Muscle Inhibition and Biofeedback with Russ Paine - Episode 30

Muscle inhibition is common after injury and surgery, and something that we always try to minimize.

Is this episode, I’m joined by Russ Paine. We talk about why muscle inhibition occurs, what we can do to prevent this, and how to tackle it down the road for people with prolonged issues.

If you want to get started with the mTrigger biofeedback device, don’t forget to head to https://mikereinold.com/mtrigger/ and use coupon code REINOLD for 10% off.

Full show notes: https://mikereinold.com/muscle-inhibition-and-biofeedback-with-russ-paine

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Transcript

0:34

On this episode of the sport physical therapy podcast, I am joined by Russ pain. Rusted the director of sports medicine rehabilitation at UT physicians in Houston, Texas. And this episode, we're going to talk about muscle inhibition, why it happens, why it's so common after surgery and some things that you can do both acutely to prevent it as well as treated when you have it down the road. We're also going to talk about biofeedback in the use of this in these patients.

Mike: 1:11

Hey, Russ. How's it going? Welcome to the podcast.

Russ: 1:13

Thank you. Doing good.

Mike: 1:15

Awesome. Well, always good to have a longtime friend here. Um, for those that don't know, uh, Russ, you've done so much for our profession, the sports physical therapy for profession over the years between your publications, all the meetings that you've spoken at over the years, you know, dozens per year, probably over your, your extremely long career. Um, current Hall of Famer for the Sports Academy, which is impressive. Very, very, you know, few people get inducted in the Hall of Fame. Um, you know, before we get going into this podcast topic, I want to hear a little bit about your journey. Right? I want you to express a little bit of that so you can share that because I, I, I think some of the young professionals. They, they want to hear like, how does somebody like yourself, how do you get from a new grad to the Hall of Fame of the sports academy? So, you know, not to start completely open-ended, but man, I'd love to hear a little bit about your journey,

Russ: 2:07

Sure, no problem. Well, It's a simple formula, but not so easy to, uh, institute that, you know, that's why I tell, you know, I have lunch sometimes with, you know, PTs that want to do what I do. You know, they come into the clinic and they see all the, the m o B guys, B a and the NFLs. How did you, how do you, how do you get all those guys? I said, well, you first thing I did my first three years outta PT school, I moved my family to four different cities. you know, I think positioning yourself, uh, and that's one of my questions at the end with you is how do you

Mike: 2:43

Nice

Russ: 2:44

successful is position yourself so that luck can find you

Mike: 2:48

Yeah. Right.

Russ: 2:50

so I'm actually moved to my, my big move was moving from Houston to Lake Charles, where I worked with a real famous orthopedic surgeon named David Dure. and so I po I didn't really know how big a name he was. I just knew it was a private practice opportunity for me to start, uh, you know, two and a half years outta school. And so, um, I did that and I had kinda like a five year plan and he helped me tremendously. So I think getting, if you really wanna be involved in sports pt, I still believe that it's a team concept and uh, you know, things are changed a little bit cuz we're a doctorate so of, of physical therapy. So you have a little more autonomy. But it's a team effort when you, when you do, uh, sports, physical therapy. So he opened me doors for me. I went to all the national meetings. I went to the arthroscopy, the academy, the A O S S M, and then I got involved and, and listened to one of our great or tours of all time Bob Manje and listened to him and I said, if Bob can do it, I can do it. no, I'm just kidding. Bob was a big groundbreaker and he's sort of a mentor for. And so then I started publishing because Dr. Dres demanded that I proved what I was doing in physical therapy. So he really opened, and always, even in PT school, I, I worked in research. I just had an interest in, in finding out why. And so that helped me. Um, and through that, his, uh, his, uh, guidance. I became integrated nationally with Kevin, Kevin Will, and Bob and, and Mike Boyd. And you and, and a lot of different people. So then I moved to Houston and um, worked under back in a private practice, and then I got an opportunity to join a bigger group. And at that point in time, it was a Hill South Days and we, um, I was in charge of this big, you know, 10,000 square foot clinic and we hosted the, or sponsored the Houston Rockets. So I became the physical therapist for the Houston Rockets. It was me, Keith Jones, Anthony Fone, three guys. And then obviously Dr. Lowe and Bruce Mosley were the team physicians. So I was running my practice. I was doing the rockets. I went to every home game and I traveled with them a little bit and I was lecturing at 25 meetings a year publishing, and then I had my own educational. Uh, meeting that me and Kevin and Bob did three meetings a year called r r Enterprises. So I worked, you know, like I said, it's basically you do things that other people are not willing to do. So I transitioned from that and developed, I've been in Houston since 1991 and I got involved in treating pro athletes. A lot of it had to do with that rocket's, uh, exposure. Uh, then I started working on PJ Tour players, and I got to work with the Astros. I went to nasa and I was there probably about 10 years. Once a month I'd go work on the, the, um, astronaut. So some of it is, is, you know, skill level and, but most of it is, is just doing things that other people aren't willing to do.

Mike: 5:57

Yeah. Yeah. And you know what, I think nowadays too, there's, I hear a lot from our PT students and some young professionals that are getting out there. They're always, they're, you know, they're worried about work-life balance, which, which, you know, that's, that's a good objective to have. But they're, they, they fear, they fear like grinding in the clinic sometimes. And, and I think we. Agree that that's not the best way to do it, but people like yourself, myself, the Kevin Will, everybody that you, you mentioned, I mean, we've all done it at some point, and I, I, I think the, the amount of learning that you have in a high volume clinic with the sports medicine doctors right upstairs, for example, or across the hall, the amount of collaboration, the amount of work that you get done in a short period of time is just, uh, astronomical for how quickly your brain can, can absorb new information. It's almost like your experience levels. Doubled or tripled in the same amount of time that you can do, and everybody always fears that. Right. So, you know, I, it was good to hear, you know, you know that, that concept, you know, grinding in the clinic, these big orthopedic clinics where it's okay to be high volume sometimes, right?

Russ: 7:01

Right. Yeah. I mean, there's absolutely no way that you can be independent out in a freestanding clinic and learn as much as if you're involved with an orthopedic SUR surgeon on a daily basis. So, I mean, uh, you know, I think you can be a great sports PT in those settings, no question. But you need some interaction with the guys that look inside the.

Mike: 7:24

right.

Russ: 7:24

Everything they do is looking through the arthroscope and fixing things inside the joint, and we look outside the box. And so we just kind of putting those two brains together makes I think the best care for for patients.

Mike: 7:37

Yeah, and, and the opportunities you get, I think are also greater, right? You can participate in grand rounds, you can go through the educational sessions with the docs, but then you get involved in all their big projects, right? Because. The, the surgeons have bigger budgets for these things. They have bigger, you know, grants and research foundations. They can get this, this, the seed money to do things like big research projects that, that we wouldn't be able to do on our own. You know, and I would say that's the one thing that Lenny and I talk about all the time, like owning our own private practice now, is we miss the collaboration with doctors every day. Right. And, and that's something that I think sometimes people take for granted is how valuable that can.

Russ: 8:16

Plus, I mean, if, if you're in private practice or in a free-standing clinic, it's a great marketing tool for you just to go and see patients with a physician. And you know, you look at images, you look at MRIs and even radiologists. Don't interpret the MRIs as well as a sports medicine orthopedic surgeon. And you can't really learn that on your own. So, you know, just learning, you know, and how they treat people. And Dr. Lowe and I have been doing our Tuesday morning clinic forever. Which we stole from, you know, Kevin Wilkin, Dr. Andrews who St. Stoler from, you know, Jack Houston, who started it. And that's been, that's grown to be a huge thing that Lane Bailey and Jackie in our clinic have taken it to another level. So we have a huge Tuesday morning from seven till noon. We, you know, evaluate all of our a ACL patients. He does 400 ACLS a year, so it's. A big population, but it's fun. It's a lot of fun. And, and then we have all the residents and the fellows and all the key sports PTs in our, in our city get to come and interact with Dr. Lowe and communicate with him. So it's, it's great care for the patients.

Mike: 9:21

And, and just again, the massive volume of what you see just helps you learn so, So much faster than you can if you're just in an independent private practice. Or even there's some PTs now that just wanna go right into cash base, which is, you know, one-on-one, you might have five patients one day, right? And you, you just saw five patients before 8:00 AM right? So it's, it's, you know, there there's pros and cons that I just, I tell people, look, the, the educational experience in those environments are, are next to nothing. So don't, don't, don't, don't forget that. Right. Don't, don't underappreciate That, I guess is how I would phrase it.

Russ: 9:55

Yeah, it is sort of like we cheat a little bit because we see it every day and then we look back and we, you know, one of your other questions coming up is, what, what have I, you know, what am I evolving? And, and I was talking to my PT today about it and I'm like, We evolve every week and we don't know it,

Mike: 10:13

Yeah.

Russ: 10:14

we're, we're, we're evolving because Dr. Lowe's techniques evolve and we change the way we do things and we're doing this stuff, and then we get a PD that comes at PT that comes in, or a patient that's been seen in another place and say, why aren't they doing this? And it's because we do it every day and it's just so natural for us. And nothing against the other outlying PTs, but they may not see, but maybe 10 acls a year.

Mike: 10:35

Exactly right. Right. You have to be careful, like it's people like yourselves that have so much volume that you become the go-to resources for that because you're, you know, it's, you can't surprise you anymore. Right. We can't stump rust pain. Right. You've seen nearly

Russ: 10:50

Oh, we can,

Mike: 10:51

be you know what I mean? Like.

Russ: 10:54

we're like the principal's office, you know, doctor Las said, hi, dear. I go See Rise. He is the wizard. But it may hurt you a little bit, you know.

Mike: 11:03

Exactly right. He may not say what you want to hear, but you know, you might not be ready to run. But that, that's awesome. Um, well, yeah, I, I love the journey. I mean, obviously I've known you for a really long time. I've been fortunate to meet you through, through my mentor Kevin, and we spent a lot of time together at meetings. So, uh, it's always good to hear that, and I think that's always good for young professionals to kind of hear about that journey and, and, and what it takes to, to, you know, to get yourself to that next level. So I appreciate you. Um, I, one of the things that I think, again, you bring a wealth of information to is just how many postoperative patients you've worked with. Right. And that's, to me, one of those benefits of working with the physicians again, is you see so many postoperative patients. Right. So what, what would you say in your practice right now, what's your percentage of post-op versus just the non-operative pain type patient you have?

Russ: 12:16

I would say, um, you know, some of our baseball guys are non-op. you know, some of'em come in, you

Mike: 12:24

thank God.

Russ: 12:24

post-season to get ready for next season. We're getting more and more of that. You know, people have actually seen me in high school and had a great result when they had a little laberal, you know, tear or something, and then they come back now with their professionals like, Hey, I want some more of that juice, you know?

Mike: 12:42

right?

Russ: 12:42

But I would, I would say it's probably 50 50, something like that.

Mike: 12:46

That's that's huge.

Russ: 12:47

Yeah, that's, that's, we see a lot of post-op and like I say, we see a lot of the post-op patients. That are having trouble, you know, that are, that have loss emotion or they, you know, they're having swelling or they have no quad and you know, and some of the things we do just work, you know, and the, the basic fundamentals that I have never gotten rid of and it's just crazy. I look at my other pt, we go, I can't believe you know this or that, or whatever, but it's just, you have to get the basic foundation of rehab principles. One thing I want to say is congratulations to you by the way.

Mike: 13:22

Uh oh.

Russ: 13:22

taking on the helm of, of presidency. And I love sports, physical therapy and I love our profession. And, you know, congrats to you and, and thanks for lead taking the flag,

Mike: 13:33

I appreciate. Well, I'm just, I'm, I'm giving back just like you guys did. That's, that's how I'm, I'm, this is, it's my time. It's my time. Right. And I, I'm already looking forward to passing the baton again.

Russ: 13:45

things getting all a sudden. Huh?

Mike: 13:48

that baton is hot, but.

Russ: 13:50

The four by one a hundred, not the, you know, mile relay.

Mike: 13:54

Exactly. So, um, well, let's talk about that a little bit here again, because again, I think one of the benefits of you is, you know, you see so many postoperative people, you see those complicated patients, right? I, one of the most complicated things that all the PTs want to ask questions about to me is muscle inhibition. Right is they get stumped by it sometimes. And, and it's, it's, it's amazing how common muscle inhibition is after a surgery. Right. Um, let's start with that a little bit and, and talk about just muscle inhibition in general and like why, why do you think that occurs? Why do you think that's so common?

Russ: 14:27

Well, I mean, we can, you know, get, get a little dry here for a minute and quote some literature, you know, but I'll, I'll try to make it simple. But, uh, if you look at immobilization, that's probably the number one cause of muscle inhibition. So there's been a couple of studies, one where they took normal subjects. And just locked them in full extension for three weeks. And then they had a second group where they had a hinge brace and they didn't do any exercise or anything. And so the group that was locked in full extension had, uh, 50% loss in strength in three weeks. Uh, the range of motion group had none basically, and they had 40% decrease in their emg, the immobilization.

Mike: 15:13

Wow.

Russ: 15:13

you have four times greater strength loss in atrophy. So you had 50% strength loss and only 11% atrophy. So it's not like the muscle size is a factor. It's a neurological inhibition when your knees full, extension, the muscles short. So that's one factor. The other factor is swelling and pain. Obviously, we know that if you inject 30 ccs of saline into a perfectly normal knee, your quad mg goes down 50.

Mike: 15:41

Yeah. That's

Russ: 15:42

and that's a spinal cord reflex inhibition of the femoral nerve, the Hoffman reflex, you know, so that's number two. And three is pain and swelling. And then another thing that caused you to have inhibition is unloading. So if you have to go non-weightbearing, you're gonna lose 20% strength over a three week period, just from just not putting your foot on the ground. So those are all things that occur, and it occurs worse in some than others, and I can't tell you why that is. So I don't, I don't, you know, I don't, I, that those are the factors that cause you to have muscle inhibition

Mike: 16:17

Yeah. So D, does it blow your mind still to this day that we still have some physicians that wait two weeks to get people into to therapy after they have surgery?

Russ: 16:28

Yeah, we don't see that obviously, but, um, some people are worried about their particular procedure and they immobilize them. We don't hardly immobilize. I can't think of anybody we immobilize except maybe a, you know, a dislocated knee with a M C L. But even while though we immobilize them, we allow them to move their knee right away, zero to 30. So there's, there's nothing unless you have a fracture that we immobilize that's a A C L M C L or ligamentous type injury. So we've learned that, you know, not only the, the atrophy, but obviously articular cartilage, it's, it's not good for articular cartilage either. So, yeah.

Mike: 17:07

that, that's one of the things that Lenny and I didn't appreciate when we, again moved from a setting like yourselves where we're with a group of really amazing physicians to being in the community and now we see people from every surgeon, dozens of different surgeons all over the region, um, how different everybody is, and we. Every day. The people that wait two weeks to start therapy always are worse for months. Right. Like two, three months. It seems like once you get behind for two weeks, it's hard. Right.

Russ: 17:37

Yeah. I mean that's one of the factors of prevention, which you'll talk about next, is you gotta turn the muscle on a S A P or you start cascading down that, you know, catabolic pathway. You know, the anabolic is, is what we want and, and I know we can't use anabolic steroids, but it seems like a perfect time to use it, you know, and nobody will do it. Take on that study you.

Mike: 17:58

Exactly right. Maybe

Russ: 17:59

I think one of the reasons that, uh, you know, physicians are maybe hesitant is that they don't have a Mike Reinhold or you know, a go-to PT in every location where they are. So they're afraid to move patients, which I think is the wrong thing. But I think that's psychologically maybe what happens sometimes.

Mike: 18:18

Right. Yeah. And that's, I think that's a fair assessment. That, that makes sense. You know, and, and I see that there's a lot of physicians I know around us in the Boston area for some reason. I don't know why the, the surgeons have shared this Excel sheet of every PT clinic, like in the world it seems like. And they all give it to the patients. They're like, Hey, here you go. Go to therapy. And there's literally 80 pt. It's like they just went to the yellow pages, right? Which doesn't exist anymore. It's so crazy that they do it that way versus trying to have some regional clinics that, you know what, I really trust these people. I really trust this, this guy or girl. Right. And you know, it, it's disappointing to see, but um, you know, maybe, maybe one day, but,

Russ: 18:57

I think the other thing is that as a pt, if you see general orthopedics and you get an A C L, the last thing you wanna do is hurt someone. So what do you do? You err on the conservative side and, and even though the protocols there, you're afraid to move them, you know? And in most cases, with most surgeries, Patient, I mean, the physician finishes the operation. They take'em through a full range of motion and make sure everything's good. There's almost no reason not to move the knee, you know, passively to 90 degrees on most, most things.

Mike: 19:29

Right. Yeah, yeah, exactly. Especially passively, right? I mean, there's like, yeah, I, I completely agree. So we talked about immobilization, we talked about limited weightbearing, we talked about obviously pain, swelling, those types of things. Um, alright, what do we do? How do we prevent this then? So if you're a pt, you're working with postoperative patients, what's, what's like the bucket of things you do to, to minimize or even prevent this inhibition as much as we can.

Russ: 19:54

So the first thing that we do is someone's swollen and they have an, if your knee is, you've got, you know, 90 ccs of fluid in your knee, you're gonna have trouble. So we aspirate. I mean, I don't, but Dr. Lowe is very aggressive with aspirations. I mean, if you got 30, 40 ccs of fluid, the he'll say you're allergi to needles, you know?

Mike: 20:16

Wow.

Russ: 20:17

uh, we that. Very, very helpful. And when I worked with Dres, he was too. I, I worked with a lot of top physicians, uh, in Texas and, and some of them do not like to aspirate. They will just not aspirate no matter what. But luckily that's one thing that we have that, that I think is great in prevention of the cascade. You, I don't think we figured out how to prevent atrophy. It's just, you know, it's there, but we can prevent the cascade.

Mike: 20:44

Right. Right. And, and and more importantly though, like again, just like, just like starting PT two weeks late, like the longer you let that swelling linger, right? The longer you immobilize it, the more and more you're gonna get behind, right? I think, I don't think people realize that that effect is almost cumulative to a nature.

Russ: 21:01

Yeah. So turning on the quad is the most important thing. It does so many things if you can make a muscle, you know, so that's, you know, that's. Getting into ball feedback. I'm a big ball feedback guy, you know, so, uh, when the patients can see their activity, it just, it just makes sense. And we'll go over some, you know, technical reasons why, but when you turn on your quad and you can, you know, force your knee straight, you, you do a, like three things. You turn on your quad, you help force active extension and you mobilize the patella, you know, so turning on the quad is extremely important. And the worst place to turn on the quad is with an in full.

Mike: 21:40

Right.

Russ: 21:40

But that's what we all do. We put'em in full extension and we put a pillow on or pad underneath the back of their knee and said, tighten your muscle up. I'm like, man, I'm crying. I I can't do it. You know, it's not working well try harder. You

Mike: 21:52

right. It's,

Russ: 21:54

if, if you've got an ACL l yeah. If you've got an A C L, that's a post-op and they can bend their knee and maybe they're not bending all the way to nine of us, sit'em over the edge of the.

Mike: 22:03

right.

Russ: 22:04

Send'em over the edge of the table if they can get to 60 degrees and they just have'em do an active knee extension. So that's so much easier. And we use the bottle feedback with that. And it, it's, it's really huge to, and then the other thing you can do is put them in a 90 90 position like we do with the rotator cuff and just lift their leg up in full extension like you're doing a hamstring stretch. And I'll have them try to lift their heel off of my hand and that'll initiate the quad and a gravity eliminated like we do with rotator cuff. You know, we start in that gravity eliminated position. So those are a couple of things you can do. And the other thing is weightbearing.

Mike: 22:41

Right,

Russ: 22:42

Weightbearing with a normal gate. I don't let them get off crutches until they can walk without a limp,

Mike: 22:48

right. That's huge.

Russ: 22:50

you know? So why? Why do people walk with the flex knee position? You've heard my lecture a thousand times. You better know the answer.

Mike: 22:57

right? Well, there, there's a lot of reasons, but yes.

Russ: 22:59

there, there's one main one, So they walk with their knee bent in a flex position.

Mike: 23:07

Because they're not turning on their quad

Russ: 23:08

Exactly. Good job, Mike So when you're in the,

Mike: 23:15

ever.

Russ: 23:16

yeah. 100%. One outta one. Um, so when you're walking, and let's say it's your left knee and you're in the stance phase. When you swing the uninvolved knee, you have to go from near full extension to maybe 20, 30 degrees, and that's an ecentric contraction.

Mike: 23:35

Right?

Russ: 23:36

And most of the time they ain't got that. They do not have that capability to go from full extension to unlocking their knee to control that. So that's the first thing we work on. We do side to side weight shifting. We have them put on the biofeedback and we'll go from full extension to a mini squat standing holding onto the table. We'll have them walk over cups. And single imbalance with their knee slightly flexed to control that position and immediately their gait pattern changes that day. But if, you know, if you don't do that, what they do is they do all this stuff and they walk outta the clinic with a bent knee again,

Mike: 24:12

Right, exactly.

Russ: 24:13

and so they're staying in that position because it's comfortable and it's stable. Uh, so you've gotta get'em out of that, or they'll lose extension and they'll never get their quad back.

Mike: 24:24

right, right. Yo, man, if you start getting tight and you start losing extension, you're, oh, man, your, your ability to get that quad back goes down significantly.

Russ: 24:34

Yeah. I think the worst thing you do, and a lot of physicians are guilty of this, is that get rid of those crutches, you know? You walk around with like a peg leg and you're like, don't tell where you're going to therapy, please. You

Mike: 24:46

right.

Russ: 24:46

you look terrible, So I keep'em on crutches and go down to one crutch until they can walk with a normal fluid gate. So I think that that's really important. PFR is great. I think BFR is another thing to tackle. Uh, we use BFR and biofeedback. I don't probably use BFR as much as I do biofeedback, but I think, you know, both of those are great in use together, especially someone who's got an articular cartilage injury, you know?

Mike: 25:12

Yeah, no, that makes sense. And you, you'd be surprised at how many people that you have to just go through that gate training that you just mentioned, the the cup walking and like the steps over the call. It's a single leg balance and you almost have to, like, you, you, it's almost like you have to, to tell them that what was once reflexive, you now have to think about it a little bit. Like, Hey, I re I want you to control that quad. I want you to stabilize. I want you to contract and hold it there. And then once they do it, it comes back. But when it's almost like, They turn it off, they just, they don't use it for two, three weeks and then now you're behind the gun and you start losing extension on top of that. And Oh, man, that's, that's gonna be a tough, tough few weeks for that person.

Russ: 25:48

We had a patient last week, uh, eight months post-op acl, who's. You know, division one cheerleader scholarship. She's running on the treadmill. She can do everything, but she can't walk. She was not able to walk with a normal gate because her, you know, she was walking this flexion E gate pattern. She had full, pretty much full passive extension. But, so we worked with her on that and two days later she was, you know, her knee, brain took over.

Mike: 26:14

right? Yeah.

Russ: 26:15

So your knee brain and your real brain don't get connected and you lack that capability and that that comes with the cortical input that we'll talk about. And that's one reason why be biofeedback works I think, is because we initiate that cortical input right away. And that's one thing that you lose when you have an A C L tear and injury or arthritis. You lose that, that transcranial magnetic stimulation that has shown that you lose some cortical input going down. So you have to, you know, overcome that.

Mike: 26:46

I feel like the trend right now in younger professionals with ACL strength, Is loading and it's load, load, load. And I don't disagree with that. I, I agree. We need a load and we've probably been guilty of underloading, underloading our patients for decades. Right. Um, but I wonder if they're not appreciating the neuromuscular control that you've really talked about this whole time indirectly. And that ability to use that quad, the neuromuscular contractions versus just load, load load. You don't wanna load somebody on top of a poor movement pattern.

Russ: 27:19

right? Yeah. I mean, that's what we talked about earlier is like if you've got 50% strength loss and 11% atrophy, it's neuromuscular. Deficit in the first, you know, two to three months of, of, of, of post-op care. You're trying to reeducate the muscle. You're not getting muscle atrophy when you're doing three sets of 20, you know, so, so that's really important. Um, and, uh, you know, now we have a way to measure it so you can look at the emg and we just finished a study with, uh, One of our pt, Steve and Sugarland and, and Lane Bailey, uh, and, and Jackie all looked at our post-op patients and measured EMG at six months. And if they are in a supervised program, uh, you know, our protocol with our key PTs, we have rided them of that neuromuscular deficit by six months. They still may have a 15, 20% strength deficit, but at least you've taken that off the table. I saw a patient last week with Dr. Lowe. and this girl was a year postop and she still had a 50% EMG deficit.

Mike: 28:25

right,

Russ: 28:26

So you've gotta take that off the table and then get to the other part. But if you just keep bloating, like you say, and you never get the base of foundation of, you know, two things that govern your, your dynamic stability. One is MG and the other is strength. And so what we have to answer is how do those two correlate? That's what we're working on right now. But for us, I mean, usually within two to three months we've got that conquered. So that there in our product, the M trigger has got a two channel product. So you can test the normal and test the involved, and you can get a percent deficit within one minute of their, you know, what they, what they've got going on with that.

Mike: 29:05

That's awesome. You know, that it reminds me, um, of a conversation I was having with Holly Silvers, uh, this summer. Um, we were talking about hamstring strains and we were talking about, you know, the recurrence of hamstring strains. And what she said to me was, she started, she, she's doing a lot of research in this cause we're trying to tackle this like in football and even baseball, that sort of thing. And she's saying, you know, sometimes these, these guys, they, they test out their strengths there. But if you look at their EMG activity while they're running, it's not there. Right. And it's, and it's, and it's amazing parallel right here to the postoperative patient, the, the postin injured person. It's the same thing. So let's talk biofeedback then. So obviously that's a tool that you use. You mentioned the M trigger, which is a device that you've helped develop, which, um, was really, really cool to like see, hit the scene like several years ago now. But let, let's talk a little bit about like what, what is biofeedback, cuz you've alluded to it a few times. What is it and, and how to you use it in your clinic?

Russ: 30:00

Sure. Well, biofeedback is just basically amplification of your quad muscle activity. So our product, you've got two electrodes, two channels, and you just put it on the target muscles and then you can adjust the sensitivity of the amplifier to make the patient work harder or make it easier for them to make a contraction. You know, biofeedback in, in our hands. I wanted it to be a very simple product that you can set the settings and then you just open it up and hit play. You know, this kinda was the knock with muscle stem. You had like 5,000 settings, and you know, what frequency and what wave did you want to use? But I'm like, I don't want that. So anyway, biofeedback is, you know, I think the reason that it works is you have increased cortical output. So when you're contracting the muscle, every rep, you have a goal and you have to get that bar up to that goal each time you can see your numbers. So for one thing, it, it involves the patient energy, you know? So you're not just doing, you know, 10 minutes of quad sets and checking their email while you're sitting at your desk looking at your computer. They actually have to work, you know? And then there's the other, this other thing called order of recruitment. So that means that when you make a muscle, you start with the slow twitch muscle fiber, and then you go to the fast twitch. So as you, you know, do a really hard isometric contraction, you establish that normal order of recruitment, which in turn increases the rate of firing of the motor units. And that's your goal is to get all the motor units. And a motor unit is one little branch that goes to seven or eight nerve fibers. So you got about two or 3000 of those in your quad. So we want all of those branches to. Alive. You know, so that's, that's kind of a nutshell of how it works. The other thing is it's visual and patients can, they love to, they like the bar thing, but they wanna see their number. I'll get'em in there the first day and they usually about, you know, 200 or 300 s of normal number micro votes for a post-op patient. And I'll say, well, let's see where your other leg is. Not to embarrass you or anything, let's just see where you need to get to. And it's usually about 2000 on the other side, you know, so, but each day they come in, they're like, okay, I'm at 1500 now look at this. Within, you know, a couple of weeks. So I think the visual thing is hard to measure, but, uh, you know, that that's kind of how it works. And we have games you play also, and the games are really cool and they make you work. I mean, I've got video of N F L guys doing quad sets and, you know, and, and playing one of our games and I did show it on his jersey and he's like, stripping and sweat, you know, so it, it is been a fun tool for us. And it's, it's kinda like limited to whatever your, you know, creativity.

Mike: 32:51

Yeah, no, and we obviously we've, we've been using it for several years now and, and, you know, for followers of my website, I mean, Russ and I have talked about this in the past, so, you know, it's the m trigger device. We'll, we'll put some info in the show notes so you understand, but, um, you know, I, I always, I, I always wonder here too, cuz when I was coming outta PT school, Biofeedback was around a little bit, right? But it was clearly on its way out, and then it just disappeared for a while. You know what, what, what happened? Why, why, why did biofeedback disappear in your mind?

Russ: 33:22

It was just like the huge, uh, market for muscle stem just overshadowed it, and no one was really using bowel feedback. I, I don't, I can't tell you why I've been using it since

Mike: 33:33

Yeah.

Russ: 33:34

probably late eighties. Used a handheld little l e d light that would go

Mike: 33:38

Yeah, I remember that. I had one of those. Yeah,

Russ: 33:41

Care EMG or something like that. But, uh, there was just not a market for it because a huge market was muscle stem. And it's purely, you know, mostly financial because you could, you know, make money from renting muscle stem units. It was insurance reimbursable.

Mike: 33:57

Hmm.

Russ: 33:58

and MP was a company that just did big guns with, uh, muscle stem rentals and they made most of money selling electrodes. And then once the insurance reimbursement quit, it just stopped. And so they also funded hundreds and hundreds of papers of research, uh, because, you know, it was a profitable entity. And that, that's the main reason I think that, uh, Um, muscle stem, overshadowed biofeedback, but now we're, we're, we're making a little wave, you know, the biofeedback, uh, community is seeing that the patients love it, they're getting results. So it's, uh, and our product is like four 50 bucks and we're coming out with a rental program we just started, so patients can rent it for a month. Not sure what the cost is, but it's gonna be about like a hundred bucks a month.

Mike: 34:42

That's

Russ: 34:43

our, our product is like a retail thing, you know, it's not reinsure. Ensure it's reinforc. There is the biofeedback code, but it pays like 10 bucks, you know,

Mike: 34:53

Yeah. You

Russ: 34:54

so we don't use it, but you can use a neuromuscular reeducation code

Mike: 34:58

Right, right.

Russ: 34:59

not using that code. It's, it just, it totally fits into that. So, The main thing I think was pretty much financial, but, uh, it's really fun to go to our website and see all the different videos that people send in that you're using it for core and shoulder and calf and, you know, a little bit of everything. So it's, it's, it's been a lot of fun.

Mike: 35:19

Yeah. All right. Well, I, I know like a, so because of this, right? We, a lot of people know neuromuscular stem. We all know what N N M E acid is, right? This is a familiar thing for most people. Uh, but you know, not so many people I think, are understanding biofeedback a little bit. Like we, obviously, there's a difference, right? One, it contracts for you. The other one almost just tells you how much you're contracting, which gives you. Biofeedback. Right. Hence the name. But tell us a little bit about the, what's the difference from the science and how it affects outcomes and, and impacts the person's function between neuromuscular stem and biofeedback.

Russ: 35:53

Sure. Well, um, there's several studies. Animal studies have been done to look at this. And, um, one study in particular looked at muscle stem and they, several studies have described this as a reverse contraction. So when you get muscle stem, um, you don't have that normal heinemann size principle where you go from a slow twitch to gradually a bigger contraction, to a fast twitch. When you use muscle stem, you get the largest. You know, cable, electrical cable is gonna pick up the signal first, right? So the fast twitch muscle fibers have a larger diameter axon, so the fast twitch picks it up first, and the slow twitch almost doesn't even get stimulated. So I think that's one reason. Um, even some other studies show that muscle stems stimulates everything at once, but the two or three studies show that it's a reverse contract. And so the normal process is slow twist to fast twist. And so if you have an a C L tear and you get immobilized, the slow twitch muscle fibers are the ones that are most effective shown by a couple of studies. So if you're not waking those up, then I think you're not getting the most beneficial treatment. The other thing is that muscle stem is a distal application of the contraction. So your distally, your brain, your the muscle stem is your.

Mike: 37:21

Right.

Russ: 37:21

So you contract the muscle, you set the intensity, you know, to where their hair's standing up and they get know, oh, we got a good contraction here. Now work with it. You're like, ah, You know, I'm trying. So and so I think what you lose with that to some extent is the cortical input.

Mike: 37:41

right?

Russ: 37:41

So with biofeedback, you're using your own electrical system that starts in your cortex, goes down the pathways to the femoral nerve. And so I think that's one other reason why we see I, you know, I've been using it forever cuz I got better benefits with biofeedback than I did muscle stem, quicker muscle return, less atrophy and that type of thing. So that's kind of it in a nutshell. Um,

Mike: 38:07

So what to me, I, I'm gonna give you an opportunity here. Um, here's what I'm doing, and you tell me if I'm wrong. I, I, I'm still, I use both. I'm still using neuromuscular stem at the very beginning, more so than biofeedback when they don't have good volitional control. And as that starts to improve, then I, I almost want to, you know, start phasing out the neuromuscular stem and into the biofeedback. A am I doing that wrong? Do you

Russ: 38:34

No, I think you, you know, I think that's fine. I don't do that, but I'm, I'm a little I'm a

Mike: 38:40

If I

Russ: 38:41

I'm a little more brutal, you know, I just make them, you know, get their own contraction. But, uh, I, I think a lot of PTs in our system that work really closely with us do the same thing. I think that's perfectly fine to, you know, get them to feel what, um, a contraction should feel like with muscle stem. But as soon as they get a volitional contraction and you can pick it up on the amplifier for me, that's, that's when you, uh, switch

Mike: 39:08

to move. Yeah,

Russ: 39:09

But if they can't make any muscle at all, then you can do muscle stem or you can send'em over the edge of the table and you know, have them doing the extension. You know. But I, you know, we, we haven't turned a muscle stem unit on in probably 10 years, you know,

Mike: 39:23

I was, I was gonna ask you that. That's funny.

Russ: 39:25

been a lot. We don't have a unit, but,

Mike: 39:27

that's

Russ: 39:27

but I mean, a lot of people, there's a lot of literature to support muscle stem, so I'm not knocking that, I'm just telling you what I have found successful. You know, in our, in our, you know, rebuilding of our.

Mike: 39:39

Yeah. And you know, I mean, if somebody doesn't have, if they don't have volitional control at all, you know, I, I, I, I wouldn't mind doing that. Like you said, even just the patellar mobility and, and you know, just getting the knee moving a little bit, like we're talking about the first week after a surgery, something like that. Like to me, I still see the use for that neuromuscular st. But you're right, like you wanna get that volitional control going. You want, enhance that as fast as you can.

Russ: 40:01

no, I think that's fine. I think that's a,

Mike: 40:03

That's what I'm looking for. I'm looking to be fine. That's good. I like that. Russ is

Russ: 40:08

Mike

Mike: 40:09

We're we're gonna hang on, we're gonna end the podcast. And Russ be like, you gotta stop that That's,

Russ: 40:16

so far ahead of your time.

Mike: 40:18

All right, so we, obviously, we talked a lot about the knee, right? I think the knee is like the, the no-brainer. Use this everywhere though, right? Use it cuff sc a, like a calf. Like where, where do you use it? The.

Russ: 40:30

Well, the one thing that we've been doing lately is really working on eccentrics. And you know that, well, I didn't mention that, but that is one thing that has been proven in the literature, that eccentric training is supposedly the best thing to, you know, inhibit muscle atrophy.

Mike: 40:49

Hmm.

Russ: 40:50

and that's not new information. That was in the eighties. And, and if you remember, all the Akinetic devices implemented eccentric modes into their programs, but nobody used it cuz it was just didn't make, it didn't feel right. You

Mike: 41:04

Right.

Russ: 41:05

to resist knee extension as you're getting pushed down. It just didn't work. So what we do is we use, we use, uh, MTRA for. Single leg squat slides where you've got that single leg thing that slides back and forth and you're doing a single-leg squat and really emphasize eccentrics. So we're doing that for quads, but we also, we have a, a great hamstring exercise. I think maybe you've seen it while I have a patient laying, you know, on their back with her head facing the door, and we've got the tlx gray band up in the door coming down. To the foot and we wrap the foot around that and, and then we, the patient in that position, you know, mimics a running position and we teach them to bring their knee to the chest, reach out with their foot, and now they're in that eccentric position to train their hamstring and they have to fire their muscle.

Mike: 41:57

Yeah. That's big.

Russ: 41:58

really interesting. It's really hard to contract your muscle during an eccentric contraction. And that's the fun part about this, is you actually see what you've read. You know, you're always reading the literature. The eccentric, my cell doesn't require as much muscle activity, but it really is hard. But once you train them to fire their muscle eccentrically, it's amazing. I've had so many chronic like. Outfielders and MLB and football players have had chronic hamstring injuries, and doing the eccentric training has been real helpful. We also use in the core, uh, Chris Galena, who I work with now, he, he does a lot of our lumbar stabilization program. He won't do it anymore without using the electrodes.

Mike: 42:37

I love that.

Russ: 42:39

you can find your T ffl, you can find your lower abs. And we had a baseball player this morning and he is like, you know, doing some of the core stabilization and we didn't show him. He said, you got it? And he said, yeah, yeah. And we showed him and the EMG was at the very bottom and he saw that, immediately fired it. And he is like, oh my God, I think you could only do like five reps. So we use it there, we use it in the scapula, uh, in the posterior. we use it in the calf, you know, eccentrically. Uh, so you know, we use it kind of all over the place. It takes a little bit of time, but it doesn't take long. It's just another. It's another tool to use and it, boy, I tell you, the results are, are really fun to see the patient's face light up and they say, oh my God, that's a, like, if you do prom planks, you think you're doing, you know, a really good contraction. But when you put the electrodes on, you can really pull in the muscle and, and it's, it's just a fun tool. Like I said, you kinda live it with your creativity and you can, you know, another thing you can do is a neuromuscular deficit test. you know, for a side to side assessment, uh, built into the program. So it's, you know, there's a lot of different applications.

Mike: 43:49

yeah, you can quantify a little bit and, and record that so that way you can, you can, you can document it for whether it be insurance or just to see their progress. I mean,

Russ: 43:56

Yeah. You can document. We've got a new program that we, we've got the beta, uh, version now where you input the patient's name and it'll store the amount of work they perform in a 10 minute period and all that kind of stuff, you know, so

Mike: 44:08

Nice. All right. Well this is somebody with inhibition right now. How many times has this happened? Right? You haven't been working with the person, they've been at a clinic elsewhere, right? It's four months after e c L. Now you haven't been working with them. They still have quad inhibition, right? What, what do you do at this point? Like does, does your strategy change for somebody that has this chronic, prolonged inhibit?

Russ: 44:33

Uh, basically what we do with most of those patients, and a lot of times they have loss of motion also. So if you've got quad inhibition in four months, you're gonna have a stiff knee, most

Mike: 44:42

Right. Good

Russ: 44:43

So we restart them back to the two week program. We treat'em like a two week post-op patient and we go back and Yeah. And start over with the Quantas and I, I, I've showed at our ICU meeting that girl that had the lighter Retin Acular tear of her, her patella, and she, you know, she was like three, four months post injury and her knee was stiff, but it was muscle co contraction. So I used the, you know, I used the one thing you can do with the M trigger is put. You know, quad activation and hamstring and use your quad to inhibit the hamstring and vice versa. So, you know, I will just, the, the first thing I'll do with that patient is make sure we turn on their quad and uh, and work on their motion. Cuz if you don't have. You know, full range of motion, you're gonna have difficulty contracting your quad because the medial and lateral re gutters of your knee are kind of stuck, and so it's pulling your patella down, your patella's anteriorly tilted. So motion and strength have to be a part of that problem that we address.

Mike: 45:48

right. Makes sense. And then in treated like everybody else, but just hopefully they progress maybe at a different pace. You know,

Russ: 45:53

Yeah. Yeah. The one thing that Chris, my, my PT said today that he's learned from me and that we see all those problem patients that come in is educate them about their injury.

Mike: 46:06

Right.

Russ: 46:07

So when you tell them, look, that discomfort and pain that you're feeling is, is not your graft. This has nothing to do with your surgery. Oh, really? Because they think that when they've been there in end, they feel all that pain and discomfort. Oh man, my graft fixing to pull apart. You know, don't tell'em this is gonna, well we're gonna do on our treatment is gonna hurt your feelings, but it won't hurt your knee. so

Mike: 46:31

That's Stealable. Everybody write that

Russ: 46:33

Yeah, for sure. That's one of my, my old, uh, old sayings. But, uh, part of it is they're afraid and if you educate them, and you and Chris, you know, he, he said that's one thing. A big thing I learned from you is you, so many patients have come in and they haven't been told you had surgery with this graft in your knee, had no meniscus to tear, so all your feelings scar your feelings, scar tissue. And so you could, if you could touch your heel to your butt in the next five seconds, it wouldn't damage anything,

Mike: 47:01

Right, right. Yeah, no, that's, I, I I think that's, I think that's good. That's good feedback. And that's, that's a good thing cuz I do think even two young clinicians might be a little scared too. Right. When that happens, they may

Russ: 47:13

just tell him to just go watch a knee manipulation if, if he

Mike: 47:18

as aggressive

Russ: 47:18

I think you can go and go into the OR and watch a 10, you know, five to 10 minute knee manipulation. Someone's got 60 degrees and it's, it is not gentle, you

Mike: 47:29

Right, right. And that doesn't tear the graft.

Russ: 47:31

No, no surgeon, surgeon's doing it to his own patient.

Mike: 47:34

Right, exactly. That's funny. So, uh, awesome. Well, great stuff, Russ. I really appreciate you taking the time out here. Uh, before I let you go, I'm gonna end with the, with the big high five at the end. Five, uh, five quick questions, five quick answers. Um, just want to hear a little bit about, about you, a little bit more about your brain, what you're up to. But first question for me is, what are you currently working on for your own professional development? What are you.

Russ: 47:59

I'm getting my lectures ready for the A S M I meeting

Mike: 48:03

You didn't send your slides in. Caroline's gonna be mad

Russ: 48:07

uh, one thing I, you know, I've kind of learned a lot from teaching and that's one point I wanted to bring out to the best way for people to learn is to teach.

Mike: 48:16

right.

Russ: 48:17

get a little bit lazy. At my older age. I'm worried about my golf swing or whatever, but when I have to get up and lecture, I can BS 90% of the people, but it's 10% in the back that I need to bone up for, so it it, it, uh, lecture or teaching, it helps me learn. One thing I'm really interested in with my patients is pitching mechanics. So I've, um, you know, we got the baseball ranch here and we've got, uh, Tom House, one of his, his CEOs that lives in Houston. So I'm trying to learn about that and I've, my best friend in town is the number one pitching coach in town. David Evans. I know you know

Mike: 48:52

Yeah. Wow. Yeah.

Russ: 48:54

he's, I'm learning a lot from them about spiraling your elbow and taking stress and trying to teach young kids how to throw with less stress through the elbow and shoulder.

Mike: 49:02

Yeah. Yeah.

Russ: 49:03

that's, that's one thing I'm doing. I'm writing a book, uh, a section with Rob Mansky. I'm working on that and, and then we're also working on deceleration testing with functional testing. So that's just a few things going.

Mike: 49:15

Yeah. You got a lot going on. You're, I, you gotta focus more on your golf game than all

Russ: 49:19

I say those are ideas. I mean, I have a you know, have people that you know, kind of help implement those. I do write, I do write most of all the stuff though.

Mike: 49:29

Uh, what is one thing that you've recently changed your mind about?

Russ: 49:34

Um, I guess, uh, recently I would say, um, Is the eccentrics, you know, to, to bringing things back to really with the, the biofeedback working on eccentrics with even with our posterior cuff, uh, pitchers, instead of just doing concentric, really teaching them to fire eccentrically. Um, the other thing is letting my young PTs that I trust work on my patients. You

Mike: 50:03

You still working on that

Russ: 50:06

Yeah, I mean, we, we, we you know, I used to like be very protective, but now, I mean, I'm right there with them. I think that it's the only way that you get better. When I had students when I was a ci, I'd throw'em to the wolves, go get that patient, evaluate'em, tell me what you found.

Mike: 50:22

right.

Russ: 50:22

know. So, um, I think, uh, I think that's one thing. The one thing that has not changed is restoring motion and.

Mike: 50:31

I know, right?

Russ: 50:32

So many people pass over that and they get in a functional movement and, which is great, but that's icing on the kink. So, so those things that have not changed. Yeah.

Mike: 50:40

Awesome. What is your favorite piece of advice that you give students nowadays?

Russ: 50:46

Um, what I said earlier is if, you know, just say how, how can I get involved in something like what you do? And it's, as I tell'em, you need to po you know, do some research and position. in a location where luck can find you. You know, people say, oh, he just got lucky. Well, yeah, okay. So he got lucky because he was there or she, she was there, you know, and in the right situation. And then once you, you find out, you kind of have a gut reaction like, this is where I need to be. Then you just put your head down and go, you know?

Mike: 51:19

I love it. That's a good one. I like that. I think a lot of people, um, take that for granted sometimes. So, good one. Um, you've already alluded to some of these things, but what else is coming up next for you? What are you working on now?

Russ: 51:30

Yeah. So my big next, uh, last hurrah is gonna be, uh,

Mike: 51:34

This is the Swan song.

Russ: 51:36

Yeah, I think so. I've got some grateful patients that are, uh, willing to help me and I'm gonna establish an institute, uh, a nonprofit institute, uh, not too far from where I work now. And so we're, we're kind of in the planning stages of that so that we can really have. All the toys and bells and whistles to put out some, some fun research and, uh, and have a, a place to, you know, to, to treat people maybe that have difficulty, financial or whatever. Uh, but continue on what I do, but take some of my ideas and thoughts and, and, uh, be able to have, uh, research people. And we've got, Craig Garrison joined us in Lane Beta. We've already got a great research set, but this will just be my own kind of baby. And then the other thing is to. To try to shoot my age in golf,

Mike: 52:24

Ooh, all right. That's getting easier and easier every

Russ: 52:27

3 times, but I'm 67, so I need a little extra work on my short game, I think

Mike: 52:34

Just wait a few years. That'll catch itself up. You'll be good.

Russ: 52:37

I hope so.

Mike: 52:38

That's awesome. Um, I've got a long ways to go for that, maybe for nine, but, um, but we'll get, we'll get there, we'll get there. But, uh, um, awesome. Well, Russ, how can people find out more about you? Do you have a place where, where people can.

Russ: 52:52

Yeah, I don't have a website, but, uh, a lot of, of this information is on m trigger.com, so that's the name of our biofeedback device. And I've got the LinkedIn thing too. Uh, so you can just Google my name and LinkedIn and I'm there. I don't really do that much on it, but other people help me with that.

Mike: 53:10

That's awesome. Awesome. Well, Russ, thanks again for taking out, uh, some time from your busy schedule to join us on this podcast and share your research and your experience. We really appreciate it. Thanks so much for coming on today.

Russ: 53:22

Thanks buddy.