Ep 170: Gimme an N - M - E - S (stimulator)! Part 2 with Drs Elanna Arhos & Naoaki Ito

[00:00:00] Professor Laura Mamosley is running three face-to-face courses in North America in 2024.

[00:00:07] He's visiting Vancouver, San Francisco and New York City in late September and early

[00:00:12] October this year.

[00:00:14] The two day courses are designed to help you embed the latest in paint science in education

[00:00:18] in your clinical practice.

[00:00:21] Check out the show notes to see Professor Mamosley's program in each of these three iconic Canadian

[00:00:27] and US destinations.

[00:00:29] Yes, you heard correctly the latest in paint science in education in person with Professor

[00:00:35] Laura Mamosley September and October 2024.

[00:00:44] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality

[00:00:49] research to quality practice.

[00:00:51] I'm Clara Don, the editor-in-chief of the Journal of Orthopedic and Sports Physical Therapy.

[00:00:57] It's great to have you listening today.

[00:01:03] Today we're getting into the nitty-gritty of how to support patients to get the most out

[00:01:07] of the very beneficial intervention that is neuro-muscular electrical stimulation.

[00:01:13] Dr. Alana Ahos and Dr. Nau Eto and their team have tested a mix of common stimulators available

[00:01:19] on the market today, and they're here to share the results with us.

[00:01:22] Plus their best tips for choosing the equipment that's right for your clinic.

[00:01:27] Dr. Ahos is a postdoctoral research associate at the Ohio State University.

[00:01:32] Her researchers focused on clinical and biomechanical outcomes after ACL rupture and reconstruction,

[00:01:38] particularly posttraumatic osteoarthritis and gate adaptability.

[00:01:42] Dr. Eto is a postdoctoral research associate at the University of Wisconsin-Madison.

[00:01:48] His expertise is in applying advanced imaging techniques, wearable technology and electrotherapy

[00:01:54] to improve rehabilitation after knee injuries.

[00:01:58] This leads us nicely into how you have the discussion with the patient, how you frame that

[00:02:03] this is going to feel uncomfortable and that feeling of discomfort to a certain extent

[00:02:09] is okay.

[00:02:10] So how do you have that conversation with people so that you can realistically acknowledge

[00:02:14] how it's going to feel and then equally get the benefits, get this to a point where

[00:02:19] you can actually get benefits out of it.

[00:02:22] It's a tough balance to strike, I think.

[00:02:24] Yeah, and absolutely is, it's something that I can continue to work on.

[00:02:27] It's something that's probably going to look different for each patient that comes

[00:02:30] in your clinic because each patient likely has a different pain tolerance or deals with

[00:02:36] pain differently.

[00:02:37] So leading really with the evidence like we do for a lot of our conversations with the

[00:02:41] post-ACL population where we share, this is an invention that will be uncomfortable and

[00:02:48] it is also an intervention that is the best supported in the literature in terms of getting

[00:02:53] your quadriceps strength back and really being in a place where you're able to return to

[00:02:58] sport, a return to activity, a return to doing things you love.

[00:03:02] I think at this point we've probably also been educating our patients on the importance

[00:03:06] of quadriceps strength and that being one of the primary impairments that we are driving

[00:03:10] and working on throughout rehab.

[00:03:12] So leading with the evidence and also sharing some strategies.

[00:03:17] So now and I talk about different strategies that we use with different patients to be able

[00:03:22] to tolerate it whether they're visual people, whether they want to put earphones in and just

[00:03:27] not look at you and just pretend you're not there or whether they want to talk through

[00:03:31] it.

[00:03:32] Every patient has a little bit of a different way to manage pain and symptoms.

[00:03:36] So getting to know the patient in front of you is really best for that conversation.

[00:03:41] Now can you share some of those examples with us?

[00:03:44] The funny thing is we're talking about with ACL injuries at least a lot of athletes and

[00:03:48] they tend to be competitive so this visual feedback and giving them a target tends to be

[00:03:52] a pretty good strategy to try to get them to that level but of course like Alana said,

[00:03:58] it's not for everyone.

[00:03:59] We have to also acknowledge that for some people it's just not going to be possible, right?

[00:04:04] It's not going to be able to be an intervention for every single patient.

[00:04:07] We just have to accept that once in a while and it's unfortunate but we have to move on

[00:04:10] with that.

[00:04:11] The other thing that's neat is depending on the personality, some patients like having control

[00:04:16] over their own contractions.

[00:04:18] So having them manipulate their own stimulant especially once they're used to it.

[00:04:23] The first several visits you want to kind of have control over is so you can almost teach

[00:04:28] them.

[00:04:29] This is how it's supposed to feel.

[00:04:30] These are the intensities you're supposed to be expecting.

[00:04:32] But once they have autonomy over that a lot of patients would feel comfortable kind of

[00:04:36] increasing the intensity throughout the session by themselves and that actually saves us time

[00:04:40] too because we have to check in less as well.

[00:04:43] When you talk about visual feedback now are you talking about a biofeedback machine or

[00:04:48] are you talking about more what you get from the isochinetic dynamometer?

[00:04:52] How does that look to the patient?

[00:04:54] Yeah, so with an isochinetic dynamometer if you can visualize you can see the torque output

[00:04:59] on a time series going across usually left to right.

[00:05:03] And what you can do is set a target line saying, hey this is your fish 50% threshold and

[00:05:07] if they're able to get beyond that with the typical intervention you might start pushing

[00:05:11] the bar up a little bit so they're targeting a little further.

[00:05:14] And now even without a nice isochinetic dynamometer a lot of these more portable types in line

[00:05:20] dynamometers now have phone apps that will connect up.

[00:05:23] So they can give you real time feedback and give that kind of visual feedback on their

[00:05:27] lab for the patient to see similar output as well.

[00:05:30] How do you figure out a line up the difference between discomfort that you are okay with

[00:05:36] as a clinician versus pain discomfort that is not okay?

[00:05:42] Yeah, that's a great question and a hard question.

[00:05:45] I think really leaning into your clinical judgment there asking where the pin is, asking

[00:05:51] for descriptors of the pin and kind of understanding where that's coming from.

[00:05:56] And then I think that brings up another important point of also looking at response to the

[00:06:01] intervention after each session and over time, you know, the same things apply with some

[00:06:06] of the soreness rules that we follow and that have been proposed in the Tundinopathy literature

[00:06:11] but also are applied to a lot of different patient populations looking at diffusion.

[00:06:16] Any of those measures that we would use to assess if an intervention is progressing appropriately

[00:06:22] over time is appropriate to also implement in the use of NMS too.

[00:06:27] And do people get doms from NMS now?

[00:06:30] What sort of aftercare advice do you provide?

[00:06:34] Domes is absolutely a consequence of the intervention whether it's because of the NMS or because

[00:06:39] of everything else they did, it's probably a combination of both but if they're not

[00:06:43] sort of the next day, you probably under those that's kind of the baseline.

[00:06:47] Now we are not expecting them to come back sore for the next 60s and so that's a little

[00:06:52] too much.

[00:06:53] So we have to, that's the clinical judgment we have to make but that's another expectation

[00:06:57] we need to explain to the patient is that you are going to be sore and this is going

[00:07:00] to be a repeated cycle until we get just strong enough and back onto the field.

[00:07:05] Yeah and again I think this is really underscoring a point that you made earlier, Alana about

[00:07:10] testing regularly measuring quads and that being something that's really key to our practice

[00:07:16] as sports and orthopedics physios.

[00:07:19] All right, let's move on and I want to talk a little bit about the best stimulator.

[00:07:25] So I've got a bit of cash to spend on my clinic.

[00:07:28] Now what would you recommend I look for in a stimulator?

[00:07:32] How should I decide how best to spend that money in this clinical commentary?

[00:07:36] You and the team have done a really great job of investigating a whole bunch of stimulators.

[00:07:41] So what did you find?

[00:07:42] Yeah so before we touch on any of this for disclosure we don't have any conflicts of

[00:07:47] interest with any of these companies.

[00:07:49] It's always good to put out there but the bottom line is we went through a pretty thorough search

[00:07:53] of what companies have and are selling NMEs units and we sent out a letter which I think

[00:08:00] is part of the supplementary material in the journal.

[00:08:03] The outlines, these are the parameters we're looking for.

[00:08:05] This is exactly what we want to do with the experiments and please send us the unit

[00:08:09] for us to test or at least give us parameters so we can compare.

[00:08:13] And I think we ended up with five or six different companies reaching out to us

[00:08:16] and we tested them out.

[00:08:17] So the first take home is that even if the stimulators can all provide the same parameters

[00:08:24] that doesn't translate to the same outputs.

[00:08:26] And now what goes on the back end and the engineering side is kind of a black box for us so it's

[00:08:30] difficult to say but we have to accept that each one of these are different even with the

[00:08:35] same numbers presenting.

[00:08:36] So in terms of overall strength and output balancing the comfort and the output from what

[00:08:43] the testing we did, the Chattanooga or now under a novices umbrella the MP or the continuum

[00:08:51] is now it's called was the stimulator that got all five of our participants to closest

[00:08:57] to their putic dose.

[00:09:00] The second one that kind of was almost there with similar output was the intensity

[00:09:07] which is a slightly affordable unit so that can be an alternative for a little more budget-friendly

[00:09:13] option and potentially if you're sending a patient home with that that's a good one as well.

[00:09:16] So the other unit that had really high intensity was the dynatronics unit and that's a wall unit

[00:09:22] so it's not battery powered and unsurprisingly it actually gave us a lot of output but at the same time

[00:09:27] it was the least comfortable unit so we weren't able to get higher intensities with the people we

[00:09:32] tested but this could be another alternative for those patients that have very high tolerance

[00:09:37] and might be able to take a little more than what the handhelds are able to provide.

[00:09:41] So really it's a matter of bouncing the pros and cons of each of these units that I talked about

[00:09:47] really commercially probably the most realistic options are the Chattanooga continuum and the

[00:09:52] intensity and again this isn't the most comprehensive list these are only the people that reach back

[00:09:56] out to us so there might be other units out there that can provide similar or even better outcomes as well.

[00:10:02] I think it's a really nice starting point though now and you've got a great summary in the paper

[00:10:07] of well first describing actually how you reached out to these companies as important as you say

[00:10:12] that there's no there's no conflict of interest here you're not interested in pushing a particular

[00:10:16] company. You're interested in helping folks who are listening to JMSPT insights make some

[00:10:21] informed decisions when they're going out to purchase these these items which is really helpful.

[00:10:26] The other thing you mentioned is about sending a patient home with a portable unit and Elana

[00:10:32] I'm interested in how you make that decision who is the person that you feel comfortable

[00:10:37] sending home with an NMS unit and and how does that work? I think a lot of patients can be sent home

[00:10:43] with NMS units. I think that we do that a lot I see that done a lot here too. I think the

[00:10:50] person that you're going to trust with that is the person that's been involved in their NMS

[00:10:55] application in the clinic too who has a good understanding of how to use it who has held it,

[00:11:00] who has done the parameters, who has good buy-in to it because that's the person that's going

[00:11:07] to go home and actually use it appropriately too. I think that the person that can't go home with

[00:11:14] that is the person that's a little bit wary each time you do it the person that's potentially not

[00:11:20] going to turn it up to a therapeutic dose. It's not that they can't go home with it it's just

[00:11:26] that how much more are you getting by sending them home with it too? Yeah and it comes back to

[00:11:30] the resources right and you don't want to be handed out units and losing them every other time

[00:11:35] you give it out so it's it's balancing all those things. Absolutely and speaking as the person who

[00:11:41] hates NMS and would really struggle to turn it up if she was sent home with the NMS unit I would

[00:11:46] much prefer you send it home with someone who would use it to its fullest capacity and then I'll

[00:11:52] try to work hard on some other quad strength training at home where I don't need to use NMS

[00:11:58] and now I think that brings me to another question which is how do you figure out when to stop using

[00:12:05] NMS and when to bump up the voluntary quads contractions in the gym in the clinic at home?

[00:12:12] Let's start with that second half of the question the voluntary quad contraction stuff they're

[00:12:16] that's happening from day one all the way through we're never removing that and honestly

[00:12:22] especially with ACL injuries these patients need to be educated that quad strength

[00:12:26] thing is going to be their lifetime friend right it's not just about getting back to their sport

[00:12:30] but it's overall long-term knee joint health we tend to forget about that in these acute settings

[00:12:35] right after surgery but this is the first line of defenses maintaining strong quads with when

[00:12:41] comes to the voluntary exercises and in terms of when determining NMS again is in an ideal world it

[00:12:49] never should be because we don't know until what point we see the benefits and but realistically

[00:12:54] once you get to these higher levels you want to spend more time on you know higher level activity

[00:12:59] and like you said not just sitting on the the dynamometer and receiving NMS so really the

[00:13:07] the cutoff we've used clinically at least at the University of Delaware is once you've achieved

[00:13:11] that 80% quad strength index as that line but again this isn't necessarily an evidence-based threshold

[00:13:18] but it's rather more of a feasibility and kind of bouncing the pros and cons

[00:13:22] and I think it really comes back to as we've been talking about through this whole discussion

[00:13:27] your clinical judgment is critical here and your clinical reasoning skills your capacity to

[00:13:33] reason through all of the different pros and cons what's working what's not change the dosage

[00:13:37] change the intensity measure again figure out what's appropriate discomfort all of these sorts

[00:13:43] of things are crucial to functioning at a really high level as a sports clinician

[00:13:50] Alana as we wrap up it's been such a great chat with both of you today I've learned a ton about

[00:13:55] using NMS I'd really love for you to summarize what are the key points what are the key things

[00:14:02] that you'd like someone to take from listening to us chat today about using NMS in the clinic

[00:14:09] sure I hope that the biggest key point that's taken away from this is that dosage is really the

[00:14:15] mean critical piece of using NMS as an intervention so like now said it's not to say that it can't

[00:14:21] be applied on top of exercises as well but really in order to get the evidence-based effects that we

[00:14:27] know relate directly to quadrature strengthening we need to use NMS as a standalone intervention where

[00:14:33] we're really able to monitor the force output and we're really able to monitor the intensity of

[00:14:39] the treatment I think the other thing is not to be afraid and as the clinician you have to experience

[00:14:45] this yourself right you can never talk to someone about this without knowing what it's supposed

[00:14:50] to feel like and it helps with patient education too these are really great points and I'm very

[00:14:56] pleased that you're able to join us today to bring these key messages very important messages

[00:15:01] to the JOSPT community thanks so much for joining me Dr. Alana Ahos and Dr. Nau Eto.

[00:15:07] Thanks so much for having us Claire this was great yeah thank you.

[00:15:17] Thanks for listening to this episode of JOSPT Insights for more discussion of the issues in

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