September 12, 2023 • 45 mins
We know that after a lower extremity injury like an ACL tear, there are often joint-related symptoms such as swelling, loss of motion, and instability. But as we learn more about these injuries, there appear to be several neuromuscular consequences as well.
In this episode, I talk to Terry Grindstaff from Creighton University about his research into these neuromuscular consequences after an ACL injury, and how this could impact our initial rehabilitation, return to sport progressions, and even long-term consequences years down the road.
Full show notes: https://mikereinold.com/neurological-consequences-of-acl-injuries-with-terry-grindstaff
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
On this episode of the sportsphysical therapy podcast.
I am joined by Terry Grindstaff.
Terry's a professor in thephysical therapy program at
Creighton university, where hecombines research education and
working with the studentathletes.
He's been focusing much of hisresearch on the neuromuscular
consequences of lower extremityinjuries, which is what we're
going to be discussing intoday's episode.
Mike (00:31):
Hey Terry.
Thanks so much for joining me onthe podcast today.
How's it going?
Terry (00:34):
I'm doing really well today.
Thanks for having me.
Mike (00:37):
Awesome.
Yeah, we, we, you know, for thelisteners, Terry and I just had
a, a fun little chat, so I thinkthis is gonna be, uh, this is
gonna be a good episode.
But, um, uh, Terry, uh, you'vedone so much research, you know,
working at Creighton, you've,you, you just had a ton of
experience with differentthings.
Um, we could go in a lot ofdifferent directions with this
podcast, but for me, I knowsomething that you're passionate
about.
Something that I've seen youspeak about is, um, how you've,
(00:59):
you've focused a little bit of,of your, your.
Your mind power, so to say, onlower extremity injuries, and
then some of the neuromuscularconsequences that we see from
that, which is huge.
Right?
That's such a huge topic.
So I, I kind of wanna start offwith that, right?
And kind of jump right in and,and talk about it.
Like, maybe we start with like abasic one with, with acls, like
(01:21):
we've seen over the years, quadstrength, neuromuscular changes.
Neurocognitive changes now arebecoming more and more, you
know, prevalent, alteredbiomechanics.
All these things happen afterinjury.
Why don't we start with that andfrom all the stuff that you've
done, all the research you'veput into this, what do we know
about some of these consequencesafter these big injuries?
Like an a c L?
Terry (01:40):
No, it's a, that's a, that's a good question.
I think,
Mike (01:43):
Huge question.
Sorry.
I was like, welcome to thepodcast and boom.
Terry (01:47):
it's good.
It's good.
Yeah.
Start off and, uh, let's getphilosophical, right?
And so I think, I think, youknow, for me and, and sort of
the, the, the, the journeythrough this and, and, and one
of the things that's been, uh,Interesting for me and sort of
hooked me into this is, isyou'll see somebody with, with a
knee injury and, and reallylike, regardless of the knee
(02:08):
injury, I think quite often wetalk about a c l reconstruction.
But yeah, I mean it could bepatella ifor pain or anterior
knee pain.
You know, somebody with, uh, youknow, post-op mastectomy.
It's sort of whatever it is.
Quadriceps doesn't work as well.
And, and so it's like this, youknow, this, this common clinical
impairment and, and somebody cando a quad set the day before
(02:30):
surgery or the day before aninjury and like the next day
they can't.
And, and you know, a lot of thetime when I'm lecturing or
talking with students orwhatever, I kind of bring up
this clinical scenario andscenario.
You could do a quad set the daybefore and you can't the day
after.
And it's like, well, what's,what's causing that?
Or what do you do to addressthat thing?
And a lot of the time it's like,well, you know, they, they need
(02:52):
strength.
We need to work onstrengthening.
And I'm like, wait a second.
If you sat in bed all day forone day, your quad wouldn't get
that week.
Like that wouldn't happen.
And so we, yeah, we know thatit's driven neurologically.
And, but a lot of the timeclinically, our approach is you
need strengthening.
And it's like, well, maybe weneed to reframe this, uh, a, a,
(03:16):
a little bit.
And, and so I think that's beenhelpful, you know, for how I
approach things in the clinic,how I approach things in the
research laboratory is reallythinking of the, you know, the.
Knee injuries as, as really, youknow, there, there are
neuromuscular consequences.
There is still a joint relatedinjury, but like why in the
(03:38):
world does a muscle stop workinglike the quadriceps when in
theory it wasn't injured and,and minus if you had like, uh,
bone Patel, uh, bone tendongraft, if you had quad tendon
graft, something like that, thenyes, there is a muscle or tendon
injury, but you had a hamstringgraft or an allograft or
something like.
There's no muscle injury to thequad.
(03:59):
Like in theory it should work,but yet it doesn't.
So it's driven neurologically.
And I think that's been kind ofthe fascinating part on some of
the things that we've looked atfrom a research perspective of,
well, what's causing this?
You know, we know that part ofit's driven by spinal reflexive
processes, uh, and some of it'sdriven from a, you know, kind of
a cortico motor standpoint.
(04:20):
And, and then, uh, and thenthere's also then this atrophy
component or kind of thisperipheral component as well.
We have central components andperipheral components.
And then the next step is like,well, if we understand some of
these mechanisms of what's goingon, then what can we do about
it?
Because ultimately, you know, I.
Thinking about, well, we need tohelp people in the clinic, we
(04:40):
need to help patients.
And, and so we can understandmechanisms all day, but we need
to be able to translate that tosomething that people can use in
clinical practice.
And I think that's kind of beenone of the joys that I've had
from, from both a researchperspective and a clinical
perspective is, is trying anywayto, to, to blend some of those,
or bridge some of those, um, youknow, concepts with, yeah, we
(05:02):
know these things happen from aneurological perspective, but
what can we do about it?
And then not only what can we doabout it, but we better be able
to do it in a timely manner inthe clinic and, and all these
other considerations that Idon't have to deal with in
athletics, like insurance and,uh, stuff like that.
So it's, uh, it's, it's, it's,it's these multiple things sort
(05:23):
of tugging at my brain at the,at the same time to, to
hopefully ask clinicallymeaningful, uh, research
questions.
So that's, That's kind of, youknow, what we do in a, in a
nutshell.
Uh, and we're, you know, I liketo think we're using the knee as
a model.
In theory, this, this, this sortof stuff.
It happens at the, at the lumbarspine, it happens at the
shoulder, it happens at otherjoints.
(05:44):
Uh, the knee just happens to be,uh, you know, something that we
can study and, uh, and look atquads, big muscle.
So it makes
Mike (05:52):
Right ex.
Right, exactly.
And, and, and it's a veryimportant muscle for lots of
different functions.
So it, it's probably more in, inour face, right.
When you have a deficit, uh, weprobably notice it more cuz the
consequences of it, I meanchanges, gait changes even, you
know, they're subjective thingsin a non-weightbearing joint or
something else may, you know,maybe you just get by, it's a
little different so we don'tnotice it as much.
But, um, yeah, you know, for me,I've always found clinically
(06:16):
that when you get behind.
With some of these things, ifyou let these neuromuscular
consequences kind of take holdand progress over time, um, they
get harder and harder toovercome.
Right.
So those, this is the type ofpeople, like I have people in my
inner circle that like, youknow, I just answered a question
this morning.
Somebody was, I think it wasabout eight months after a c l
reconstruction and.
(06:37):
Still, you know, they stilldon't have knee extension, so,
you know, that's not great.
But, um, which might be part ofthe problem, but again, they
can't get the quad to turn on.
Right.
So like going back to yourthoughts on central, uh, you
know, concepts that go intothat, like what is it
specifically you think that,cause some people to have this
consequence more than others andsome to have it delayed for so
(06:59):
long, like what is it that doesthat?
Terry (07:01):
Yeah, I think that's a, that's a, that that is a great
question right there.
And, and, uh, and I mean, I've,I've seen people in the clinic
like this as well, and I'd liketo think I'm at least reasonable
at, uh, at some of the, uh, someof the approaches that I take.
But it's, you know, it's, it's,uh, I, I, I know better enough
now to to, to not say it's thisone thing and that's it.
(07:23):
So there's a lot of differentfactors, um, that, uh, that,
that play into it.
Um, you know, and, and I'm like,oh, you know, is, is, is it, you
know, are, are people just morelikely to have, say, persistent
swelling?
Is there something going on, youknow, sort of from a.
You know, like a, a metabolicperspective or, uh, you know,
(07:45):
systemic perspective that, that,that, uh, they are more prone
to, uh, you know, to, toinflammation.
Or do they just heal, uh, a, a alittle bit more slowly, or do
they lay down more scar tissue?
You know, so I think that thosecan be components.
Some people just have, uh, youknow, different, uh, capacity to
(08:07):
process pain or to, to mitigatepain.
Uh, you know, and, and then you,you can add in kind of these
psychological factors as wellthat, that play into it.
And then really some of thesethings also to a degree, become
like this chicken or egg thing.
But like you were saying, Icompletely agree that it's
probably.
Better to take care of thesethings early on and, and to jump
(08:31):
on it early on versus later.
Um, I think an unfortunateaspect right now is that we
don't have great ways tomeasure, like quadriceps
inhibition in the clinic.
Mike (08:45):
Mm-hmm.
Terry (08:46):
We have great ways in the research lab and we have great
ways to look at like spinalreflexive excitability and
cortical motor, uh,excitability, but we don't have
great ways to do this in theclinic.
And then I think then theconsequence of that is if, if,
if we don't have a good way tomeasure something, then we may
not, one, pay attention to it asmuch.
(09:08):
Or, or, or, or dedicate, youknow, intervention resources to
address it because then we can'tmeasure it.
We don't know if we did a goodjob or not, with the exception
of hindsight.
Hindsight seems to, oh, youknow, this person at four months
out, six months out, eightmonths out, like we were saying,
they seem to be struggling.
And it's like, yeah, like itwould've been really helpful
(09:32):
have, have had some of thesemeasures early on.
Um, you know, to either say, youknow, we need to stick with
these particular interventionsthat are addressing some of
these neuromuscularconsequences.
We need to stick with thoselonger, or we need to employ
those earlier or just employthem at all.
Um, and so I think that thoseare, um, those are things for
(09:53):
consideration if you sort oflike, let's speculate, right?
And, and, and, uh, and, and so Ithink some of the things that
I've seen, like in the clinic,some of the things that we've
seen in the research lab and,and we probably just haven't
studied it enough.
I think there, there, there,there's something to be said for
the persistent in the fusion.
(10:14):
There's something to be said forthe delayed capacity to achieve
full extension.
And the other that we've lookedat or, or, or that I've at least
noticed, and I'm sure thatyou've seen this, I'm sure a lot
of the listeners have seen this.
You know, it's this personpost-op day one or week one or
whatever it is, and for the lifeof them, like you look at their
(10:34):
face and they, they are tryingso hard.
To get like a quad set with,with a substantial amount of
intensity.
They're looking at their quad.
They, they are using everyresource that they have
absolutely available and theycan't do it.
And, and.
I think there's something there.
I'm not quite sure the best wayto quantify that right now.
(10:57):
And you know that I like to beable to quantify things,
Mike (11:00):
Yeah.
Terry (11:00):
that's at least something that I picked up on and, and
just kinda looking at thepatient and like, this person's
probably going to struggle forwhatever reason.
Like, and, and they can't dothis quad set, which you're
like, in theory that should bereally simple, but they're
throwing so many resources at itto get it to happen.
Um, And, and so I'm like, Ithink we, maybe the best way to
(11:22):
deal with this is to bestappreciate this as a reflexive
reaction and, and let's employsome of these, you know, kind of
neurological approaches to ourorthopedic or sports medicine
kind of framework.
Mike (11:36):
I think that's great.
And I, I, I love too how, like,I, I think you're completely
right.
It's the people that struggleweek one, right?
You can almost tell they're,they're, they're gonna be set up
to have difficulties for awhile.
And then I always wonder, is it,does that mean we have to be
real diligent week one, weektwo, like early on?
Or is this person gonna struggleno matter what we do?
Right.
That sort of thing.
So, you know, and, and, and Ihate to say that, but like we,
(11:59):
we see that sometimes.
So, uh, I think we're, we'reboth in agreement with the
statement, so I'm just gonnaproceed to a question here.
But like, if the first week ortwo are this important to make
sure we're setting the stage forfuture success, what are some of
the things that you like to doat this phase in the rehab
process to try to get thisneuromuscular control back?
(12:19):
I mean, I know there's a bunchof tools, there's a bunch of
things out there, but what, whatis it that you prefer?
Terry (12:23):
I think, you know, and, and these are conversations we
try to have early on and to, andto get these, you know, sort of
ideas into place.
And, and really the, the, thethree things, you know, I try to
take a, a, a simplistic approachtalking with patients or people
that come into the research laband I'm like, look, we need to
do three things.
We need to take care of yourswelling.
We need to get your extensionback, and we need you to have
(12:45):
good quad function.
And that's really going to thenset things up and it's like,
well, when can I get off ofcrutches?
And I'm like, when you have.
Mike (12:54):
One.
Terry (12:55):
Control of the swelling, get full extension, and you have
good quad control.
And, and then I think that's,that's kind of one thing that I
think people are really eager tojump to.
I wanna get rid of this assisteddevice, and I completely
understand it.
Um, you know, particularly foryounger individuals that are
pretty active, it's like, Iwanna get rid of these crutches.
I'm fine.
I'll limp around and I'll figureit out.
And I'm like, well, if that inof itself is contributing to
(13:18):
persistent swelling, that isthen driving a lack of full
extension and a lack of quad uh,uh, function, that's
problematic.
So that's kind of one of thefirst things I'm like, let's
protect.
The joint and, and allow it toheal some of the, some of like
the old accelerated rehab stuffwhere it's like people are just
like in a CPM for a couple ofweeks and not doing anything.
(13:39):
I'm not saying that we need togo to that specifically, but I'm
like, there's probably somethingto be said for respecting that
tissue healing.
So then, yeah.
Mike (13:50):
I, I was gonna say, especially too where sometimes w
we don't even understand hisphysical therapist sometimes,
uh, the level of, like, forexample, like meniscus pathology
or bone bruising going on, thatcould be causing even more
consequences within the knee.
Right.
So, so, so keep that in mindwith that.
It's, it's, you don't just, notevery ACL's the same and you get
off the crutches at 10 days orwhatever day.
(14:11):
Your surgeon wants to get, Imean, if you have a huge bone
bruise that may persist and, andsometimes you're, you're, you're
not setting them up to succeedby just discharging them because
the protocol says day 10.
Right.
So I I, I, that's the firstthing that jumped my mind when
you said that is, you know,sometimes I think people rush or
sometimes people follow aprotocol too much.
It's, it's just, it's just aguideline.
Not everybody's the same.
(14:32):
So, um, but I, I love thatthat's a.
Great.
First way to start is, is it'salmost like that's the
foundational building block.
If you don't do those threethings, you're gonna struggle.
So you have to focus on that.
And, and even patient educationis, once they hear that from
you, Terry, they hear thosethree things, they're probably
like, oh, okay.
All right, well, all right,well, I did too much yesterday
and puffed up.
Okay.
Maybe I'll adjust tomorrow.
(14:53):
I, and so I think that's huge.
So love that first step.
What's next?
Terry (14:57):
Yeah.
So, and then, and then, so, youknow, that's, that's to at least
build that foundation, right?
And then, and then, uh, nextreally thinking about, well,
what are ways that we can reduceswelling?
And, and so, you know, I lovethe ideas of, of just some sort
of compressive device that, youknow, like, you know,
compression stocking thatthey're just gonna wear around
and.
(15:18):
Thinking like this, swelling'swith them all day, this
quadriceps inhibition is withthem all day.
So I need to do things that havemore prolonged effects because
they may come into the clinicfor 30 minutes, 45 minutes, one
hour, whatever it is, and that'sit.
It may be every day, it may be acouple times a day.
It may be every two, three days,you know, depending on your
situation.
So we need to think aboutlasting interventions.
(15:39):
So that's where we start.
Okay.
We need, we need compression.
Some sort of compression wrap.
And then I, I do, like, I don'tget paid by anybody
unfortunately.
Um, you know, as far as productsand things like that.
So I really have no disclosures.
I always throw it out there.
If somebody wants to talk abouta relationship with that, we
always could.
But, uh, you know, I do like theidea of of, you know, uh, you
(16:02):
know, cold and compression,something like that, that they
can, that they can put on, youknow, throughout the day.
Uh, and, and, you know, havingthe good fortune of working with
student athletes at likeCreighton University, that, that
we can do that and really try tostress, you know, protecting
that joint early on from, fromdoing too much.
And, and, and cold andcompression like multiple times
(16:25):
a day.
And, and those are kind of like,uh, you know, they have multiple
benefits, like it's helping toreduce the swelling.
If we're reducing the swellingand, and you, and you get some
cold on there, then you're alsomitigating some of the pain.
Uh, and you're helping tofacilitate quadriceps function
by addressing both of those.
So I like cold and compression.
Um, and, and then, and then alsoearly on, I think that one
(16:49):
that's probably underutilized,and I think part of it is just,
um, patient compliance.
Maybe we don't fully understandand appreciate, uh, the, the,
the capacity is is somethinglike sensory tens.
Mike (17:05):
Mm-hmm.
Terry (17:05):
and, and, and I'm talking about sensory tends, we're not
trying to create a motorcontraction, but what I want you
to think of, or, or have peoplethink of is, is like gait
control theory that they may nothave a lot of knee pain, but a
lot of the things that driveceps inhibition particularly
early on, are consistent with,let's say pain pathways or
swelling.
(17:25):
And we just need to overridethose.
And so again, think gate controltheory, but that's where like
sensory tends around the kneejoint.
I think is helpful.
We know that people that wearsensory tends longer, like
throughout the day, like morethan eight hours is better than
just the one hour in the clinic.
And again, they have quadricepsinhibition all day.
(17:46):
So sensory tends might besomething easy that we can put,
uh, just around their kneejoint, strong but comfortable
sensory stimulus.
Then they can pull up theircompression stocking and they
can wear that around, um,
Mike (18:00):
Yeah.
Terry (18:00):
as ways to kind of mitigate.
Um, you know, some of thatquadriceps dysfunction or just
overall muscle dysfunction earlyon.
So those are kind of my go-tos.
And then you layer in all of theother therapeutic exercise that
we're typically doing, uh, earlyon.
Mike (18:17):
I, I like though the, I like the concept of tens, right?
Because, you know, again, like alot of modalities are becoming
less and less popular.
But, and, and that doesn't meaneverybody gets 10, but if, if
somebody is struggling, ifsomebody is having a hard time
with that volitional control ofthe quad, Right.
Or just being able to, toneuromodulate the pain.
That's a, that's a great thingthat I would say even I
(18:38):
underutilize, right?
But like, try to identify thatperson week one that's like, oh,
you know what, let's get'em atens to go home with.
Especially nowadays, you can geta tens on Amazon delivered
tomorrow for 30 bucks, right?
So like, there, there's reallyno reason why you can, you, you,
you shouldn't do that.
So, uh, so I love that.
I think that's awesome.
Um, I I gotta ask you, this is alittle off topic,
Terry (18:59):
Hey, here we go.
Mike (18:59):
this, this is the, this is the generation now where, um,
you know, again, a lot of youngclinicians are kind of, you
know, they're wondering aboutice.
They're wondering if, uh, theinflammatory process is helpful,
and if we inhibit that, thatcould be a bad thing.
I, I, I'll preface this questionwith saying that it sounds like
you and I are on the same page,but like, like, like what do you
(19:20):
say to your students that are,you know, they're on Instagram
and you know, There's people youknow that may or may have
financial, you know,implications in devices.
I'll leave it at that.
But like, what do you say topeople that are like, really
trying to buck this ice trend?
Like, you know, like, like, youknow what, why do you use ice
after a c l reconstruction inthe first week?
Terry (19:41):
No, it's a, that's a good question.
And literally, yeah.
One that I was having yesterdaywith a, uh, with a student and
ironically, and, uh, and, andso, you know, is, is there
potential, you know, regardingice, you know, to, to be
inflammatory.
Uh, Yeah, maybe it's, I don't, Idon't think it's specifically
(20:02):
like mitigating a lot ofinflammation.
Um, you know, and, and thatbeing said, like, um, ICE is a
great analgesic
Mike (20:12):
Huge.
Terry (20:13):
And, and it works really, really, uh, well, or an
anesthetic response rather.
And so, um, and so it worksreally well in that regard.
And so, you know, I think, Ithink a lot of the application
of that and, and particularlyhelping to address things like
pain.
Um, uh, helping to slow nerveconduction velocity or helping
(20:37):
to mitigate some of that, um,uh, negative neuromuscular
response, let's say.
I think that far outweighs anyof the, of, of, of the
potential, um, you know,inflammatory effects that, that
it, uh, that it might have.
So it's, it's, uh, you know, butI like tens is kind of the same
way.
It's like, did we not?
(20:57):
Did we not fully understand andappreciate like the parameters
or the outcomes that we wereshooting for here?
Um, and, and that's, that's whywe're, we're saying that this is
a bad thing.
Like if you don't use the TENSparameters, correct.
Well, no wonder you got a badoutcome.
Like if you didn't take aparticular medication with the
appropriate dosing, why shouldit come as a surprise that it
(21:18):
didn't work, right?
Um, or you had an adverseoutcome.
Same or if you're measuringsomething that's completely
different and uh, you know, ifyou take Tylenol to try to get
taller, uh, or stronger, likethat's not gonna work.
You, you like measure thecorrect outcome.
And so that's, that's where Ithink thinking along the lines
of, of cryotherapy, it's like,well what are we using it for
(21:39):
here?
Are we, you know, are we usingit to help mitigate pain works
really well?
Are we using it to helpfacilitate a neuromuscular
response?
Works really well.
Um, again, and that's, that's,that's short term.
You know, it's probably going towork while they're in the clinic
doing that, or you may have kindof a window of opportunity to do
some of these exercises.
(22:00):
But I think for, for, for whatthat is, that can be helpful.
Now, if you study something longenough, a lot of the treatment
effects wash out or we have aregression to the means.
So you're like, well, how werethey doing five years from now?
It was all the same.
So ICE doesn't work and it'slike, Maybe, but like if it has
short term effects, we're notgoing to see that at two years
out, five years out.
Mike (22:20):
Right.
And I can't imagine, I can'timagine like 10, 15 minutes of
ice for all those positivebenefits are gonna have such a
negative consequence on theinflammatory process that's
happening the rest of the 24hours of the day.
It's just, it's, you know,we're, I think we're, we're
getting a little carried awaywith some of those things, but,
you know, I, I think I can say,and I, I, it sounds like you
might agree, I don't wanna putwords in your mouth, but like
(22:41):
together we have.
Probably 50 years of clinicalexperience and, you know, my, my
patients that, that ice andcompress after a cell surgery,
uh, you know, with, with themost, the most frequency in
compliance, uh, tend to dobetter and feel better than,
than the ones that don't.
So, uh, I don't know what, what.
I don't know what journal I canpublish that in, but, uh, you
(23:01):
know, like it's, you know, yousee it every day, so, um, so
Awesome.
All right, so started to put youon the spot with a controversial
topic we'll say.
I like that.
But,
Terry (23:09):
it's good.
Mike (23:10):
alright, so tell me next now about, because again, I love
the framework you're outliningand how it's almost like you're
providing the building blocks.
It's like, sure, you can do afancy thing at week four, but if
you didn't do these things weekone, you're gonna be behind.
But, um, what are your thoughtson neuromuscular stem and
biofeedback?
Do you use those?
Terry (23:28):
Yes.
Uh, both and, and both have bothhave great evidence, right?
And, um, Although I think theywork for different reasons than
we, than we think.
So, you know, the, the, thefirst, the first things that I
was talking about with like, youknow, sensory tens and
cryotherapy, those are on theafferent side that is helping to
(23:49):
override some of those afferentsignals already that are either,
you know, kind of, um, you know,dull pain, c fiber, you know,
that sort of thing.
And, and so things likebiofeedback.
Um, or, um, N M E S or, orRussian or whatever you want to
call it, um, that, that, thoseare on the efferent side of
(24:10):
things.
And so I don't think that theynecessarily specifically address
the.
Underlying cause of, ofdysfunction.
Now, now they can, they can havean effect because they can help,
you know, help promote betterneuromuscular control of the
quad or increase quad strengthand thereby decreasing things
like knee joint stress.
(24:31):
And so they do work, but I thinkthey work on the efferent side
of things.
And so usually earlier on I'lltry to address, um, the fert
side of things and then start toadd in some of the fert side of
things.
But I will say if you took careof the underlying issue, that in
theory, we wouldn't need to thenjump to these other things.
(24:54):
Now, I also realize it's aprolonged healing process, and
we have to appreciate that.
Now, that being said, um, youknow, N M E S great for, you
know, helping to really promote,uh, you know, a good, strong
quadriceps contraction.
That's kind of the, if that's agoal as far as helping to
improve function and, and theneventually serve as a precursor
(25:16):
to improving strengthbiofeedback, um, works really
well for, for somebody tryingto, you know, get a quadriceps
contraction, gives'em good ideaof, you know, uh, knowledge of
performance, but, I'm just, I'm,I'm kind of stuck right now on,
(25:39):
was that the thing that wewanted to do?
Because like we were justtalking about at the beginning,
like the person that needs tostare at their quadriceps to get
it to contract, that's probablynot a good thing.
And we know now that, you know,particularly more so prolong
that some of these cortico motorchanges probably like, Express
(25:59):
themselves maybe more sixmonths-ish out.
And it takes somebody morecognitive resources to be able
to do simple things like a quadset.
And, and we also know thatthey're extre more often than
not extremely reliant on vision.
So now we're going to say, here,stare at this computer screen
(26:20):
or, or iPad or, or whateverelse.
And I want you to do aquadriceps contraction, and
we're going to give you thisfeedback system.
Of, of did you do this thingand, and, but you're using a lot
of resources to then do thatthing.
And so I'll still use it, butlike in the back of my head, I'm
kind of like, are we creating anadaptive strategy that maybe we
(26:45):
should have tried to approachthis a little bit differently
in, in addressing the reflexivecomponent.
So yes, I think it works.
I think it might work cuz theydevelop a compensation.
Um, but I think there's way moreto come on that.
So yeah, there, there're thingsthat I use, um, but, uh, I, I,
I, I, I would love to, to seewhere things are in 10 years as
(27:08):
we develop a betterunderstanding, you know, what is
a, a, a better approach here?
Mike (27:13):
so, so, Terry, do you, do you think neuromuscular stem
biofeedback, do you think we canalmost.
Equate that to something verysimilar to like an assisted
device like crutches, wheremaybe there's some use for it
early on when we're, we'restruggling, but we don't wanna
become overly reliant on themand we should progress away from
them over time.
Or do you just think there'sconcerns in general?
Terry (27:35):
Uh, yeah, both.
Um, yeah, I, you know, I'm not,I'm not ready to throw'em out
and, and, uh, You know, becauseagain, I think, and, and, and
adaptive strategies may notnecessarily be a bad thing.
I mean, this, this person hashad a, a knee injury, you know,
ACL reconstruction, meniscussurgery, whatever, you know, pat
Polyphoral pain, you know, neoosteoarthritis, whatever it is,
(27:58):
they still have an injury.
And so maybe a compensatorystrategy is, is, is helpful in,
in, uh, in this case.
So that's where I'm, I'm, I'mhesitant to say no on these
things, especially knowing like,The, the consequence of
potentially not addressing thesethings could be, could be in
theory, far, far worse, and thenalso appreciating that, well, it
(28:21):
may not matter either.
So it's, you know, it's, it's,I, I get it.
That's not an answer.
Um, but, uh, but yeah, I think,you know, at least, at least
early on, I think whatever, youknow, it's like this kitchen
sink approach a little bit, youknow, but it's, hey, it's sports
medicine.
And so, um, that, that can,that, that can be helpful
(28:43):
because I think if we don't.
Get somebody you know and takecare of swelling, take care of,
uh, you know, knee motion, youknow, extension, inflection,
developing good, you know,neuromuscular control that is
going to make it really hard forthis person to then say, well,
now we're going to progress tohopping and jogging and running
(29:05):
and cutting and, and back tosport.
It's like,
Mike (29:08):
right.
Terry (29:09):
All right, let's, let's take care of these basics early
on.
So I think, I think they do havea place, um, and that's, you
know, that's where, you know,I'll probably use the
biofeedback more early on.
Uh, and then as the person isstarting to get better knee
flexion and can tolerate, youknow, uh, N M E S, you know,
we'll, we'll start it at fullextension and then, you know,
we'll get to 60 or 70 degrees,work our way to 90.
(29:32):
Um, but that it takes a while.
It takes a week or two to, youknow, Work three, four to
actually, that they can becomfortable with their leg
hanging off the end of the tablewith a full muscle contraction.
And so that's kind of how I'llbuild those things in.
Um, but you know, that's a lotof what our focus is, is, is
let's really address these,these, uh, these neuromuscular
(29:56):
consequences early on.
Mike (29:58):
That, that, that's awesome.
All right, so let, let's shiftgears a little bit.
So we talked a lot about earlyon, which I think is huge.
Um, let's talk about maybe somelonger term, uh, consequences
here.
And I know yourself because I'veheard you speak on this a little
bit, but you have some up andcoming research that is
hopefully gonna be publishedfairly soon.
But, um, looking at things like.
(30:19):
Bone mineral density changesafter E C L and how that may
correlate to their outcomes,their quad strength, those sorts
of things.
Um, do you have any informationyou could share, uh, with us on
some of these future findingsthat you're still in development
with?
Terry (30:34):
Yeah, good question.
And so I think one of the, youknow, one of the things, and,
and you know, from a researchperspective and a clinical
perspective is really thinkingof, well, what do these people
look like?
You know, one year out, twoyears out, three years out, five
years, 10 years, 15 years.
And, uh, you know, what, what,what's the potential for like
post-traumatic osteoarthritis?
And, and if we wanna mitigatethat, we need to be able to
(30:56):
identify changes early on.
And, and so quite often I thinkwe think of like, you know,
osteoarthritis as, uh, you know,really looking at, at, at
changes in like articularcartilage.
And, and, but by the time a lotof those things develop, it's,
it's, it's probably.
(31:16):
Becoming too late to actuallyintervene.
And so that's, that's what ledus to look at some of the
changes in bone density.
And, uh, because, and, and we'veseen this in like animal
studies, that the changes inbone density actually precede
changes in particular cartilage.
So from my end, thinking, well,if we want to intervene at the
(31:38):
earliest possible opportunity,and then to be able to show a
change, something like, Lookingat bone density seems to make
sense.
And so one of the studies thatwe did, and it was a
cross-sectional study, webrought, uh, you know, 20
individuals in that had an a C Lreconstruction within the past
two years.
And, and compared them to, uh,you know, a, a a a healthy, uh,
(32:01):
or non-injured, physicallyactive, uh, group.
And so they had, you know,relatively comparable like TEGNA
activity scale scores, you know,if we had a high school CL or
high school athlete, their, youknow, kind of their peer
comparison was also another, um,you know, uh, sex matched high
school athlete, you know, from asimilar sport.
(32:22):
And, and so on average,everybody was about a year out
of, um, uh, following a c lreconstruction.
And we looked at, uh, we used PQ C T, um, which is, uh, it's
different than dxa.
I think a often we think of Dxaas being able to look at bone
density pq.
C t offers the opportunity to,to look at.
(32:44):
Look at a limb also in 3d, andwe can then separate out things
like cortical bone density orkind of that outer shell versus
trabecular, kind of that innerpart.
And the trabecular is moremetabolically active.
And, and in our study, that'swhere we saw a lot of the big
changes.
So we looked at both the femuras well as the tibia and, uh, at
(33:07):
least our preliminary stuff.
Big changes at the tibia.
Probably, you know, on, onaverage, healthy people had
about a 5% difference, or alittle, you know, about a four,
four and a half percentdifference side to side.
On average people, uh, a c lreconstruction had like a, like
12% difference.
So there was about a seven ishpercent difference, uh, between
(33:31):
the groups.
And in theory, these people area year out.
A lot of'em were back to,
Mike (33:37):
Right.
Yeah.
Terry (33:38):
back to physical activity.
They're, you know, they've beenreleased, they've, they've, you
know, met some of these, youknow, benchmarks or whatever
else.
They're out functioning anddoing pretty high level
activities.
And, and so we weren't, youknow, we're not definite.
We're definitely not the firstgroup to show this decreased
bone density occur, but a lot ofthe other studies just sort of
(33:58):
stopped there and they're like,yeah, there's, they have
decreased bone density.
And we're like, well, like,probably not every clinic in the
country has P Q C T or Dex to beable to measure these things.
So we need to correlate it tosomething.
And, and so you know, we havethe opportunity or capacity to
look at things like, you know,quadriceps and hamstring
(34:18):
strength, looking at jumpingbiomechanics, running
biomechanics, these sort ofthings because I think it makes
sense that, you know, wellpeople that are loading their
limb more probably have betterbone density or people that are
unloading their lamb probablyhave lower.
And so I think that's, Like aprecursor or, or a sort of a
signal to what we would see inthe clinic.
(34:40):
But we also realize noteverybody has force plates to be
able to measure these things.
The other aspect is, is sort oflooking at, well, what's, what's
this interaction between thebone and the muscle?
And that's like this als, youknow, this little forgotten
aspect that that also matters.
And so, um, you know, those werekind of our main, uh, outcome
(35:05):
measures.
We also had, you know, blooddraws and things like that
looking at like vitamin D andcalcium and some inflammatory
biomarkers.
Um, And we plugged a few ofthese things in, um, you know,
to this, uh, this, thisregression equation and, and
really tried to figure out,well, what's, what's the, what's
the best predictor here?
Mike (35:25):
Mm-hmm.
Terry (35:26):
and people that had more symmetrical quadricep strength
tended to have more symmetrical.
Um, side to side bone densityin, you know, or trabecular, uh,
bone density in, in their tibiaand more so, and, and it's not
that joint loading, like withrunning biomechanics or jumping
(35:47):
biomechanics.
It's not that that didn't factorin, but the quad symmetry seemed
to, it explained 50% of thevariants in, um, in, in, in, uh,
symmetrical bone density.
And so that interaction betweenthe.
The muscle and the bone seems tobe really important.
And, and, and so that's, that'skind of preliminary findings.
(36:12):
And then I think then the followup will be one, um, you know,
how long do these thingspersist?
What's kind of the normal timecourse for what this looks like?
And then two, what can we doabout it?
Like if we know that theseindividuals, you know, are more
at risk for lower bone densityafter surgery, um, you know, or
(36:35):
because there may be unloadingthat limb that's serving as a
precursor for the development ofNEO a later on, what can we do?
And at least right now, if I hadto speculate, I'm like, probably
need to get stronger and havemore symmetrical strength.
And so then you're like, wow.
It can't be that simplistic, butI, that really starts to set
(36:57):
that up.
And then, then we also then needto look at things like
symmetrical loading.
And they, so they need to havethe capacity to symmetrically
load.
And I think that'll be kind ofthe continuum of, of where we
see this, this, this play out.
That's just my
Mike (37:14):
And
Terry (37:15):
but it's pretty cool to think about.
Mike (37:17):
I, it's, I, I think that's huge.
And I think really this podcastreally, I think it just really
came together, right, because wetalked about the early
consequences, and I think thisis the late consequences, right?
So again, it goes back to haveto be on top of this early, but
I, you know, I like what yousaid there about symmetry stuff,
and I, I think like forceplates, for example, you brought
up forest plates at one point.
Like I think they're becomingmore common in the rehab setting
(37:39):
and.
There's some technology now,there's companies out there like
Vault that you know, has niceforce plates that you can use
clinically.
Very easy.
I I, it just shows you that,like, just because somebody's.
Squatting, for example, doesn'tmean they're squatting well.
Right.
And it's a, it's a quality and aand and a quantity thing.
It's, it's, you have to put themtogether sometimes.
So, um, I, I dramatic, uh,results I think in my mind from
(38:02):
the study and, you know, I'msure we can extrapolate that to
other pathologies too.
I'm sure it's not just a c l,but you know, of course we have
to be careful with theliterature that way.
Right.
But like, you know, I, I, again,I think it just, it shows you
that like we, we have to dothat.
So, um, so.
Terry, this was awesome.
Uh, I really appreciate yousharing some of your new
research and some of yourthoughts on this.
(38:22):
Um, I know that was superhelpful to me.
I learned a bunch.
Uh, your students at Creightonare lucky to have you here, man.
But, um, bef before I let you goquick, uh, e ending segment, the
high five, five quick questions,five quick answers to learn a
little bit more about you.
But question number one, whatare you currently reading or, or
doing for your own Con-Ed andyour own professional
development?
What are you doing for yourself?
Terry (38:44):
Oh, good question.
Uh, right now, one of the thingsthat I'm reading is, uh, It's a,
uh, it's a book calledAttributes, and it's, and it's
really looking at, you know,just sort of the underlying, uh,
you know, psychological thingsthat, uh, you know, from kind of
a leadership perspective and,uh, you know, how do people deal
with, you know, adversity and,and things like that.
(39:04):
So, super great, uh, super greatbook that I'm into right now.
Mike (39:08):
I love it.
That's awesome.
There's been so many good booksuggestions too, people, so
please, if you're listening,like write these down.
I, I go to Amazon and I'll justput'em in my wishlist, and then
next time I'm, you know, I'm,I'm loading up books for like a
flight or something like that.
I'll get'em.
So, good one.
Uh, all right, next one.
Um, what's one thing that you'verecently changed your mind about
Terry (39:26):
uh, changed my mind about.
Mike (39:28):
professionally?
Terry (39:29):
what.
Yeah, I'll tell you whatProfessionally, uh, no joke
podcast and, and, uh, you know,I think, you know, it's, I don't
know if it's an age thing orwhat, and I think, you know,
kind of initially, you know,sort of giggled or snickered at
the idea or, or, or whateverelse, but realizing like, To be
able to disseminate information,has to go much more beyond, you
know, writing a paper or doing atalk at a national meeting or
(39:52):
whatever it is.
And, and so I think, you know,being, you know, open and
willing to, uh, you know, thatthat learning can occur a lot
across a lot of differentformats.
And, and, uh, you know, as a, asa, as an educator and a
researcher that, that I need tobe more aware of, you know,
what, what methods are out therebeyond standing up in front of a
(40:12):
classroom or, or, or in a, youknow, a, a con ed session or at
a national meeting.
And I think this is, you know,things like a podcast.
Great idea.
Mike (40:22):
Well, I'm honored to have you, but it sounds like you're
about to start your own.
So, uh, let me, uh, awesome.
Um, so you have a ton ofstudents there at Creighton.
What's the best piece of advicethat you like to give them?
Terry (40:35):
Um, you know, I think as far as best piece of advice, I
think really just, you know,thinking about what those next,
uh, next steps are gonna be.
A lot of, one of the things thatI'll consistently ask people is
tell me about your, you know,where you wanna be in five
years.
And, and really thinking about,well, what are the steps that I
need to take to get to thatspot?
(40:55):
So that's really one of the joysthat I have in, in being able to
have conversations with peopleearly on in their career and,
and realizing, you know, thatfive year plan can change, but
it's about the process ofgetting there and the process
for each individual may vary.
There's no cookie cutterapproach, but it's something
that I think you should thinkabout early on.
Mike (41:16):
That's huge.
I, I, I, I love that one.
That's one of my favorite onesso far.
I, I think that's great.
A lot of people are, they'rejust thinking about their end
game or they're thinking abouttheir next step.
They don't realize that theprocess is so important and, you
know, and, and sometimes, likeyou said, you don't evolve the
way you think you are, butevolution is evolution, right?
And, and it's just part of the,so, um, and I love that.
(41:36):
So great answer.
Uh, what's coming up next foryou?
Anything new in the works oranything we're building other
than the podcast?
You're about to start anythingnew.
Terry (41:43):
No, uh, no podcast.
We're, uh, we're, I'll tell youwhat, we're, we're moving into a
new health science building,
Mike (41:48):
Oh,
Terry (41:49):
and, uh, at, at Creighton And I, you know, I've spent a
considerable amount of time, youknow, helping to build out new
research lab space, you know,help work with, you know, a
number of our.
Uh, you know, our faculty that,you know, from a research
perspective that'll be using thelab.
So I've learned a lot aboutconstruction and, uh, you know,
working with contractors and,and, uh, and sort of serving as
(42:09):
this, uh, person in the middleif, if you will.
So that's kind of what's comingup next is, you know, just
building out this wonderfulspace, uh, where I hope we're
able to, you know, really comeup with great ideas and help
impact patient
Mike (42:22):
Yeah.
Pump out some good research.
That'd be great.
Awesome.
Well, uh, where can people learnmore about you, Terry?
Any place you wanna send them orobviously, you know, PubMed and
look up all, all Terry's greatworks, but anything else you'd
recommend?
Terry (42:34):
I think, you know, I, I'm on, uh, I, I am on PubMed and
that's at least a kind of ahistorical perspective of, of
the things that I've done.
Um, you know, I'm on Twitter,you know, Sometimes I tend to
use Instagram less.
Um, and uh, but kind of Twitteris probably where I would have
more of the professional side ofthings.
Facebook, kind of the morepersonal side of things, but,
(42:55):
but sometimes they'll, uh,they'll, they'll, they'll blend,
um, a little bit.
But uh, that's just kind ofanother way as far as reaching
out to me and, uh,
Mike (43:03):
Awesome.
Yeah.
Well, I'll, I'll put, I'll putsome of those links in the, uh,
in the show notes so people canfind you.
So, um, that'd be great.
But yeah.
But, uh, stay on top of Terry'sresearch.
It sounds like they're gonnahave some great stuff coming out
soon.
Um, it's gonna be amazing.
So, uh, Terry, great episode.
Thank you so much for sharingall your knowledge with us.
That was amazing.
Uh, we'll have to have you on inthe future to do even more, but
(43:24):
thank you so much.
Terry (43:25):
Hey, thank you.
And, and yeah, thanks for doingthe podcast.
Thanks for, uh, thanks for beinga, a, a leader in the, in the
sports academy and, and just theprofession overall.
So, yeah, it was an honor beinghere today.
On this episode of the sportsphysical therapy podcast.
I am joined by Terry Grindstaff.
Terry's a professor in thephysical therapy program at
Creighton university, where hecombines research education and
working with the studentathletes.
He's been focusing much of hisresearch on the neuromuscular
consequences of lower extremityinjuries, which is what we're
going to be discussing intoday's episode.
Mike (00:31):
Hey Terry.
Thanks so much for joining me onthe podcast today.
How's it going?
Terry (00:34):
I'm doing really well today.
Thanks for having me.
Mike (00:37):
Awesome.
Yeah, we, we, you know, for thelisteners, Terry and I just had
a, a fun little chat, so I thinkthis is gonna be, uh, this is
gonna be a good episode.
But, um, uh, Terry, uh, you'vedone so much research, you know,
working at Creighton, you've,you, you just had a ton of
experience with differentthings.
Um, we could go in a lot ofdifferent directions with this
podcast, but for me, I knowsomething that you're passionate
about.
Something that I've seen youspeak about is, um, how you've,
(00:59):
you've focused a little bit of,of your, your.
Your mind power, so to say, onlower extremity injuries, and
then some of the neuromuscularconsequences that we see from
that, which is huge.
Right?
That's such a huge topic.
So I, I kind of wanna start offwith that, right?
And kind of jump right in and,and talk about it.
Like, maybe we start with like abasic one with, with acls, like
(01:21):
we've seen over the years, quadstrength, neuromuscular changes.
Neurocognitive changes now arebecoming more and more, you
know, prevalent, alteredbiomechanics.
All these things happen afterinjury.
Why don't we start with that andfrom all the stuff that you've
done, all the research you'veput into this, what do we know
about some of these consequencesafter these big injuries?
Like an a c L?
Terry (01:40):
No, it's a, that's a, that's a good question.
I think,
Mike (01:43):
Huge question.
Sorry.
I was like, welcome to thepodcast and boom.
Terry (01:47):
it's good.
It's good.
Yeah.
Start off and, uh, let's getphilosophical, right?
And so I think, I think, youknow, for me and, and sort of
the, the, the, the journeythrough this and, and, and one
of the things that's been, uh,Interesting for me and sort of
hooked me into this is, isyou'll see somebody with, with a
knee injury and, and reallylike, regardless of the knee
(02:08):
injury, I think quite often wetalk about a c l reconstruction.
But yeah, I mean it could bepatella ifor pain or anterior
knee pain.
You know, somebody with, uh, youknow, post-op mastectomy.
It's sort of whatever it is.
Quadriceps doesn't work as well.
And, and so it's like this, youknow, this, this common clinical
impairment and, and somebody cando a quad set the day before
(02:30):
surgery or the day before aninjury and like the next day
they can't.
And, and you know, a lot of thetime when I'm lecturing or
talking with students orwhatever, I kind of bring up
this clinical scenario andscenario.
You could do a quad set the daybefore and you can't the day
after.
And it's like, well, what's,what's causing that?
Or what do you do to addressthat thing?
And a lot of the time it's like,well, you know, they, they need
(02:52):
strength.
We need to work onstrengthening.
And I'm like, wait a second.
If you sat in bed all day forone day, your quad wouldn't get
that week.
Like that wouldn't happen.
And so we, yeah, we know thatit's driven neurologically.
And, but a lot of the timeclinically, our approach is you
need strengthening.
And it's like, well, maybe weneed to reframe this, uh, a, a,
(03:16):
a little bit.
And, and so I think that's beenhelpful, you know, for how I
approach things in the clinic,how I approach things in the
research laboratory is reallythinking of the, you know, the.
Knee injuries as, as really, youknow, there, there are
neuromuscular consequences.
There is still a joint relatedinjury, but like why in the
(03:38):
world does a muscle stop workinglike the quadriceps when in
theory it wasn't injured and,and minus if you had like, uh,
bone Patel, uh, bone tendongraft, if you had quad tendon
graft, something like that, thenyes, there is a muscle or tendon
injury, but you had a hamstringgraft or an allograft or
something like.
There's no muscle injury to thequad.
(03:59):
Like in theory it should work,but yet it doesn't.
So it's driven neurologically.
And I think that's been kind ofthe fascinating part on some of
the things that we've looked atfrom a research perspective of,
well, what's causing this?
You know, we know that part ofit's driven by spinal reflexive
processes, uh, and some of it'sdriven from a, you know, kind of
a cortico motor standpoint.
(04:20):
And, and then, uh, and thenthere's also then this atrophy
component or kind of thisperipheral component as well.
We have central components andperipheral components.
And then the next step is like,well, if we understand some of
these mechanisms of what's goingon, then what can we do about
it?
Because ultimately, you know, I.
Thinking about, well, we need tohelp people in the clinic, we
(04:40):
need to help patients.
And, and so we can understandmechanisms all day, but we need
to be able to translate that tosomething that people can use in
clinical practice.
And I think that's kind of beenone of the joys that I've had
from, from both a researchperspective and a clinical
perspective is, is trying anywayto, to, to blend some of those,
or bridge some of those, um, youknow, concepts with, yeah, we
(05:02):
know these things happen from aneurological perspective, but
what can we do about it?
And then not only what can we doabout it, but we better be able
to do it in a timely manner inthe clinic and, and all these
other considerations that Idon't have to deal with in
athletics, like insurance and,uh, stuff like that.
So it's, uh, it's, it's, it's,it's these multiple things sort
(05:23):
of tugging at my brain at the,at the same time to, to
hopefully ask clinicallymeaningful, uh, research
questions.
So that's, That's kind of, youknow, what we do in a, in a
nutshell.
Uh, and we're, you know, I liketo think we're using the knee as
a model.
In theory, this, this, this sortof stuff.
It happens at the, at the lumbarspine, it happens at the
shoulder, it happens at otherjoints.
(05:44):
Uh, the knee just happens to be,uh, you know, something that we
can study and, uh, and look atquads, big muscle.
So it makes
Mike (05:52):
Right ex.
Right, exactly.
And, and, and it's a veryimportant muscle for lots of
different functions.
So it, it's probably more in, inour face, right.
When you have a deficit, uh, weprobably notice it more cuz the
consequences of it, I meanchanges, gait changes even, you
know, they're subjective thingsin a non-weightbearing joint or
something else may, you know,maybe you just get by, it's a
little different so we don'tnotice it as much.
But, um, yeah, you know, for me,I've always found clinically
(06:16):
that when you get behind.
With some of these things, ifyou let these neuromuscular
consequences kind of take holdand progress over time, um, they
get harder and harder toovercome.
Right.
So those, this is the type ofpeople, like I have people in my
inner circle that like, youknow, I just answered a question
this morning.
Somebody was, I think it wasabout eight months after a c l
reconstruction and.
(06:37):
Still, you know, they stilldon't have knee extension, so,
you know, that's not great.
But, um, which might be part ofthe problem, but again, they
can't get the quad to turn on.
Right.
So like going back to yourthoughts on central, uh, you
know, concepts that go intothat, like what is it
specifically you think that,cause some people to have this
consequence more than others andsome to have it delayed for so
(06:59):
long, like what is it that doesthat?
Terry (07:01):
Yeah, I think that's a, that's a, that that is a great
question right there.
And, and, uh, and I mean, I've,I've seen people in the clinic
like this as well, and I'd liketo think I'm at least reasonable
at, uh, at some of the, uh, someof the approaches that I take.
But it's, you know, it's, it's,uh, I, I, I know better enough
now to to, to not say it's thisone thing and that's it.
(07:23):
So there's a lot of differentfactors, um, that, uh, that,
that play into it.
Um, you know, and, and I'm like,oh, you know, is, is, is it, you
know, are, are people just morelikely to have, say, persistent
swelling?
Is there something going on, youknow, sort of from a.
You know, like a, a metabolicperspective or, uh, you know,
(07:45):
systemic perspective that, that,that, uh, they are more prone
to, uh, you know, to, toinflammation.
Or do they just heal, uh, a, a alittle bit more slowly, or do
they lay down more scar tissue?
You know, so I think that thosecan be components.
Some people just have, uh, youknow, different, uh, capacity to
(08:07):
process pain or to, to mitigatepain.
Uh, you know, and, and then you,you can add in kind of these
psychological factors as wellthat, that play into it.
And then really some of thesethings also to a degree, become
like this chicken or egg thing.
But like you were saying, Icompletely agree that it's
probably.
Better to take care of thesethings early on and, and to jump
(08:31):
on it early on versus later.
Um, I think an unfortunateaspect right now is that we
don't have great ways tomeasure, like quadriceps
inhibition in the clinic.
Mike (08:45):
Mm-hmm.
Terry (08:46):
We have great ways in the research lab and we have great
ways to look at like spinalreflexive excitability and
cortical motor, uh,excitability, but we don't have
great ways to do this in theclinic.
And then I think then theconsequence of that is if, if,
if we don't have a good way tomeasure something, then we may
not, one, pay attention to it asmuch.
(09:08):
Or, or, or, or dedicate, youknow, intervention resources to
address it because then we can'tmeasure it.
We don't know if we did a goodjob or not, with the exception
of hindsight.
Hindsight seems to, oh, youknow, this person at four months
out, six months out, eightmonths out, like we were saying,
they seem to be struggling.
And it's like, yeah, like itwould've been really helpful
(09:32):
have, have had some of thesemeasures early on.
Um, you know, to either say, youknow, we need to stick with
these particular interventionsthat are addressing some of
these neuromuscularconsequences.
We need to stick with thoselonger, or we need to employ
those earlier or just employthem at all.
Um, and so I think that thoseare, um, those are things for
(09:53):
consideration if you sort oflike, let's speculate, right?
And, and, and, uh, and, and so Ithink some of the things that
I've seen, like in the clinic,some of the things that we've
seen in the research lab and,and we probably just haven't
studied it enough.
I think there, there, there,there's something to be said for
the persistent in the fusion.
(10:14):
There's something to be said forthe delayed capacity to achieve
full extension.
And the other that we've lookedat or, or, or that I've at least
noticed, and I'm sure thatyou've seen this, I'm sure a lot
of the listeners have seen this.
You know, it's this personpost-op day one or week one or
whatever it is, and for the lifeof them, like you look at their
(10:34):
face and they, they are tryingso hard.
To get like a quad set with,with a substantial amount of
intensity.
They're looking at their quad.
They, they are using everyresource that they have
absolutely available and theycan't do it.
And, and.
I think there's something there.
I'm not quite sure the best wayto quantify that right now.
(10:57):
And you know that I like to beable to quantify things,
Mike (11:00):
Yeah.
Terry (11:00):
that's at least something that I picked up on and, and
just kinda looking at thepatient and like, this person's
probably going to struggle forwhatever reason.
Like, and, and they can't dothis quad set, which you're
like, in theory that should bereally simple, but they're
throwing so many resources at itto get it to happen.
Um, And, and so I'm like, Ithink we, maybe the best way to
(11:22):
deal with this is to bestappreciate this as a reflexive
reaction and, and let's employsome of these, you know, kind of
neurological approaches to ourorthopedic or sports medicine
kind of framework.
Mike (11:36):
I think that's great.
And I, I, I love too how, like,I, I think you're completely
right.
It's the people that struggleweek one, right?
You can almost tell they're,they're, they're gonna be set up
to have difficulties for awhile.
And then I always wonder, is it,does that mean we have to be
real diligent week one, weektwo, like early on?
Or is this person gonna struggleno matter what we do?
Right.
That sort of thing.
So, you know, and, and, and Ihate to say that, but like we,
(11:59):
we see that sometimes.
So, uh, I think we're, we'reboth in agreement with the
statement, so I'm just gonnaproceed to a question here.
But like, if the first week ortwo are this important to make
sure we're setting the stage forfuture success, what are some of
the things that you like to doat this phase in the rehab
process to try to get thisneuromuscular control back?
(12:19):
I mean, I know there's a bunchof tools, there's a bunch of
things out there, but what, whatis it that you prefer?
Terry (12:23):
I think, you know, and, and these are conversations we
try to have early on and to, andto get these, you know, sort of
ideas into place.
And, and really the, the, thethree things, you know, I try to
take a, a, a simplistic approachtalking with patients or people
that come into the research laband I'm like, look, we need to
do three things.
We need to take care of yourswelling.
We need to get your extensionback, and we need you to have
(12:45):
good quad function.
And that's really going to thenset things up and it's like,
well, when can I get off ofcrutches?
And I'm like, when you have.
Mike (12:54):
One.
Terry (12:55):
Control of the swelling, get full extension, and you have
good quad control.
And, and then I think that's,that's kind of one thing that I
think people are really eager tojump to.
I wanna get rid of this assisteddevice, and I completely
understand it.
Um, you know, particularly foryounger individuals that are
pretty active, it's like, Iwanna get rid of these crutches.
I'm fine.
I'll limp around and I'll figureit out.
And I'm like, well, if that inof itself is contributing to
(13:18):
persistent swelling, that isthen driving a lack of full
extension and a lack of quad uh,uh, function, that's
problematic.
So that's kind of one of thefirst things I'm like, let's
protect.
The joint and, and allow it toheal some of the, some of like
the old accelerated rehab stuffwhere it's like people are just
like in a CPM for a couple ofweeks and not doing anything.
(13:39):
I'm not saying that we need togo to that specifically, but I'm
like, there's probably somethingto be said for respecting that
tissue healing.
So then, yeah.
Mike (13:50):
I, I was gonna say, especially too where sometimes w
we don't even understand hisphysical therapist sometimes,
uh, the level of, like, forexample, like meniscus pathology
or bone bruising going on, thatcould be causing even more
consequences within the knee.
Right.
So, so, so keep that in mindwith that.
It's, it's, you don't just, notevery ACL's the same and you get
off the crutches at 10 days orwhatever day.
(14:11):
Your surgeon wants to get, Imean, if you have a huge bone
bruise that may persist and, andsometimes you're, you're, you're
not setting them up to succeedby just discharging them because
the protocol says day 10.
Right.
So I I, I, that's the firstthing that jumped my mind when
you said that is, you know,sometimes I think people rush or
sometimes people follow aprotocol too much.
It's, it's just, it's just aguideline.
Not everybody's the same.
(14:32):
So, um, but I, I love thatthat's a.
Great.
First way to start is, is it'salmost like that's the
foundational building block.
If you don't do those threethings, you're gonna struggle.
So you have to focus on that.
And, and even patient educationis, once they hear that from
you, Terry, they hear thosethree things, they're probably
like, oh, okay.
All right, well, all right,well, I did too much yesterday
and puffed up.
Okay.
Maybe I'll adjust tomorrow.
(14:53):
I, and so I think that's huge.
So love that first step.
What's next?
Terry (14:57):
Yeah.
So, and then, and then, so, youknow, that's, that's to at least
build that foundation, right?
And then, and then, uh, nextreally thinking about, well,
what are ways that we can reduceswelling?
And, and so, you know, I lovethe ideas of, of just some sort
of compressive device that, youknow, like, you know,
compression stocking thatthey're just gonna wear around
and.
(15:18):
Thinking like this, swelling'swith them all day, this
quadriceps inhibition is withthem all day.
So I need to do things that havemore prolonged effects because
they may come into the clinicfor 30 minutes, 45 minutes, one
hour, whatever it is, and that'sit.
It may be every day, it may be acouple times a day.
It may be every two, three days,you know, depending on your
situation.
So we need to think aboutlasting interventions.
(15:39):
So that's where we start.
Okay.
We need, we need compression.
Some sort of compression wrap.
And then I, I do, like, I don'tget paid by anybody
unfortunately.
Um, you know, as far as productsand things like that.
So I really have no disclosures.
I always throw it out there.
If somebody wants to talk abouta relationship with that, we
always could.
But, uh, you know, I do like theidea of of, you know, uh, you
(16:02):
know, cold and compression,something like that, that they
can, that they can put on, youknow, throughout the day.
Uh, and, and, you know, havingthe good fortune of working with
student athletes at likeCreighton University, that, that
we can do that and really try tostress, you know, protecting
that joint early on from, fromdoing too much.
And, and, and cold andcompression like multiple times
(16:25):
a day.
And, and those are kind of like,uh, you know, they have multiple
benefits, like it's helping toreduce the swelling.
If we're reducing the swellingand, and you, and you get some
cold on there, then you're alsomitigating some of the pain.
Uh, and you're helping tofacilitate quadriceps function
by addressing both of those.
So I like cold and compression.
Um, and, and then, and then alsoearly on, I think that one
(16:49):
that's probably underutilized,and I think part of it is just,
um, patient compliance.
Maybe we don't fully understandand appreciate, uh, the, the,
the capacity is is somethinglike sensory tens.
Mike (17:05):
Mm-hmm.
Terry (17:05):
and, and, and I'm talking about sensory tends, we're not
trying to create a motorcontraction, but what I want you
to think of, or, or have peoplethink of is, is like gait
control theory that they may nothave a lot of knee pain, but a
lot of the things that driveceps inhibition particularly
early on, are consistent with,let's say pain pathways or
swelling.
(17:25):
And we just need to overridethose.
And so again, think gate controltheory, but that's where like
sensory tends around the kneejoint.
I think is helpful.
We know that people that wearsensory tends longer, like
throughout the day, like morethan eight hours is better than
just the one hour in the clinic.
And again, they have quadricepsinhibition all day.
(17:46):
So sensory tends might besomething easy that we can put,
uh, just around their kneejoint, strong but comfortable
sensory stimulus.
Then they can pull up theircompression stocking and they
can wear that around, um,
Mike (18:00):
Yeah.
Terry (18:00):
as ways to kind of mitigate.
Um, you know, some of thatquadriceps dysfunction or just
overall muscle dysfunction earlyon.
So those are kind of my go-tos.
And then you layer in all of theother therapeutic exercise that
we're typically doing, uh, earlyon.
Mike (18:17):
I, I like though the, I like the concept of tens, right?
Because, you know, again, like alot of modalities are becoming
less and less popular.
But, and, and that doesn't meaneverybody gets 10, but if, if
somebody is struggling, ifsomebody is having a hard time
with that volitional control ofthe quad, Right.
Or just being able to, toneuromodulate the pain.
That's a, that's a great thingthat I would say even I
(18:38):
underutilize, right?
But like, try to identify thatperson week one that's like, oh,
you know what, let's get'em atens to go home with.
Especially nowadays, you can geta tens on Amazon delivered
tomorrow for 30 bucks, right?
So like, there, there's reallyno reason why you can, you, you,
you shouldn't do that.
So, uh, so I love that.
I think that's awesome.
Um, I I gotta ask you, this is alittle off topic,
Terry (18:59):
Hey, here we go.
Mike (18:59):
this, this is the, this is the generation now where, um,
you know, again, a lot of youngclinicians are kind of, you
know, they're wondering aboutice.
They're wondering if, uh, theinflammatory process is helpful,
and if we inhibit that, thatcould be a bad thing.
I, I, I'll preface this questionwith saying that it sounds like
you and I are on the same page,but like, like, like what do you
(19:20):
say to your students that are,you know, they're on Instagram
and you know, There's people youknow that may or may have
financial, you know,implications in devices.
I'll leave it at that.
But like, what do you say topeople that are like, really
trying to buck this ice trend?
Like, you know, like, like, youknow what, why do you use ice
after a c l reconstruction inthe first week?
Terry (19:41):
No, it's a, that's a good question.
And literally, yeah.
One that I was having yesterdaywith a, uh, with a student and
ironically, and, uh, and, andso, you know, is, is there
potential, you know, regardingice, you know, to, to be
inflammatory.
Uh, Yeah, maybe it's, I don't, Idon't think it's specifically
(20:02):
like mitigating a lot ofinflammation.
Um, you know, and, and thatbeing said, like, um, ICE is a
great analgesic
Mike (20:12):
Huge.
Terry (20:13):
And, and it works really, really, uh, well, or an
anesthetic response rather.
And so, um, and so it worksreally well in that regard.
And so, you know, I think, Ithink a lot of the application
of that and, and particularlyhelping to address things like
pain.
Um, uh, helping to slow nerveconduction velocity or helping
(20:37):
to mitigate some of that, um,uh, negative neuromuscular
response, let's say.
I think that far outweighs anyof the, of, of, of the
potential, um, you know,inflammatory effects that, that
it, uh, that it might have.
So it's, it's, uh, you know, butI like tens is kind of the same
way.
It's like, did we not?
(20:57):
Did we not fully understand andappreciate like the parameters
or the outcomes that we wereshooting for here?
Um, and, and that's, that's whywe're, we're saying that this is
a bad thing.
Like if you don't use the TENSparameters, correct.
Well, no wonder you got a badoutcome.
Like if you didn't take aparticular medication with the
appropriate dosing, why shouldit come as a surprise that it
(21:18):
didn't work, right?
Um, or you had an adverseoutcome.
Same or if you're measuringsomething that's completely
different and uh, you know, ifyou take Tylenol to try to get
taller, uh, or stronger, likethat's not gonna work.
You, you like measure thecorrect outcome.
And so that's, that's where Ithink thinking along the lines
of, of cryotherapy, it's like,well what are we using it for
(21:39):
here?
Are we, you know, are we usingit to help mitigate pain works
really well?
Are we using it to helpfacilitate a neuromuscular
response?
Works really well.
Um, again, and that's, that's,that's short term.
You know, it's probably going towork while they're in the clinic
doing that, or you may have kindof a window of opportunity to do
some of these exercises.
(22:00):
But I think for, for, for whatthat is, that can be helpful.
Now, if you study something longenough, a lot of the treatment
effects wash out or we have aregression to the means.
So you're like, well, how werethey doing five years from now?
It was all the same.
So ICE doesn't work and it'slike, Maybe, but like if it has
short term effects, we're notgoing to see that at two years
out, five years out.
Mike (22:20):
Right.
And I can't imagine, I can'timagine like 10, 15 minutes of
ice for all those positivebenefits are gonna have such a
negative consequence on theinflammatory process that's
happening the rest of the 24hours of the day.
It's just, it's, you know,we're, I think we're, we're
getting a little carried awaywith some of those things, but,
you know, I, I think I can say,and I, I, it sounds like you
might agree, I don't wanna putwords in your mouth, but like
(22:41):
together we have.
Probably 50 years of clinicalexperience and, you know, my, my
patients that, that ice andcompress after a cell surgery,
uh, you know, with, with themost, the most frequency in
compliance, uh, tend to dobetter and feel better than,
than the ones that don't.
So, uh, I don't know what, what.
I don't know what journal I canpublish that in, but, uh, you
(23:01):
know, like it's, you know, yousee it every day, so, um, so
Awesome.
All right, so started to put youon the spot with a controversial
topic we'll say.
I like that.
But,
Terry (23:09):
it's good.
Mike (23:10):
alright, so tell me next now about, because again, I love
the framework you're outliningand how it's almost like you're
providing the building blocks.
It's like, sure, you can do afancy thing at week four, but if
you didn't do these things weekone, you're gonna be behind.
But, um, what are your thoughtson neuromuscular stem and
biofeedback?
Do you use those?
Terry (23:28):
Yes.
Uh, both and, and both have bothhave great evidence, right?
And, um, Although I think theywork for different reasons than
we, than we think.
So, you know, the, the, thefirst, the first things that I
was talking about with like, youknow, sensory tens and
cryotherapy, those are on theafferent side that is helping to
(23:49):
override some of those afferentsignals already that are either,
you know, kind of, um, you know,dull pain, c fiber, you know,
that sort of thing.
And, and so things likebiofeedback.
Um, or, um, N M E S or, orRussian or whatever you want to
call it, um, that, that, thoseare on the efferent side of
(24:10):
things.
And so I don't think that theynecessarily specifically address
the.
Underlying cause of, ofdysfunction.
Now, now they can, they can havean effect because they can help,
you know, help promote betterneuromuscular control of the
quad or increase quad strengthand thereby decreasing things
like knee joint stress.
(24:31):
And so they do work, but I thinkthey work on the efferent side
of things.
And so usually earlier on I'lltry to address, um, the fert
side of things and then start toadd in some of the fert side of
things.
But I will say if you took careof the underlying issue, that in
theory, we wouldn't need to thenjump to these other things.
(24:54):
Now, I also realize it's aprolonged healing process, and
we have to appreciate that.
Now, that being said, um, youknow, N M E S great for, you
know, helping to really promote,uh, you know, a good, strong
quadriceps contraction.
That's kind of the, if that's agoal as far as helping to
improve function and, and theneventually serve as a precursor
(25:16):
to improving strengthbiofeedback, um, works really
well for, for somebody tryingto, you know, get a quadriceps
contraction, gives'em good ideaof, you know, uh, knowledge of
performance, but, I'm just, I'm,I'm kind of stuck right now on,
(25:39):
was that the thing that wewanted to do?
Because like we were justtalking about at the beginning,
like the person that needs tostare at their quadriceps to get
it to contract, that's probablynot a good thing.
And we know now that, you know,particularly more so prolong
that some of these cortico motorchanges probably like, Express
(25:59):
themselves maybe more sixmonths-ish out.
And it takes somebody morecognitive resources to be able
to do simple things like a quadset.
And, and we also know thatthey're extre more often than
not extremely reliant on vision.
So now we're going to say, here,stare at this computer screen
(26:20):
or, or iPad or, or whateverelse.
And I want you to do aquadriceps contraction, and
we're going to give you thisfeedback system.
Of, of did you do this thingand, and, but you're using a lot
of resources to then do thatthing.
And so I'll still use it, butlike in the back of my head, I'm
kind of like, are we creating anadaptive strategy that maybe we
(26:45):
should have tried to approachthis a little bit differently
in, in addressing the reflexivecomponent.
So yes, I think it works.
I think it might work cuz theydevelop a compensation.
Um, but I think there's way moreto come on that.
So yeah, there, there're thingsthat I use, um, but, uh, I, I,
I, I, I would love to, to seewhere things are in 10 years as
(27:08):
we develop a betterunderstanding, you know, what is
a, a, a better approach here?
Mike (27:13):
so, so, Terry, do you, do you think neuromuscular stem
biofeedback, do you think we canalmost.
Equate that to something verysimilar to like an assisted
device like crutches, wheremaybe there's some use for it
early on when we're, we'restruggling, but we don't wanna
become overly reliant on themand we should progress away from
them over time.
Or do you just think there'sconcerns in general?
Terry (27:35):
Uh, yeah, both.
Um, yeah, I, you know, I'm not,I'm not ready to throw'em out
and, and, uh, You know, becauseagain, I think, and, and, and
adaptive strategies may notnecessarily be a bad thing.
I mean, this, this person hashad a, a knee injury, you know,
ACL reconstruction, meniscussurgery, whatever, you know, pat
Polyphoral pain, you know, neoosteoarthritis, whatever it is,
(27:58):
they still have an injury.
And so maybe a compensatorystrategy is, is, is helpful in,
in, uh, in this case.
So that's where I'm, I'm, I'mhesitant to say no on these
things, especially knowing like,The, the consequence of
potentially not addressing thesethings could be, could be in
theory, far, far worse, and thenalso appreciating that, well, it
(28:21):
may not matter either.
So it's, you know, it's, it's,I, I get it.
That's not an answer.
Um, but, uh, but yeah, I think,you know, at least, at least
early on, I think whatever, youknow, it's like this kitchen
sink approach a little bit, youknow, but it's, hey, it's sports
medicine.
And so, um, that, that can,that, that can be helpful
(28:43):
because I think if we don't.
Get somebody you know and takecare of swelling, take care of,
uh, you know, knee motion, youknow, extension, inflection,
developing good, you know,neuromuscular control that is
going to make it really hard forthis person to then say, well,
now we're going to progress tohopping and jogging and running
(29:05):
and cutting and, and back tosport.
It's like,
Mike (29:08):
right.
Terry (29:09):
All right, let's, let's take care of these basics early
on.
So I think, I think they do havea place, um, and that's, you
know, that's where, you know,I'll probably use the
biofeedback more early on.
Uh, and then as the person isstarting to get better knee
flexion and can tolerate, youknow, uh, N M E S, you know,
we'll, we'll start it at fullextension and then, you know,
we'll get to 60 or 70 degrees,work our way to 90.
(29:32):
Um, but that it takes a while.
It takes a week or two to, youknow, Work three, four to
actually, that they can becomfortable with their leg
hanging off the end of the tablewith a full muscle contraction.
And so that's kind of how I'llbuild those things in.
Um, but you know, that's a lotof what our focus is, is, is
let's really address these,these, uh, these neuromuscular
(29:56):
consequences early on.
Mike (29:58):
That, that, that's awesome.
All right, so let, let's shiftgears a little bit.
So we talked a lot about earlyon, which I think is huge.
Um, let's talk about maybe somelonger term, uh, consequences
here.
And I know yourself because I'veheard you speak on this a little
bit, but you have some up andcoming research that is
hopefully gonna be publishedfairly soon.
But, um, looking at things like.
(30:19):
Bone mineral density changesafter E C L and how that may
correlate to their outcomes,their quad strength, those sorts
of things.
Um, do you have any informationyou could share, uh, with us on
some of these future findingsthat you're still in development
with?
Terry (30:34):
Yeah, good question.
And so I think one of the, youknow, one of the things, and,
and you know, from a researchperspective and a clinical
perspective is really thinkingof, well, what do these people
look like?
You know, one year out, twoyears out, three years out, five
years, 10 years, 15 years.
And, uh, you know, what, what,what's the potential for like
post-traumatic osteoarthritis?
And, and if we wanna mitigatethat, we need to be able to
(30:56):
identify changes early on.
And, and so quite often I thinkwe think of like, you know,
osteoarthritis as, uh, you know,really looking at, at, at
changes in like articularcartilage.
And, and, but by the time a lotof those things develop, it's,
it's, it's probably.
(31:16):
Becoming too late to actuallyintervene.
And so that's, that's what ledus to look at some of the
changes in bone density.
And, uh, because, and, and we'veseen this in like animal
studies, that the changes inbone density actually precede
changes in particular cartilage.
So from my end, thinking, well,if we want to intervene at the
(31:38):
earliest possible opportunity,and then to be able to show a
change, something like, Lookingat bone density seems to make
sense.
And so one of the studies thatwe did, and it was a
cross-sectional study, webrought, uh, you know, 20
individuals in that had an a C Lreconstruction within the past
two years.
And, and compared them to, uh,you know, a, a a a healthy, uh,
(32:01):
or non-injured, physicallyactive, uh, group.
And so they had, you know,relatively comparable like TEGNA
activity scale scores, you know,if we had a high school CL or
high school athlete, their, youknow, kind of their peer
comparison was also another, um,you know, uh, sex matched high
school athlete, you know, from asimilar sport.
(32:22):
And, and so on average,everybody was about a year out
of, um, uh, following a c lreconstruction.
And we looked at, uh, we used PQ C T, um, which is, uh, it's
different than dxa.
I think a often we think of Dxaas being able to look at bone
density pq.
C t offers the opportunity to,to look at.
(32:44):
Look at a limb also in 3d, andwe can then separate out things
like cortical bone density orkind of that outer shell versus
trabecular, kind of that innerpart.
And the trabecular is moremetabolically active.
And, and in our study, that'swhere we saw a lot of the big
changes.
So we looked at both the femuras well as the tibia and, uh, at
(33:07):
least our preliminary stuff.
Big changes at the tibia.
Probably, you know, on, onaverage, healthy people had
about a 5% difference, or alittle, you know, about a four,
four and a half percentdifference side to side.
On average people, uh, a c lreconstruction had like a, like
12% difference.
So there was about a seven ishpercent difference, uh, between
(33:31):
the groups.
And in theory, these people area year out.
A lot of'em were back to,
Mike (33:37):
Right.
Yeah.
Terry (33:38):
back to physical activity.
They're, you know, they've beenreleased, they've, they've, you
know, met some of these, youknow, benchmarks or whatever
else.
They're out functioning anddoing pretty high level
activities.
And, and so we weren't, youknow, we're not definite.
We're definitely not the firstgroup to show this decreased
bone density occur, but a lot ofthe other studies just sort of
(33:58):
stopped there and they're like,yeah, there's, they have
decreased bone density.
And we're like, well, like,probably not every clinic in the
country has P Q C T or Dex to beable to measure these things.
So we need to correlate it tosomething.
And, and so you know, we havethe opportunity or capacity to
look at things like, you know,quadriceps and hamstring
(34:18):
strength, looking at jumpingbiomechanics, running
biomechanics, these sort ofthings because I think it makes
sense that, you know, wellpeople that are loading their
limb more probably have betterbone density or people that are
unloading their lamb probablyhave lower.
And so I think that's, Like aprecursor or, or a sort of a
signal to what we would see inthe clinic.
(34:40):
But we also realize noteverybody has force plates to be
able to measure these things.
The other aspect is, is sort oflooking at, well, what's, what's
this interaction between thebone and the muscle?
And that's like this als, youknow, this little forgotten
aspect that that also matters.
And so, um, you know, those werekind of our main, uh, outcome
(35:05):
measures.
We also had, you know, blooddraws and things like that
looking at like vitamin D andcalcium and some inflammatory
biomarkers.
Um, And we plugged a few ofthese things in, um, you know,
to this, uh, this, thisregression equation and, and
really tried to figure out,well, what's, what's the, what's
the best predictor here?
Mike (35:25):
Mm-hmm.
Terry (35:26):
and people that had more symmetrical quadricep strength
tended to have more symmetrical.
Um, side to side bone densityin, you know, or trabecular, uh,
bone density in, in their tibiaand more so, and, and it's not
that joint loading, like withrunning biomechanics or jumping
(35:47):
biomechanics.
It's not that that didn't factorin, but the quad symmetry seemed
to, it explained 50% of thevariants in, um, in, in, in, uh,
symmetrical bone density.
And so that interaction betweenthe.
The muscle and the bone seems tobe really important.
And, and, and so that's, that'skind of preliminary findings.
(36:12):
And then I think then the followup will be one, um, you know,
how long do these thingspersist?
What's kind of the normal timecourse for what this looks like?
And then two, what can we doabout it?
Like if we know that theseindividuals, you know, are more
at risk for lower bone densityafter surgery, um, you know, or
(36:35):
because there may be unloadingthat limb that's serving as a
precursor for the development ofNEO a later on, what can we do?
And at least right now, if I hadto speculate, I'm like, probably
need to get stronger and havemore symmetrical strength.
And so then you're like, wow.
It can't be that simplistic, butI, that really starts to set
(36:57):
that up.
And then, then we also then needto look at things like
symmetrical loading.
And they, so they need to havethe capacity to symmetrically
load.
And I think that'll be kind ofthe continuum of, of where we
see this, this, this play out.
That's just my
Mike (37:14):
And
Terry (37:15):
but it's pretty cool to think about.
Mike (37:17):
I, it's, I, I think that's huge.
And I think really this podcastreally, I think it just really
came together, right, because wetalked about the early
consequences, and I think thisis the late consequences, right?
So again, it goes back to haveto be on top of this early, but
I, you know, I like what yousaid there about symmetry stuff,
and I, I think like forceplates, for example, you brought
up forest plates at one point.
Like I think they're becomingmore common in the rehab setting
(37:39):
and.
There's some technology now,there's companies out there like
Vault that you know, has niceforce plates that you can use
clinically.
Very easy.
I I, it just shows you that,like, just because somebody's.
Squatting, for example, doesn'tmean they're squatting well.
Right.
And it's a, it's a quality and aand and a quantity thing.
It's, it's, you have to put themtogether sometimes.
So, um, I, I dramatic, uh,results I think in my mind from
(38:02):
the study and, you know, I'msure we can extrapolate that to
other pathologies too.
I'm sure it's not just a c l,but you know, of course we have
to be careful with theliterature that way.
Right.
But like, you know, I, I, again,I think it just, it shows you
that like we, we have to dothat.
So, um, so.
Terry, this was awesome.
Uh, I really appreciate yousharing some of your new
research and some of yourthoughts on this.
(38:22):
Um, I know that was superhelpful to me.
I learned a bunch.
Uh, your students at Creightonare lucky to have you here, man.
But, um, bef before I let you goquick, uh, e ending segment, the
high five, five quick questions,five quick answers to learn a
little bit more about you.
But question number one, whatare you currently reading or, or
doing for your own Con-Ed andyour own professional
development?
What are you doing for yourself?
Terry (38:44):
Oh, good question.
Uh, right now, one of the thingsthat I'm reading is, uh, It's a,
uh, it's a book calledAttributes, and it's, and it's
really looking at, you know,just sort of the underlying, uh,
you know, psychological thingsthat, uh, you know, from kind of
a leadership perspective and,uh, you know, how do people deal
with, you know, adversity and,and things like that.
(39:04):
So, super great, uh, super greatbook that I'm into right now.
Mike (39:08):
I love it.
That's awesome.
There's been so many good booksuggestions too, people, so
please, if you're listening,like write these down.
I, I go to Amazon and I'll justput'em in my wishlist, and then
next time I'm, you know, I'm,I'm loading up books for like a
flight or something like that.
I'll get'em.
So, good one.
Uh, all right, next one.
Um, what's one thing that you'verecently changed your mind about
Terry (39:26):
uh, changed my mind about.
Mike (39:28):
professionally?
Terry (39:29):
what.
Yeah, I'll tell you whatProfessionally, uh, no joke
podcast and, and, uh, you know,I think, you know, it's, I don't
know if it's an age thing orwhat, and I think, you know,
kind of initially, you know,sort of giggled or snickered at
the idea or, or, or whateverelse, but realizing like, To be
able to disseminate information,has to go much more beyond, you
know, writing a paper or doing atalk at a national meeting or
(39:52):
whatever it is.
And, and so I think, you know,being, you know, open and
willing to, uh, you know, thatthat learning can occur a lot
across a lot of differentformats.
And, and, uh, you know, as a, asa, as an educator and a
researcher that, that I need tobe more aware of, you know,
what, what methods are out therebeyond standing up in front of a
(40:12):
classroom or, or, or in a, youknow, a, a con ed session or at
a national meeting.
And I think this is, you know,things like a podcast.
Great idea.
Mike (40:22):
Well, I'm honored to have you, but it sounds like you're
about to start your own.
So, uh, let me, uh, awesome.
Um, so you have a ton ofstudents there at Creighton.
What's the best piece of advicethat you like to give them?
Terry (40:35):
Um, you know, I think as far as best piece of advice, I
think really just, you know,thinking about what those next,
uh, next steps are gonna be.
A lot of, one of the things thatI'll consistently ask people is
tell me about your, you know,where you wanna be in five
years.
And, and really thinking about,well, what are the steps that I
need to take to get to thatspot?
(40:55):
So that's really one of the joysthat I have in, in being able to
have conversations with peopleearly on in their career and,
and realizing, you know, thatfive year plan can change, but
it's about the process ofgetting there and the process
for each individual may vary.
There's no cookie cutterapproach, but it's something
that I think you should thinkabout early on.
Mike (41:16):
That's huge.
I, I, I, I love that one.
That's one of my favorite onesso far.
I, I think that's great.
A lot of people are, they'rejust thinking about their end
game or they're thinking abouttheir next step.
They don't realize that theprocess is so important and, you
know, and, and sometimes, likeyou said, you don't evolve the
way you think you are, butevolution is evolution, right?
And, and it's just part of the,so, um, and I love that.
(41:36):
So great answer.
Uh, what's coming up next foryou?
Anything new in the works oranything we're building other
than the podcast?
You're about to start anythingnew.
Terry (41:43):
No, uh, no podcast.
We're, uh, we're, I'll tell youwhat, we're, we're moving into a
new health science building,
Mike (41:48):
Oh,
Terry (41:49):
and, uh, at, at Creighton And I, you know, I've spent a
considerable amount of time, youknow, helping to build out new
research lab space, you know,help work with, you know, a
number of our.
Uh, you know, our faculty that,you know, from a research
perspective that'll be using thelab.
So I've learned a lot aboutconstruction and, uh, you know,
working with contractors and,and, uh, and sort of serving as
(42:09):
this, uh, person in the middleif, if you will.
So that's kind of what's comingup next is, you know, just
building out this wonderfulspace, uh, where I hope we're
able to, you know, really comeup with great ideas and help
impact patient
Mike (42:22):
Yeah.
Pump out some good research.
That'd be great.
Awesome.
Well, uh, where can people learnmore about you, Terry?
Any place you wanna send them orobviously, you know, PubMed and
look up all, all Terry's greatworks, but anything else you'd
recommend?
Terry (42:34):
I think, you know, I, I'm on, uh, I, I am on PubMed and
that's at least a kind of ahistorical perspective of, of
the things that I've done.
Um, you know, I'm on Twitter,you know, Sometimes I tend to
use Instagram less.
Um, and uh, but kind of Twitteris probably where I would have
more of the professional side ofthings.
Facebook, kind of the morepersonal side of things, but,
(42:55):
but sometimes they'll, uh,they'll, they'll, they'll blend,
um, a little bit.
But uh, that's just kind ofanother way as far as reaching
out to me and, uh,
Mike (43:03):
Awesome.
Yeah.
Well, I'll, I'll put, I'll putsome of those links in the, uh,
in the show notes so people canfind you.
So, um, that'd be great.
But yeah.
But, uh, stay on top of Terry'sresearch.
It sounds like they're gonnahave some great stuff coming out
soon.
Um, it's gonna be amazing.
So, uh, Terry, great episode.
Thank you so much for sharingall your knowledge with us.
That was amazing.
Uh, we'll have to have you on inthe future to do even more, but
(43:24):
thank you so much.
Terry (43:25):
Hey, thank you.
And, and yeah, thanks for doingthe podcast.
Thanks for, uh, thanks for beinga, a, a leader in the, in the
sports academy and, and just theprofession overall.
So, yeah, it was an honor beinghere today.
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