  SPEAKER_00: Now, I've done a lot of research on this in multiple ways.
• 11:53
  SPEAKER_00: In PT school, we had to be very intentional about where we put this because we had to shock people to get their max voluntary contractions doing research.
• 12:04
  SPEAKER_00: And so it was not fun, but we had to use these pads and put them in the right placements, and if we did not, then it would influence the contraction.
• 12:11
  SPEAKER_00: So we had tons of data testing this out with NMES devices, and these are high, high twitch outputs, like high voltage input to the quad.
• 12:22
  SPEAKER_00: And so that is something that we had to get right.
• 12:25
  SPEAKER_00: The other thing, too, is that I have tested a bunch of these units, and I have also tested a bunch of different pads out, and I also tested different pad placement, and it will influence how much of that quad is squeezing, how uncomfortable it is.
• 12:43
  SPEAKER_00: It plays into a lot of how you can get the most out of it.
• 12:47
  SPEAKER_00: So make sure the pad placement is correct, and you're not also overlapping other muscles like your groin.
• 12:53
  SPEAKER_00: Sometimes you can go too far on the inside when you're doing your VMO, and you can hit some of your groin muscles too.
• 12:59
  SPEAKER_00: So make sure it's quad only and max amount of coverage you can get across and hitting those motor points.
• 13:06
  SPEAKER_00: Mistake number eight, using pads that are too small.
• 13:10
  SPEAKER_00: A lot of athletes are using those two by two electrode pads.
• 13:14
  SPEAKER_00: Now, don't get me wrong, if you don't have access to the other pads, then these will get the job done and they will help and you'll still get some work out of it.
• 13:23
  SPEAKER_00: But a lot of these devices, including the ones that I've linked in the show notes, they come with these two by two electrode pads.
• 13:30
  SPEAKER_00: And they are a bit small, and so then therefore, like you don't really get a ton of coverage, you're not really touching a ton of muscle surface area, and it's a lot of distance to cover for such small pads, especially for something like the quad where there is a lot of area to cover, right?
• 13:50
  SPEAKER_00: And sometimes it is also just what's available on Amazon, but in reality, like these pads that come with a lot of these units are not necessarily big enough.
• 13:59
  SPEAKER_00: And so the minimum that I recommend is at least a two by four pad, or a four by four pad is really great too.
• 14:06
  SPEAKER_00: That's even more.
• 14:07
  SPEAKER_00: We're talking about more and more surface area of being able to do this.
• 14:12
  SPEAKER_00: And if you have really, really big quads, then you can even get away with the three by five or the four by eight pads, and those could be valuable too.
• 14:21
  SPEAKER_00: And I've used those before, work great.
• 14:24
  SPEAKER_00: Um got to make sure that it all just kind of aligns with your anatomy.
• 14:27
  SPEAKER_00: I think a lot of people can get by with the two by four and the four by fours as well.
• 14:32
  SPEAKER_00: But here's why this matters the larger the surface area coverage means the current is able to distribute across more muscle tissue.
• 14:42
  SPEAKER_00: Also, that means we might be able to hit more motor points coverage-wise, that is going to help us activate that muscle more.
• 14:50
  SPEAKER_00: But what this does is two things simultaneously.
• 14:53
  SPEAKER_00: It brings more muscle fibers into contact with that stimulus that you're giving it, which is going to increase that output of the contraction.
• 15:00
  SPEAKER_00: And it also reduces the concentration of current at any single point, which makes the whole session significantly more comfortable.
• 15:10
  SPEAKER_00: And I will tell you guys, I've tested this.
• 15:12
  SPEAKER_00: And if you put those small pads and you turn it up, it does not feel good.
• 15:16
  SPEAKER_00: It feels very prickly and it feels very itchy, and it starts to get real uncomfortable locally in that spot.
• 15:22
  SPEAKER_00: The bigger these pads are, the more it disperses across tissue, and the more that it helps to be more comfortable.
• 15:29
  SPEAKER_00: But guess what?
• 15:30
  SPEAKER_00: We also get to activate more muscle fibers as well.
• 15:34
  SPEAKER_00: Small pads concentrate the area in that current.
• 15:38
  SPEAKER_00: So that means you're getting more of an intense, more localized sensation without any necessarily better contraction benefits.
• 15:45
  SPEAKER_00: So the bigger pads will spread it out, you're gonna get a more even, complete muscle activation at a better intensity that is more tolerable.
• 15:54
  SPEAKER_00: The pad size and pad placement work together.
• 15:56
  SPEAKER_00: So get both of those right, and you will squeeze a lot more out of your NMES because those are the things that will be really helpful.
• 16:04
  SPEAKER_00: And the pads specifically are also linked in the show notes that you guys can check out with this in terms of being able to look at what are the best ones.
• 16:15
  SPEAKER_00: Mistake number nine poor skin contact and not changing these pads.
• 16:20
  SPEAKER_00: Talking a lot about pads here, but it actually ends up being an important factor.
• 16:24
  SPEAKER_00: This one sounds like a small detail, it's really not though.
• 16:28
  SPEAKER_00: Fresh pads with the strong adhesion, the stickiness creates clean skin contact.
• 16:33
  SPEAKER_00: And clean skin contact is how you're gonna get a strong, consistent current delivered to that muscle.
• 16:38
  SPEAKER_00: When that contact is compromised, old pads that have lost their stickiness.
• 16:43
  SPEAKER_00: I've seen this a ton of time from athletes.
• 16:45
  SPEAKER_00: I've even personally experienced this.
• 16:48
  SPEAKER_00: Maybe there's like some moisture lotion on the skin, or maybe there's hair in the way.
• 16:53
  SPEAKER_00: The current becomes inconsistent with those things.
• 16:56
  SPEAKER_00: It actually reduces that current.
• 16:59
  SPEAKER_00: The contraction quality drops, and you're doing sessions that look like NMES but aren't necessarily delivering what they should.
• 17:06
  SPEAKER_00: You're only getting maybe 60-70% if that out of what you could be with this unit.
• 17:13
  SPEAKER_00: And so before you apply pads, wife off any lotion on the skin.
• 17:18
  SPEAKER_00: You could use alcohol pads to kind of clean the area if needed.
• 17:21
  SPEAKER_00: You can trim or shave the hair if you can in that area at the placement sites, if you feel like it's getting in the way of a good contact.
• 17:28
  SPEAKER_00: This kind of makes me think of when we did AED, and sometimes they will say, you know, you have the two sticky pads for using an AED, the defibrillator that you need to be able to, you know, shock people back into rhythm.
• 17:42
  SPEAKER_00: So if someone is super hairy, you actually take a pad and you remove the sticky, kind of like covering the bandage cover, and then you put the sticky thing on their chest, and then you actually rip it off and rip the hair off.
• 17:56
  SPEAKER_00: It sucks.
• 17:56
  SPEAKER_00: It's like getting waxed.
• 17:57
  SPEAKER_00: But then you put a new pad on it, and that's essentially the goal.
• 18:01
  SPEAKER_00: So then that way you get way more current in there because that hair is out of the way.
• 18:05
  SPEAKER_00: And we're talking about a pretty hairy person.
• 18:07
  SPEAKER_00: But the thing is, is that you know, many of us can be hairy or have some, you know, kind of areas where we need to kind of be able to factor that in.
• 18:15
  SPEAKER_00: So then, therefore, let's get some consistency, get some good quality contractions to be able to help that.
• 18:22
  SPEAKER_00: But if it's getting in the way of a good contact, then that's going to be important.
• 18:25
  SPEAKER_00: And these are the small steps that can make a huge difference in your NMES.
• 18:29
  SPEAKER_00: The pads themselves need to be swapped out regularly and very consistently.
• 18:33
  SPEAKER_00: I see this most often with my younger athletes as I shared.
• 18:37
  SPEAKER_00: They will keep using the same pads session after session and weeks, and they won't necessarily mention anything, especially the units they're doing at home.
• 18:45
  SPEAKER_00: They'll just kind of keep using it and being like, yeah, it's just not having as much of an effect.
• 18:49
  SPEAKER_00: And then I'll tell them to bring in their pads or show me their pads, and yeah, sure enough, like they're barely hanging on, right?
• 18:56
  SPEAKER_00: So we need to make sure that they're sticky and that they could do their job.
• 19:00
  SPEAKER_00: And so then, therefore, again, kind of getting only like 50% out of something they should get 100% of because of not the best pad contact.
• 19:08
  SPEAKER_00: So change the pads, new pads with solid adhesion are one of the simplest variables that you can really influence with this.
• 19:15
  SPEAKER_00: And then mistake number 10 are weak batteries.
• 19:20
  SPEAKER_00: This one is about something that quietly undermines a session without athletes realizing it happening.
• 19:27
  SPEAKER_00: And I've seen this a lot, especially with these battery-operated NMES units, which is probably every one of you that are using these at home, can lose output capacity as the battery drains.
• 19:40
  SPEAKER_00: The current becomes a little inconsistent, the contraction quality drops, and the change is gradual enough that athletes often do not notice it is happening because they have acclimated to the weaker output over time.
• 19:52
  SPEAKER_00: So they just are like, oh, well, this is probably just the normal of the unit.
• 19:56
  SPEAKER_00: And I kind of think about this like my son's books that he has with batteries in them.
• 20:01
  SPEAKER_00: When the batteries are brand new, the sound is clear, it's super sharp and strong.
• 20:04
  SPEAKER_00: When they start to fade, so is everything within the book itself.
• 20:10
  SPEAKER_00: It will essentially say the song or whatever it is quoting from my son's books, and it will just kind of fade or taper off, or it will be weaker.
• 20:19
  SPEAKER_00: It's just the battery is getting weak, right?
• 20:22
  SPEAKER_00: So then therefore we need to change it.
• 20:23
  SPEAKER_00: As soon as we change it, it powers right back up.
• 20:26
  SPEAKER_00: So that's that same principle here with the NMES unit.
• 20:29
  SPEAKER_00: If the batteries are not charged up, you're not getting the full stimulus from the device, even if it appears to be working.
• 20:36
  SPEAKER_00: So keep fresh batteries in your unit, change them regularly.
• 20:40
  SPEAKER_00: If you have a rechargeable unit, make sure it is fully charged before each session.
• 20:45
  SPEAKER_00: Do not let dead or weak batteries silently influence how you're using that because you will get used to it and you'll just think it's normal or you're getting used to it.
• 20:55
  SPEAKER_00: Now, parameters you should know.
• 20:56
  SPEAKER_00: I'm just gonna shoot this out as rapid fire because I think it's important.
• 21:00
  SPEAKER_00: Other variables that can factor into some of the pieces of using the NMES device correctly.
• 21:08
  SPEAKER_00: So pulse duration is one.
• 21:11
  SPEAKER_00: Make sure your pulse duration is at least 400 microseconds.
• 21:15
  SPEAKER_00: The research, including work from Glaviano and Saliba, points to a range of 400 plus to even 600 microseconds as the sweet spot for targeting motor neurons, maximizing torque production, and reducing muscle fatigue.
• 21:31
  SPEAKER_00: If your device gives you control over this setting, some don't, they're just kind of preset.
• 21:36
  SPEAKER_00: Push it wider than shorter.
• 21:38
  SPEAKER_00: And it might only go to 400, right?
• 21:41
  SPEAKER_00: It just depends on what range it can do, but at least a 400 for pulse duration of microseconds is going to be helpful based on some of this research and what we know about these contraction types.
• 21:52
  SPEAKER_00: Pulse frequency 30 to 50 hertz is the range you want to be in.
• 21:57
  SPEAKER_00: We try to have our athletes closer to 50 hertz.
• 22:00
  SPEAKER_00: Here, too low, and you're not generating a real contraction, too high, and it becomes more sensitive and painful, and it's harder to sustain over a session.
• 22:09
  SPEAKER_00: So, this range gives you a strong motor unit activation without tipping into that discomfort that might work against you.
• 24:21
  SPEAKER_00: Now, this is a different one, but it's varying your contraction rate.
• 24:27
  SPEAKER_00: And this is something we do intentionally in programming, and something I've been doing more with my ACLers just to kind of give them some more variety of input.
• 24:36
  SPEAKER_00: Sometimes we will have the athletes do a little bit of a slower contraction.
• 24:41
  SPEAKER_00: Sometimes it's that controlled slow contraction with that stem going on.
• 24:45
  SPEAKER_00: And sometimes we want to push the rate faster.
• 24:48
  SPEAKER_00: And so this taps into some different aspects of the neuromuscular recruitment.
• 24:53
  SPEAKER_00: We're looking at rate coding, reflex responses, different fiber types.
• 24:58
  SPEAKER_00: So I think that this could be something that we can also evolve more, is just looking that at the contraction rate for the quads.
• 25:07
  SPEAKER_00: So instead of it being, you know, when you do that two to three second on-ramp, and then you're on that 10-second squeeze, for example, maybe you do it really, really quickly.
• 25:16
  SPEAKER_00: And then on some you gradually build up that contraction.
• 25:21
  SPEAKER_00: And then some you do very quickly, and then some you do a gradual build up to the max contraction, right?
• 25:27
  SPEAKER_00: So thinking about how hard you can squeeze versus how quickly you can squeeze, right?
• 25:32
  SPEAKER_00: So those are things that we can also think about from a contraction rate that can potentially help and provide a little bit of variety of input for the rate coding and reflexes and those different fiber types that we're trying to tap into.
• 25:46
  SPEAKER_00: And then there's voluntary versus involuntary contraction.
• 25:50
  SPEAKER_00: And this is an ongoing conversation in the research and in the clinical world.
• 25:54
  SPEAKER_00: And the question is: should you actively contract with the stem or let it stimulate passively without adding your own effort?
• 26:03
  SPEAKER_00: Now, Lynchneier Mackler has claimed, who is one of the OG researchers who has done a lot in the ACL field, that you should not actually contract with it because it could work against the NMES.
• 26:17
  SPEAKER_00: And I think that that is very opposite to what you probably see and have learned and what we learned in school, what we have learned just through the clinical world in general.
• 26:29
  SPEAKER_00: You typically contract with the device, right?
• 26:32
  SPEAKER_00: You squeeze the quad whenever it turns on with the NMES.
• 26:36
  SPEAKER_00: And so I think that this is something that is important to just more so leave as an open-ended to share with you because I don't have a definitive like yes or no, like you should do one or the other.
• 26:47
  SPEAKER_00: To me, why not do both?
• 26:51
  SPEAKER_00: And I don't think that this has to be one or the other until there's more research that is consistently coming out saying you need to not contract while you do the NMES or you should contract with it.
• 27:02
  SPEAKER_00: I think that there is value in potentially tapping into both, doing it with an active contraction with it, and then also turning this thing up and not contracting with it actively, but letting it do its thing, right?
• 27:14
  SPEAKER_00: So we're tapping into different neurological kind of pathways, if you will, or outputs.
• 27:19
  SPEAKER_00: And so we will pair the NMES with terminal knee extension based exercises.
• 27:25
  SPEAKER_00: We also will fix it with an isometric hold at let's say a 90 or a 60 degree knee flexion angle to kick out into something.
• 27:34
  SPEAKER_00: Let's say it's like a physio ball or a band or a wall or a knee extension machine fixed at 90 degrees.
• 27:40
  SPEAKER_00: And then whenever that NMES kicks on for that 10 seconds, it's kicking into that immovable object, especially at that angle where the quad has the best link tension relationship.
• 27:50
  SPEAKER_00: So you're gonna get more squeeze out of that quad and more recruitment because it's at the optimal position.
• 27:56
  SPEAKER_00: Just like if you took your elbow and bent it to 90 degrees, like you're flexing your bicep, and you try to resist on the inside of your wrist, it's gonna your biceps the strongest there at 90 degrees.
• 28:06
  SPEAKER_00: It's not the strongest when it's fully extended, it's not the strongest when it's fully flexed and bent.
• 28:11
  SPEAKER_00: It's in that middle of the range.
• 28:13
  SPEAKER_00: And the same thing with the quads, it's not the strongest when it's fully extended and fully bent, it's in that middle range where it's at roughly around 60 degrees.
• 28:22
  SPEAKER_00: 90 degrees still work really well, and you're able to kick out, and that's where you're gonna produce the maximum amount of force of that quad or torque, I should say.
• 28:33
  SPEAKER_00: And that is something that we can also kind of consider in this process.
• 28:37
  SPEAKER_00: And so the nice thing is that you can set up the stem, get that thing kind of fixated, and then kind of kick into something and let the stem do it.
• 28:46
  SPEAKER_00: And then you can also play around with doing some reps yourself, actively contracting with the electrical stem as well.
• 28:52
  SPEAKER_00: The combination gives you the most complete stimulus, if you will, across the different contexts.
• 28:58
  SPEAKER_00: So while there is still kind of speculation around should you voluntarily contract with the NMES or should you involuntarily contract, meaning just let the NMES do it and not contract with it, jury's still out, and we'll continue to hopefully find out more.
• 29:15
  SPEAKER_00: But I would say 99% of the time, if you look across most of the clinical world, ACL, NMES, people are doing it with movement actively.
• 29:26
  SPEAKER_00: But I think that there's a ton of value in also doing it involuntarily and letting it do its own thing in certain bouts and certain movements too, just like Lynn Snyder Mackler was saying too.
• 29:37
  SPEAKER_00: And so these are the quote unquote rapid fire that I still ended up talking long on because I think it's important.
• 29:44
  SPEAKER_00: But across part one and part two, we covered 10 common mistakes that we see.
• 29:49
  SPEAKER_00: And so here's the full list one more time for you guys.
• 29:52
  SPEAKER_00: Number one, only using NMES in the early post-op phase.
• 29:56
  SPEAKER_00: I think it can go beyond that and it should in many cases.
• 30:00
  SPEAKER_00: Number two, using a TENS unit instead of an NMES device.
• 30:05
  SPEAKER_00: TENS is for pain, NMES is for muscle contraction.
• 30:09
  SPEAKER_00: Three, not using it frequently enough.
• 30:12
  SPEAKER_00: I used the two times a week for 10 minutes at physical therapy, that's 20 minutes total.
• 30:20
  SPEAKER_00: Versus if you have your own unit using it at home, it could be anywhere from 70 to even 140 minutes a week.
• 30:27
  SPEAKER_00: It's a huge difference.
• 30:29
  SPEAKER_00: Four, intensity too low.
• 30:30
  SPEAKER_00: Crank it up, y'all.
• 30:32
  SPEAKER_00: Make it uncomfortable, close to that kind of tolerable threshold, if you will.
• 30:36
  SPEAKER_00: You'll get used to it.
• 30:37
  SPEAKER_00: So turn it up more after a few reps if you're getting used to it.
• 30:41
  SPEAKER_00: Five, not using NMES when the quads plateau.
• 30:45
  SPEAKER_00: So if there's a plateau point that exists in this process, let's say someone's at the 60%, 70%, 80%, and they're further in this process and they're doing all the things, but the quad isn't necessarily getting to where we need to, then it can't hurt to just throw that baby in there and just see can we get more out of this quad by using NMES?
• 31:05
  SPEAKER_00: And we have had success with ACLers when we throw this in there at certain points and seeing if we could just get a little bit more out of there.
• 31:12
  SPEAKER_00: Number six, rushing through the duty cycle.
• 31:15
  SPEAKER_00: So trying to speed that thing up and doing more reps or getting through the exercise versus giving it the adequate amount of rest.
• 31:21
  SPEAKER_00: Number seven, wrong pad placement, put it on the right points as far as you can kind of cover on those motor points on the quad.
• 31:28
  SPEAKER_00: Number eight, using pads that are too small.
• 31:31
  SPEAKER_00: Get bigger pads, don't use the two by twos, get at least the two by fours off of Amazon or wherever you get them.
• 31:37
  SPEAKER_00: You can get the four by fours as well.
• 31:39
  SPEAKER_00: You can get almost like a pack of five to ten of these for pretty, pretty cheap, cheap.
• 31:45
  SPEAKER_00: Number nine, poor skin contact and not changing the pads.
• 31:49
  SPEAKER_00: Change the pads, y'all, especially when the stickiness wears off.
• 31:53
  SPEAKER_00: And then poor skin contact.
• 31:55
  SPEAKER_00: Just make sure it's clean.
• 31:57
  SPEAKER_00: Make sure that if you have a ton of hair, shave it.
• 32:00
  SPEAKER_00: Just do it for the quad, do it for the rehab.
• 32:03
  SPEAKER_00: It's needed.
• 32:04
  SPEAKER_00: Number 10, dead batteries, weak batteries.
• 32:07
  SPEAKER_00: We don't want them.
• 32:08
  SPEAKER_00: Keep them charged, make sure they're strong.
• 32:10
  SPEAKER_00: And the parameters to know pulse duration, at least 400 microseconds, frequency between 30 to 50 hertz, vary your contraction rates, some slow, some fast, and use both voluntary and involuntary approaches.
• 32:24
  SPEAKER_00: I will say it again because I mean it.
• 32:27
  SPEAKER_00: I think that NMES should be the standard for post-operative knee cases.
• 32:31
  SPEAKER_00: It is cost effective, the research behind it is strong, and it is still being underused across the board.
• 32:37
  SPEAKER_00: My hope is that across these two episodes, you now have a clear enough picture of how to use it well that you can actually get the full benefit from it.
• 32:46
  SPEAKER_00: Get the most out of it, y'all.
• 32:47
  SPEAKER_00: It's so, so important.
• 32:49
  SPEAKER_00: And if you're not using it at all today, then I would say look into it, especially if you're someone who's early post op.
• 32:56
  SPEAKER_00: If you're someone who is first week post op ACL and you're not using any type of electrical stem, that needs to change.
• 33:04
  SPEAKER_00: There's not very many cases where I think that that is not going to be the case.
• 33:08
  SPEAKER_00: And so this is something that I think is very important, especially early on.
• 33:12
  SPEAKER_00: Especially early on, because we are trying to get those quads awake.
• 33:15
  SPEAKER_00: We're trying to get those things to join the party.
• 33:17
  SPEAKER_00: And especially for those of you with quad tendons, many of you listening, I am so sure, you need to make sure that this is on the radar to use because we need to wake that thing up and it's going to take a little bit longer for you guys.
• 33:29
  SPEAKER_00: So we want to make sure that you are able to put that in play.
• 33:33
  SPEAKER_00: And if you're using it, go back through the list, find one or two things to tighten it up and make those changes and see if it improves.
• 33:40
  SPEAKER_00: I literally had one of our team members share that some of our athletes are now kind of changing a couple things up because they listen to this and they're like, oh, well, maybe I wasn't kind of considering this because we're not checking in on their devices every single day and every week.
• 33:57
  SPEAKER_00: You know, we periodically check in to make sure, but at the same time, like, you know, there's going to be a lot of time passing.
• 34:02
  SPEAKER_00: And so then, therefore, we're not always able to check every single device every single session that they're doing it.
• 34:07
  SPEAKER_00: So then sometimes these details can sometimes slip.
• 34:11
  SPEAKER_00: And one of the athletes had already changed one of the things that they had realized, and they were like, wow, I'm getting more out of this.
• 34:17
  SPEAKER_00: So this is something that I hope that you can kind of tighten up and be able to kind of put into play for yourself if you're using NMES, or maybe if you're a clinician using it.
• 34:26
  SPEAKER_00: All the device recommendations, the links, the research references from both episodes are in the show notes.
• 34:34
  SPEAKER_00: And if you need us, if you need help, if you are like my PT never mentioned NMES, and I'm post op ACL and I am further out in the process, and I feel blinded, I feel betrayed.
• 34:47
  SPEAKER_00: Don't feel betrayed, but it is good to ask questions and be like, why did we not use this?
• 34:52
  SPEAKER_00: But it is something that we want to make sure we are using the most current up-to-date research.
• 34:57
  SPEAKER_00: So I think that that is something that we need to just kind of flag a little bit and be like, why didn't we use this?
• 35:02
  SPEAKER_00: I'm always so shocked.
• 35:04
  SPEAKER_00: And if you need some help, if you need some advice, if you need some input, we're here to help in any way that we can.
• 35:10
  SPEAKER_00: Please reach out to us at the ACL Athletes.
• 35:14
  SPEAKER_00: Our info is in the show notes.
• 35:16
  SPEAKER_00: Thank you guys so much for being here for both parts of this series.
• 35:19
  SPEAKER_00: Now go shock your quads, get after it, get those things freakishly strong and big.
• 35:26
  SPEAKER_00: And we're here if you need us.
• 35:28
  SPEAKER_00: Until next time, this is your host, Robbie Patel, signing off.