Ep 211: REVISITED: Gimme an N-M-E-S (stimulator)! With Drs Elanna Arhos & Naoaki Ito

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Clare Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. As 2024 wraps up and the JOSPT Insights team are taking a few weeks break, we're taking the opportunity to revisit a few of the episodes that were definite fan favourites in 2024. The topics

[00:00:34] are just as relevant today as they were when the episodes first aired. Before today's episode begins though, a big thanks to everyone who's listened, shared episodes with colleagues, offered feedback and requested guests in 2024. Whether you're new to the podcast or a Stalwart subscriber, we're so grateful for your support and always happy to hear your feedback. Please get in touch with us on Facebook, X, LinkedIn, Blue Sky or Instagram.

[00:01:02] To my wonderful co-hosts, Drs Chelsea Koeman and Dan Chapman, your interviews are going from strength to strength. It's such a joy to work with you both to bring JOSPT Insights to our listeners each week. Listeners, you'll hear us back with new JOSPT Insights episodes in your feed in January. Until then, our very best holiday wishes to you and those you love. And here's today's episode. Today, we're getting into the nitty gritty of how to support patients to get the most

[00:01:31] out of the very beneficial intervention that is neuromuscular electrical stimulation. Dr. Alana Arhos and Dr. Nao Ito and their team have tested a mix of common stimulators available on the market today and they're here to share the results with us, plus their best tips for choosing the equipment that's right for your clinic. Dr. Arhos is a postdoctoral research associate at The Ohio State University. Her research is focused

[00:01:59] on clinical and biomechanical outcomes after ACL rupture and reconstruction, particularly post-traumatic osteoarthritis and gait adaptability. Dr. Ito is a postdoctoral research associate at the University of Wisconsin-Madison. His expertise is in applying advanced imaging techniques, wearable technology, and electrotherapy to improve rehabilitation after knee injuries. This leads us nicely into how you have the discussion with the patient, how you frame that

[00:02:29] this is going to feel uncomfortable and that that feeling of discomfort to a certain extent is okay. So how do you have that conversation with people so that you can realistically acknowledge how it's going to feel and then equally get the benefits, get this to a point where you can actually get benefits out of it? It's a tough balance to strike, I think. Dr. Yeah, it absolutely is. It's something that I can continue to work on. It's something that's probably going to look different for each patient that comes in your clinic because each patient

[00:02:58] likely has a different pain tolerance or deals with pain differently. So leading really with the evidence like we do for a lot of our conversations with the post-ACL population where we share, you know, this is an invention that will be uncomfortable and it is also an intervention that is the best supported in the literature in terms of getting your quadrisp strength back and really being in a place where you're able to return to sport or return to activity or return to doing the things you love.

[00:03:28] You know, I think at this point, we've probably also been educating our patients on the importance of quadrisp strength and that being one of the primary impairments that we are driving and working on throughout rehab. So leading with the evidence and also sharing some strategies. So now and I talk about different strategies that we use with different patients to be able to tolerate it, whether they're visual people, whether they want to put earphones in and just not look at you and

[00:03:54] just pretend you're not there, whether, you know, they want to talk through it. Every patient has a little bit of a different way to manage pain and symptoms. So getting to know the patient in front of you is really best for that conversation. Now, can you share some of those examples with us? The funny thing is we're talking about with ACL injuries, at least a lot of athletes and they tend to be competitive. So this visual feedback and giving them a target tends to be a pretty good strategy to try to

[00:04:21] get them to that level. But of course, like Ilana said, it's not for everyone. We have to also acknowledge that for some people, it's just not going to be possible, right? It's not going to be able to be an intervention for every single patient. We just have to accept that once in a while. And it's unfortunate, but we have to move on with that. The other thing that's neat is depending on the personality, some patients like having control over their own contractions. So having them manipulate their own stim unit, especially once they're used to it, the first several visits,

[00:04:50] you want to kind of have control over it. So you can almost teach them this is how it's supposed to feel. These are the intensities you're supposed to be expecting. But once they have autonomy over that, a lot of patients would feel comfortable kind of increasing the intensity throughout the session by themselves. And that actually saves us time too, because we have to check in less as well. When you talk about visual feedback now, are you talking about a biofeedback machine or are you talking about more what you get from the isokinetic dynamometer? How does that look to the patient?

[00:05:20] Yeah. So with an isokinetic dynamometer, if you can visualize, you can see the torque output on a time series going across, usually left to right. And what you can do is set a target line saying, hey, this is your 50% threshold. And if they're able to get beyond that with the typical intervention, you might start pushing the bar up a little bit. So they're targeting a little further. And now even without an isokinetic dynamometer, a lot of these more portable types, inline dynamometers

[00:05:47] now have phone apps that will connect up. So they can give you real-time feedback and give that kind of visual feedback on their lap for the patient to see similar output as well. How do you figure out, Alana, the difference between discomfort that you are okay with as a clinician versus pain discomfort that is not okay? Yeah, that's a great question and a hard question. I think really leaning into your clinical judgment

[00:06:14] there, asking where the pain is, asking for descriptors of the pain and kind of understanding where that's coming from. And then I think that brings up another important point of also looking at response to the intervention after each session and over time, you know, the same things apply with some of the soreness rules that we follow and, you know, that have been proposed in the tendinopathy literature, but also are applied to a lot of different patient populations, looking at effusion,

[00:06:42] you know, any of those measures that we would use to assess if an intervention is progressing appropriately over time. It is appropriate to also implement in the use of NMES too. And do people get DOMS from NMES now? What sort of aftercare advice do you provide? DOMS is absolutely a consequence of the intervention. Whether it's because of NMES or because of everything else they did, it's probably a combination of both. But if they're not sore the next day,

[00:07:10] you probably underdosed. That's kind of the baseline. Now, we're not expecting them to come back sore for the next 60s. And so that's a little too much. So we have to, that's the clinical judgment we have to make, but that's another expectation we need to explain to the patient is that you are going to be sore and this is going to be a repeated cycle until it gets you strong enough and back onto the field. Yeah. And again, I think this is really underscoring a point that you made earlier,

[00:07:35] Alana, about testing regularly, measuring quads, and that being something that's really key to our practice as sports and orthopedics physios. All right, let's move on. And I want to talk a little bit about the best stimulator. So I've got a bit of cash to spend on my clinic. Now, what would you recommend I look for in a stimulator? How should I decide how best to spend that money? In this

[00:08:01] clinical commentary, you and the team have done a really great job of investigating a whole bunch of stimulators. So what did you find? Yeah. So before we touch on any of this, full disclosure, we don't have any conflicts of interest with any of these companies. That's good to put out there. But the bottom line is we went through a pretty thorough search of what companies have and are selling NMES units. And we sent out a letter, which I think is part of the supplementary material

[00:08:28] in the journal that outlines, these are the parameters we're looking for. This is exactly what we want to do with the experiment. And they send us a unit for us to test or at least give us parameters so we can compare. And I think we ended up with five or six different companies reaching out to us and we tested them out. So the first take home is that even if the stimulators can all provide the same parameters, that doesn't translate to the same outputs. And now what goes on the backend and

[00:08:54] the engineering side is kind of a black box to us. So it's difficult to say, but we have to accept that each one of these are different, even with the same numbers presenting. So in terms of overall strength and output, balancing the comfort and the output from the testing we did, the Chattanooga or now under a novice's umbrella, the MP or the continuum is now it's called, was the stimulator that

[00:09:20] got all five of our participants to closest to a therapeutic dose. The second one that kind of was almost there with similar output was the intensity, which is a slightly affordable unit. So that can be an alternative for a little more budget-friendly option. And potentially if you're sending a patient home with that, that's a good one as well. So the other unit that had really high intensity was the dinatronics unit and that's a wall unit. So it's not battery powered. And

[00:09:50] unsurprisingly, it actually gave us a lot of output, but at the same time, it was the least comfortable unit. So we weren't able to get higher intensities with the people we tested. But this could be another alternative for those patients that have very high tolerance and might be able to take a little more than what the handhelds are able to provide. So really it's a matter of balancing the pros and cons of each of these units that I talked about. Really commercially, probably the most realistic options are the Chattanooga continuum and the intensity. And again,

[00:10:19] this isn't the most comprehensive list. These are only the people that reach back out to us. So there might be other units out there that can provide similar or even better outcomes as well. I think it's a really nice starting point though now, and you've got a great summary in the paper of, well, first describing actually how you reached out to these companies is important. As you say, that there's no conflict of interest here. You're not interested in pushing a particular company. You're interested in helping folks who are listening to JOSPT Insights make some informed

[00:10:48] decisions when they're going out to purchase these items, which is really helpful. The other thing you mentioned is about sending a patient home with a portable unit. And Alana, I'm interested in how you make that decision. Who is the person that you feel comfortable sending home with an NMES unit and how does that work? I think a lot of patients can be sent home with NMES units. I think that we do that a lot. I see that

[00:11:13] done a lot here too. I think the person that you're going to trust with that is the person that's been involved in their NMES application in the clinic too, who has a good understanding of how to use it, who has held it, who has done the parameters, who has good buy-in to it, because that's the person that's going to go home and actually use it appropriately too. I think that the person that can't go home with

[00:11:41] it is the person that's a little bit wary each time you do it, the person that's potentially not going to turn it up to a therapeutic dose. It's not that they can't go home with it. It's just that how much more are you getting by sending them home with it too? Yeah. And it comes back down to the resources, right? You don't want to be handing out units and losing them every other time you give it out. So it's balancing all those things. Absolutely. And speaking as the person who hates NMES and would really struggle to turn it up if

[00:12:10] she was sent home with the NMES unit, I would much prefer you send it home with someone who would use it to its fullest capacity. And then I'll try to work hard on some other quad strength training at home where I don't need to use NMES. And now I think that brings me to another question, which is how do you figure out when to stop using NMES and when to bump up the voluntary quads contractions in the gym, in the clinic at home?

[00:12:39] Let's start with that second half of the question. The voluntary quad contraction stuff, that's happening from day one all the way through. We're never removing that. And honestly, especially with ACL injuries, these patients need to be educated that quad strengthening is going to be their lifetime friend, right? It's not just about getting back to their sport, but it's overall long-term knee joint health. We tend to forget about that in these acute settings right after surgery, but this is the first line of defense is maintaining strong quads

[00:13:07] when it comes to the voluntary exercises. And in terms of when to terminate NMES, again, in an ideal world, it never should be because we don't know until what point we see the benefits in. But realistically, once you get to these higher levels, you want to spend more time on higher level activity. And like you said, not just sitting on the dynamometer and receiving NMES. So really, the cutoff we used clinically, at least at the University of Delaware,

[00:13:36] is once you achieve that 80% quad strength index as that line. But again, this isn't necessarily an evidence-based threshold, but it's rather more of a feasibility and kind of balancing the pros and cons. And I think it really comes back to, as we've been talking about through this whole discussion, your clinical judgment is critical here and your clinical reasoning skills, your capacity to reason through all of the different pros and cons, what's working, what's not, change the dosage,

[00:14:04] change the intensity, measure again, figure out what's appropriate discomfort. All of these sorts of things are crucial to functioning at a really high level as a sports clinician. Elana, as we wrap up, it's been such a great chat with both of you today. I've learned a ton about using NMES. I'd really love for you to summarize what are the key points, what are the key

[00:14:28] things that you'd like someone to take from listening to us chat today about using NMES in the clinic? Sure. I hope that the biggest key point that's taken away from this is that dosage is really the main critical piece of using NMES as an intervention. So like Nau said, it's not to say that it can't be applied on top of exercises as well, but really in order to get the evidence-based effects that we know

[00:14:54] relate directly to quad shift strengthening, we need to use NMES as a standalone intervention where we're really able to monitor the force output and we're really able to monitor the intensity of the treatment. I think the other thing is not to be afraid. And as the clinician, you have to experience this yourself, right? You can never talk to someone about this without knowing what it's supposed to feel like. And it helps with patient education too. These are really great points. And I'm very pleased

[00:15:23] that you were able to join us today to bring these key messages, very important messages to the JOSPT community. Thanks so much for joining me, Dr. Alana Ahos and Dr. Nau Ito. Thanks so much for having us, Claire. This was great. Yeah, thank you. Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOSPT Insights

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