Neurological Consequences on ACL Injuries with Terry Grindstaff - Episode 39

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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Transcript

0:34

On this episode of the sports physical therapy podcast. I am joined by Terry Grindstaff. Terry's a professor in the physical therapy program at Creighton university, where he combines research education and working with the student athletes. He's been focusing much of his research on the neuromuscular consequences of lower extremity injuries, which is what we're going to be discussing in today's episode.

Mike: 1:05

Hey Terry. Thanks so much for joining me on the podcast today. How's it going?

Terry: 1:08

I'm doing really well today. Thanks for having me.

Mike: 1:11

Awesome. Yeah, we, we, you know, for the listeners, Terry and I just had a, a fun little chat, so I think this is gonna be, uh, this is gonna be a good episode. But, um, uh, Terry, uh, you've done so much research, you know, working at Creighton, you've, you, you just had a ton of experience with different things. Um, we could go in a lot of different directions with this podcast, but for me, I know something that you're passionate about. Something that I've seen you speak about is, um, how you've, you've focused a little bit of, of your, your. Your mind power, so to say, on lower extremity injuries, and then some of the neuromuscular consequences that we see from that, which is huge. Right? That's such a huge topic. So I, I kind of wanna start off with that, right? And kind of jump right in and, and talk about it. Like, maybe we start with like a basic one with, with acls, like we've seen over the years, quad strength, neuromuscular changes. Neurocognitive changes now are becoming more and more, you know, prevalent, altered biomechanics. All these things happen after injury. Why don't we start with that and from all the stuff that you've done, all the research you've put into this, what do we know about some of these consequences after these big injuries? Like an a c L?

Terry: 2:14

No, it's a, that's a, that's a good question. I think,

Mike: 2:17

Huge question. Sorry. I was like, welcome to the podcast and boom.

Terry: 2:21

it's good. It's good. Yeah. Start off and, uh, let's get philosophical, right? And so I think, I think, you know, for me and, and sort of the, the, the, the journey through this and, and, and one of the things that's been, uh, Interesting for me and sort of hooked me into this is, is you'll see somebody with, with a knee injury and, and really like, regardless of the knee injury, I think quite often we talk about a c l reconstruction. But yeah, I mean it could be patella ifor pain or anterior knee pain. You know, somebody with, uh, you know, post-op mastectomy. It's sort of whatever it is. Quadriceps doesn't work as well. And, and so it's like this, you know, this, this common clinical impairment and, and somebody can do a quad set the day before surgery or the day before an injury and like the next day they can't. And, and you know, a lot of the time when I'm lecturing or talking with students or whatever, I kind of bring up this clinical scenario and scenario. You could do a quad set the day before and you can't the day after. And it's like, well, what's, what's causing that? Or what do you do to address that thing? And a lot of the time it's like, well, you know, they, they need strength. We need to work on strengthening. And I'm like, wait a second. If you sat in bed all day for one day, your quad wouldn't get that week. Like that wouldn't happen. And so we, yeah, we know that it's driven neurologically. And, but a lot of the time clinically, our approach is you need strengthening. And it's like, well, maybe we need to reframe this, uh, a, a, a little bit. And, and so I think that's been helpful, you know, for how I approach things in the clinic, how I approach things in the research laboratory is really thinking of the, you know, the. Knee injuries as, as really, you know, there, there are neuromuscular consequences. There is still a joint related injury, but like why in the world does a muscle stop working like the quadriceps when in theory it wasn't injured and, and minus if you had like, uh, bone Patel, uh, bone tendon graft, if you had quad tendon graft, something like that, then yes, there is a muscle or tendon injury, but you had a hamstring graft or an allograft or something like. There's no muscle injury to the quad. Like in theory it should work, but yet it doesn't. So it's driven neurologically. And I think that's been kind of the fascinating part on some of the things that we've looked at from a research perspective of, well, what's causing this? You know, we know that part of it's driven by spinal reflexive processes, uh, and some of it's driven from a, you know, kind of a cortico motor standpoint. And, and then, uh, and then there's also then this atrophy component or kind of this peripheral component as well. We have central components and peripheral components. And then the next step is like, well, if we understand some of these mechanisms of what's going on, then what can we do about it? Because ultimately, you know, I. Thinking about, well, we need to help people in the clinic, we need to help patients. And, and so we can understand mechanisms all day, but we need to be able to translate that to something that people can use in clinical practice. And I think that's kind of been one of the joys that I've had from, from both a research perspective and a clinical perspective is, is trying anyway to, to, to blend some of those, or bridge some of those, um, you know, concepts with, yeah, we know these things happen from a neurological perspective, but what can we do about it? And then not only what can we do about it, but we better be able to do it in a timely manner in the clinic and, and all these other considerations that I don'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 of tugging at my brain at the, at the same time to, to hopefully ask clinically meaningful, uh, research questions. So that's, That's kind of, you know, what we do in a, in a nutshell. Uh, and we're, you know, I like to think we're using the knee as a model. In theory, this, this, this sort of stuff. It happens at the, at the lumbar spine, it happens at the shoulder, it happens at other joints. Uh, the knee just happens to be, uh, you know, something that we can study and, uh, and look at quads, big muscle. So it makes

Mike: 6:26

Right ex. Right, exactly. And, and, and it's a very important muscle for lots of different functions. So it, it's probably more in, in our face, right. When you have a deficit, uh, we probably notice it more cuz the consequences of it, I mean changes, gait changes even, you know, they're subjective things in a non-weightbearing joint or something else may, you know, maybe you just get by, it's a little different so we don't notice it as much. But, um, yeah, you know, for me, I've always found clinically that when you get behind. With some of these things, if you let these neuromuscular consequences kind of take hold and progress over time, um, they get harder and harder to overcome. Right. So those, this is the type of people, like I have people in my inner circle that like, you know, I just answered a question this morning. Somebody was, I think it was about eight months after a c l reconstruction and. Still, you know, they still don't have knee extension, so, you know, that's not great. But, um, which might be part of the problem, but again, they can't get the quad to turn on. Right. So like going back to your thoughts on central, uh, you know, concepts that go into that, like what is it specifically you think that, cause some people to have this consequence more than others and some to have it delayed for so long, like what is it that does that?

Terry: 7:36

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 like to think I'm at least reasonable at, uh, at some of the, uh, some of 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 this one thing and that's it. So there's a lot of different factors, 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 more likely to have, say, persistent swelling? Is there something going on, you know, sort of from a. You know, like a, a metabolic perspective or, uh, you know, systemic perspective that, that, that, uh, they are more prone to, uh, you know, to, to inflammation. Or do they just heal, uh, a, a a little bit more slowly, or do they lay down more scar tissue? You know, so I think that those can be components. Some people just have, uh, you know, different, uh, capacity to process pain or to, to mitigate pain. Uh, you know, and, and then you, you can add in kind of these psychological factors as well that, that play into it. And then really some of these things also to a degree, become like this chicken or egg thing. But like you were saying, I completely agree that it's probably. Better to take care of these things early on and, and to jump on it early on versus later. Um, I think an unfortunate aspect right now is that we don't have great ways to measure, like quadriceps inhibition in the clinic.

Mike: 9:19

Mm-hmm.

Terry: 9:20

We have great ways in the research lab and we have great ways to look at like spinal reflexive excitability and cortical motor, uh, excitability, but we don't have great ways to do this in the clinic. And then I think then the consequence of that is if, if, if we don't have a good way to measure something, then we may not, one, pay attention to it as much. Or, or, or, or dedicate, you know, intervention resources to address it because then we can't measure it. We don't know if we did a good job or not, with the exception of hindsight. Hindsight seems to, oh, you know, this person at four months out, six months out, eight months out, like we were saying, they seem to be struggling. And it's like, yeah, like it would've been really helpful have, have had some of these measures early on. Um, you know, to either say, you know, we need to stick with these particular interventions that are addressing some of these neuromuscular consequences. We need to stick with those longer, or we need to employ those earlier or just employ them at all. Um, and so I think that those are, um, those are things for consideration if you sort of like, let's speculate, right? And, and, and, uh, and, and so I think 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. There's something to be said for the delayed capacity to achieve full extension. And the other that we've looked at or, or, or that I've at least noticed, and I'm sure that you've seen this, I'm sure a lot of the listeners have seen this. You know, it's this person post-op day one or week one or whatever it is, and for the life of them, like you look at their face and they, they are trying so hard. To get like a quad set with, with a substantial amount of intensity. They're looking at their quad. They, they are using every resource that they have absolutely available and they can't do it. And, and. I think there's something there. I'm not quite sure the best way to quantify that right now. And you know that I like to be able to quantify things,

Mike: 11:34

Yeah.

Terry: 11:34

that's at least something that I picked up on and, and just kinda looking at the patient and like, this person's probably going to struggle for whatever reason. Like, and, and they can't do this quad set, which you're like, in theory that should be really simple, but they're throwing so many resources at it to get it to happen. Um, And, and so I'm like, I think we, maybe the best way to deal with this is to best appreciate this as a reflexive reaction and, and let's employ some of these, you know, kind of neurological approaches to our orthopedic or sports medicine kind of framework.

Mike: 12:10

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 struggle week one, right? You can almost tell they're, they're, they're gonna be set up to have difficulties for a while. And then I always wonder, is it, does that mean we have to be real diligent week one, week two, like early on? Or is this person gonna struggle no matter what we do? Right. That sort of thing. So, you know, and, and, and I hate to say that, but like we, we see that sometimes. So, uh, I think we're, we're both in agreement with the statement, so I'm just gonna proceed to a question here. But like, if the first week or two are this important to make sure we're setting the stage for future success, what are some of the things that you like to do at this phase in the rehab process to try to get this neuromuscular control back? I mean, I know there's a bunch of tools, there's a bunch of things out there, but what, what is it that you prefer?

Terry: 12:58

I think, you know, and, and these are conversations we try to have early on and to, and to get these, you know, sort of ideas into place. And, and really the, the, the three things, you know, I try to take a, a, a simplistic approach talking with patients or people that come into the research lab and I'm like, look, we need to do three things. We need to take care of your swelling. We need to get your extension back, and we need you to have good quad function. And that's really going to then set things up and it's like, well, when can I get off of crutches? And I'm like, when you have.

Mike: 13:28

One.

Terry: 13:29

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 to jump to. I wanna get rid of this assisted device, and I completely understand it. Um, you know, particularly for younger individuals that are pretty active, it's like, I wanna get rid of these crutches. I'm fine. I'll limp around and I'll figure it out. And I'm like, well, if that in of itself is contributing to persistent swelling, that is then driving a lack of full extension and a lack of quad uh, uh, function, that's problematic. So that's kind of one of the first things I'm like, let's protect. The joint and, and allow it to heal some of the, some of like the old accelerated rehab stuff where it's like people are just like in a CPM for a couple of weeks and not doing anything. I'm not saying that we need to go to that specifically, but I'm like, there's probably something to be said for respecting that tissue healing. So then, yeah.

Mike: 14:24

I, I was gonna say, especially too where sometimes w we don't even understand his physical therapist sometimes, uh, the level of, like, for example, like meniscus pathology or bone bruising going on, that could be causing even more consequences within the knee. Right. So, so, so keep that in mind with that. It's, it's, you don't just, not every ACL's the same and you get off the crutches at 10 days or whatever day. Your surgeon wants to get, I mean, if you have a huge bone bruise that may persist and, and sometimes you're, you're, you're not setting them up to succeed by just discharging them because the protocol says day 10. Right. So I I, I, that's the first thing that jumped my mind when you said that is, you know, sometimes I think people rush or sometimes people follow a protocol too much. It's, it's just, it's just a guideline. Not everybody's the same. So, um, but I, I love that that's a. Great. First way to start is, is it's almost like that's the foundational building block. If you don't do those three things, you're gonna struggle. So you have to focus on that. And, and even patient education is, once they hear that from you, Terry, they hear those three 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. I, and so I think that's huge. So love that first step. What's next?

Terry: 15:31

Yeah. So, and then, and then, so, you know, that's, that's to at least build that foundation, right? And then, and then, uh, next really thinking about, well, what are ways that we can reduce swelling? And, and so, you know, I love the ideas of, of just some sort of compressive device that, you know, like, you know, compression stocking that they're just gonna wear around and. Thinking like this, swelling's with them all day, this quadriceps inhibition is with them all day. So I need to do things that have more prolonged effects because they may come into the clinic for 30 minutes, 45 minutes, one hour, whatever it is, and that's it. It may be every day, it may be a couple times a day. It may be every two, three days, you know, depending on your situation. So we need to think about lasting interventions. 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't get paid by anybody unfortunately. Um, you know, as far as products and things like that. So I really have no disclosures. I always throw it out there. If somebody wants to talk about a relationship with that, we always could. But, uh, you know, I do like the idea of of, you know, uh, you know, cold and compression, something like that, that they can, that they can put on, you know, throughout the day. Uh, and, and, you know, having the good fortune of working with student athletes at like Creighton University, that, that we can do that and really try to stress, you know, protecting that joint early on from, from doing too much. And, and, and cold and compression like multiple times a day. And, and those are kind of like, uh, you know, they have multiple benefits, like it's helping to reduce the swelling. If we're reducing the swelling and, and you, and you get some cold on there, then you're also mitigating some of the pain. Uh, and you're helping to facilitate quadriceps function by addressing both of those. So I like cold and compression. Um, and, and then, and then also early on, I think that one that's probably underutilized, and I think part of it is just, um, patient compliance. Maybe we don't fully understand and appreciate, uh, the, the, the capacity is is something like sensory tens.

Mike: 17:39

Mm-hmm.

Terry: 17:39

and, and, and I'm talking about sensory tends, we're not trying to create a motor contraction, but what I want you to think of, or, or have people think of is, is like gait control theory that they may not have a lot of knee pain, but a lot of the things that drive ceps inhibition particularly early on, are consistent with, let's say pain pathways or swelling. And we just need to override those. And so again, think gate control theory, but that's where like sensory tends around the knee joint. I think is helpful. We know that people that wear sensory tends longer, like throughout the day, like more than eight hours is better than just the one hour in the clinic. And again, they have quadriceps inhibition all day. So sensory tends might be something easy that we can put, uh, just around their knee joint, strong but comfortable sensory stimulus. Then they can pull up their compression stocking and they can wear that around, um,

Mike: 18:34

Yeah.

Terry: 18:34

as ways to kind of mitigate. Um, you know, some of that quadriceps dysfunction or just overall muscle dysfunction early on. So those are kind of my go-tos. And then you layer in all of the other therapeutic exercise that we're typically doing, uh, early on.

Mike: 18:51

I, I like though the, I like the concept of tens, right? Because, you know, again, like a lot of modalities are becoming less and less popular. But, and, and that doesn't mean everybody gets 10, but if, if somebody is struggling, if somebody is having a hard time with that volitional control of the quad, Right. Or just being able to, to neuromodulate the pain. That's a, that's a great thing that I would say even I underutilize, right? But like, try to identify that person week one that's like, oh, you know what, let's get'em a tens to go home with. Especially nowadays, you can get a tens on Amazon delivered tomorrow for 30 bucks, right? So like, there, there's really no 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 a little off topic,

Terry: 19:33

Hey, here we go.

Mike: 19:33

this, this is the, this is the generation now where, um, you know, again, a lot of young clinicians are kind of, you know, they're wondering about ice. They're wondering if, uh, the inflammatory process is helpful, and if we inhibit that, that could be a bad thing. I, I, I'll preface this question with saying that it sounds like you and I are on the same page, but like, like, like what do you say to your students that are, you know, they're on Instagram and you know, There's people you know that may or may have financial, you know, implications in devices. I'll leave it at that. But like, what do you say to people that are like, really trying to buck this ice trend? Like, you know, like, like, you know what, why do you use ice after a c l reconstruction in the first week?

Terry: 20:42

No, it's a, that's a good question. And literally, yeah. One that I was having yesterday with a, uh, with a student and ironically, and, uh, and, and so, you know, is, is there potential, you know, regarding ice, you know, to, to be inflammatory. Uh, Yeah, maybe it's, I don't, I don't think it's specifically like mitigating a lot of inflammation. Um, you know, and, and that being said, like, um, ICE is a great analgesic

Mike: 21:13

Huge.

Terry: 21:14

And, and it works really, really, uh, well, or an anesthetic response rather. And so, um, and so it works really well in that regard. And so, you know, I think, I think a lot of the application of that and, and particularly helping to address things like pain. Um, uh, helping to slow nerve conduction velocity or helping to mitigate some of that, um, uh, negative neuromuscular response, let's say. I think that far outweighs any of 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, but I like tens is kind of the same way. It's like, did we not? Did we not fully understand and appreciate like the parameters or the outcomes that we were shooting for here? Um, and, and that's, that's why we're, we're saying that this is a bad thing. Like if you don't use the TENS parameters, correct. Well, no wonder you got a bad outcome. Like if you didn't take a particular medication with the appropriate dosing, why should it come as a surprise that it didn't work, right? Um, or you had an adverse outcome. Same or if you're measuring something that's completely different and uh, you know, if you take Tylenol to try to get taller, uh, or stronger, like that's not gonna work. You, you like measure the correct outcome. And so that's, that's where I think thinking along the lines of, of cryotherapy, it's like, well what are we using it for here? Are we, you know, are we using it to help mitigate pain works really well? Are we using it to help facilitate a neuromuscular response? Works really well. Um, again, and that's, that's, that's short term. You know, it's probably going to work while they're in the clinic doing that, or you may have kind of a window of opportunity to do some of these exercises. But I think for, for, for what that is, that can be helpful. Now, if you study something long enough, a lot of the treatment effects wash out or we have a regression to the means. So you're like, well, how were they doing five years from now? It was all the same. So ICE doesn't work and it's like, Maybe, but like if it has short term effects, we're not going to see that at two years out, five years out.

Mike: 23:21

Right. And I can't imagine, I can't imagine like 10, 15 minutes of ice for all those positive benefits are gonna have such a negative consequence on the inflammatory process that's happening the rest of the 24 hours of the day. It's just, it's, you know, we're, I think we're, we're getting a little carried away with 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 put words in your mouth, but like together we have. Probably 50 years of clinical experience and, you know, my, my patients that, that ice and compress after a cell surgery, uh, you know, with, with the most, the most frequency in compliance, uh, tend to do better 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 can publish that in, but, uh, you know, like it's, you know, you see it every day, so, um, so Awesome. All right, so started to put you on the spot with a controversial topic we'll say. I like that. But,

Terry: 24:10

it's good.

Mike: 24:11

alright, so tell me next now about, because again, I love the framework you're outlining and how it's almost like you're providing the building blocks. It's like, sure, you can do a fancy thing at week four, but if you didn't do these things week one, you're gonna be behind. But, um, what are your thoughts on neuromuscular stem and biofeedback? Do you use those?

Terry: 24:29

Yes. Uh, both and, and both have both have great evidence, right? And, um, Although I think they work for different reasons than we, than we think. So, you know, the, the, the first, the first things that I was talking about with like, you know, sensory tens and cryotherapy, those are on the afferent side that is helping to override some of those afferent signals 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 like biofeedback. Um, or, um, N M E S or, or Russian or whatever you want to call it, um, that, that, those are on the efferent side of things. And so I don't think that they necessarily specifically address the. Underlying cause of, of dysfunction. Now, now they can, they can have an effect because they can help, you know, help promote better neuromuscular control of the quad or increase quad strength and thereby decreasing things like knee joint stress. And so they do work, but I think they work on the efferent side of things. And so usually earlier on I'll try to address, um, the fert side of things and then start to add in some of the fert side of things. But I will say if you took care of the underlying issue, that in theory, we wouldn't need to then jump to these other things. Now, I also realize it's a prolonged healing process, and we have to appreciate that. Now, that being said, um, you know, 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 a goal as far as helping to improve function and, and then eventually serve as a precursor to improving strength biofeedback, um, works really well for, for somebody trying to, you know, get a quadriceps contraction, gives'em good idea of, you know, uh, knowledge of performance, but, I'm just, I'm, I'm kind of stuck right now on, was that the thing that we wanted to do? Because like we were just talking about at the beginning, like the person that needs to stare at their quadriceps to get it to contract, that's probably not a good thing. And we know now that, you know, particularly more so prolong that some of these cortico motor changes probably like, Express themselves maybe more six months-ish out. And it takes somebody more cognitive resources to be able to do simple things like a quad set. And, and we also know that they're extre more often than not extremely reliant on vision. So now we're going to say, here, stare at this computer screen or, or iPad or, or whatever else. And I want you to do a quadriceps contraction, and we're going to give you this feedback system. Of, of did you do this thing and, and, but you're using a lot of resources to then do that thing. And so I'll still use it, but like in the back of my head, I'm kind of like, are we creating an adaptive strategy that maybe we should have tried to approach this a little bit differently in, in addressing the reflexive component. So yes, I think it works. I think it might work cuz they develop a compensation. Um, but I think there's way more to come on that. So yeah, there, there're things that I use, um, but, uh, I, I, I, I, I would love to, to see where things are in 10 years as we develop a better understanding, you know, what is a, a, a better approach here?

Mike: 28:14

so, so, Terry, do you, do you think neuromuscular stem biofeedback, do you think we can almost. Equate that to something very similar to like an assisted device like crutches, where maybe there's some use for it early on when we're, we're struggling, but we don't wanna become overly reliant on them and we should progress away from them over time. Or do you just think there's concerns in general?

Terry: 28:36

Uh, yeah, both. Um, yeah, I, you know, I'm not, I'm not ready to throw'em out and, and, uh, You know, because again, I think, and, and, and adaptive strategies may not necessarily be a bad thing. I mean, this, this person has had a, a knee injury, you know, ACL reconstruction, meniscus surgery, whatever, you know, pat Polyphoral pain, you know, neo osteoarthritis, whatever it is, they still have an injury. And so maybe a compensatory strategy is, is, is helpful in, in, uh, in this case. So that's where I'm, I'm, I'm hesitant to say no on these things, especially knowing like, The, the consequence of potentially not addressing these things could be, could be in theory, far, far worse, and then also appreciating that, well, it 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, you know, it's like this kitchen sink approach a little bit, you know, but it's, hey, it's sports medicine. And so, um, that, that can, that, that can be helpful because I think if we don't. Get somebody you know and take care of swelling, take care of, uh, you know, knee motion, you know, extension, inflection, developing good, you know, neuromuscular control that is going to make it really hard for this person to then say, well, now we're going to progress to hopping and jogging and running and cutting and, and back to sport. It's like,

Mike: 30:09

right.

Terry: 30:09

All right, let's, let's take care of these basics early on. So I think, I think they do have a 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 is starting to get better knee flexion and can tolerate, you know, uh, N M E S, you know, we'll, we'll start it at full extension and then, you know, we'll get to 60 or 70 degrees, work our way to 90. Um, but that it takes a while. It takes a week or two to, you know, Work three, four to actually, that they can be comfortable with their leg hanging off the end of the table with a full muscle contraction. And so that's kind of how I'll build those things in. Um, but you know, that's a lot of what our focus is, is, is let's really address these, these, uh, these neuromuscular consequences early on.

Mike: 30:58

That, that, that's awesome. All right, so let, let's shift gears a little bit. So we talked a lot about early on, which I think is huge. Um, let's talk about maybe some longer term, uh, consequences here. And I know yourself because I've heard you speak on this a little bit, but you have some up and coming research that is hopefully gonna be published fairly soon. But, um, looking at things like. Bone mineral density changes after E C L and how that may correlate to their outcomes, their quad strength, those sorts of things. Um, do you have any information you could share, uh, with us on some of these future findings that you're still in development with?

Terry: 31:35

Yeah, good question. And so I think one of the, you know, one of the things, and, and you know, from a research perspective and a clinical perspective is really thinking of, well, what do these people look like? You know, one year out, two years 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 mitigate that, we need to be able to identify changes early on. And, and so quite often I think we think of like, you know, osteoarthritis as, uh, you know, really looking at, at, at changes in like articular cartilage. And, and, but by the time a lot of those things develop, it's, it's, it's probably. Becoming too late to actually intervene. And so that's, that's what led us to look at some of the changes in bone density. And, uh, because, and, and we've seen this in like animal studies, that the changes in bone density actually precede changes in particular cartilage. So from my end, thinking, well, if we want to intervene at the earliest possible opportunity, and then to be able to show a change, something like, Looking at bone density seems to make sense. And so one of the studies that we did, and it was a cross-sectional study, we brought, uh, you know, 20 individuals in that had an a C L reconstruction within the past two years. And, and compared them to, uh, you know, a, a a a healthy, uh, or non-injured, physically active, 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, you know, kind of their peer comparison was also another, um, you know, uh, sex matched high school athlete, you know, from a similar sport. And, and so on average, everybody was about a year out of, um, uh, following a c l reconstruction. And we looked at, uh, we used P Q C T, um, which is, uh, it's different than dxa. I think a often we think of Dxa as being able to look at bone density pq. C t offers the opportunity to, to look at. Look at a limb also in 3d, and we can then separate out things like cortical bone density or kind of that outer shell versus trabecular, kind of that inner part. And the trabecular is more metabolically active. And, and in our study, that's where we saw a lot of the big changes. So we looked at both the femur as well as the tibia and, uh, at least our preliminary stuff. Big changes at the tibia. Probably, you know, on, on average, healthy people had about a 5% difference, or a little, you know, about a four, four and a half percent difference side to side. On average people, uh, a c l reconstruction had like a, like 12% difference. So there was about a seven ish percent difference, uh, between the groups. And in theory, these people are a year out. A lot of'em were back to,

Mike: 34:38

Right. Yeah.

Terry: 34:38

back to physical activity. They're, you know, they've been released, they've, they've, you know, met some of these, you know, benchmarks or whatever else. They're out functioning and doing pretty high level activities. And, and so we weren't, you know, we're not definite. We're definitely not the first group to show this decreased bone density occur, but a lot of the other studies just sort of 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 be able to measure these things. So we need to correlate it to something. And, and so you know, we have the opportunity or capacity to look at things like, you know, quadriceps and hamstring strength, looking at jumping biomechanics, running biomechanics, these sort of things because I think it makes sense that, you know, well people that are loading their limb more probably have better bone density or people that are unloading their lamb probably have lower. And so I think that's, Like a precursor or, or a sort of a signal to what we would see in the clinic. But we also realize not everybody has force plates to be able to measure these things. The other aspect is, is sort of looking at, well, what's, what's this interaction between the bone and the muscle? And that's like this als, you know, this little forgotten aspect that that also matters. And so, um, you know, those were kind of our main, uh, outcome measures. We also had, you know, blood draws and things like that looking at like vitamin D and calcium and some inflammatory biomarkers. Um, And we plugged a few of these things in, um, you know, to this, uh, this, this regression equation and, and really tried to figure out, well, what's, what's the, what's the best predictor here?

Mike: 36:25

Mm-hmm.

Terry: 36:26

and people that had more symmetrical quadricep strength tended to have more symmetrical. Um, side to side bone density in, you know, or trabecular, uh, bone density in, in their tibia and more so, and, and it's not that joint loading, like with running biomechanics or jumping biomechanics. It's not that that didn't factor in, but the quad symmetry seemed to, it explained 50% of the variants in, um, in, in, in, uh, symmetrical bone density. And so that interaction between the. The muscle and the bone seems to be really important. And, and, and so that's, that's kind of preliminary findings. And then I think then the follow up will be one, um, you know, how long do these things persist? What's kind of the normal time course for what this looks like? And then two, what can we do about it? Like if we know that these individuals, you know, are more at risk for lower bone density after surgery, um, you know, or because there may be unloading that limb that's serving as a precursor for the development of NEO a later on, what can we do? And at least right now, if I had to speculate, I'm like, probably need to get stronger and have more symmetrical strength. And so then you're like, wow. It can't be that simplistic, but I, that really starts to set that up. And then, then we also then need to look at things like symmetrical loading. And they, so they need to have the capacity to symmetrically load. And I think that'll be kind of the continuum of, of where we see this, this, this play out. That's just my

Mike: 38:15

And

Terry: 38:16

but it's pretty cool to think about.

Mike: 38:18

I, it's, I, I think that's huge. And I think really this podcast really, I think it just really came together, right, because we talked about the early consequences, and I think this is the late consequences, right? So again, it goes back to have to be on top of this early, but I, you know, I like what you said there about symmetry stuff, and I, I think like force plates, for example, you brought up forest plates at one point. Like I think they're becoming more common in the rehab setting and. There's some technology now, there's companies out there like Vault that you know, has nice force plates that you can use clinically. Very easy. I I, it just shows you that, like, just because somebody's. Squatting, for example, doesn't mean they're squatting well. Right. And it's a, it's a quality and a and and a quantity thing. It's, it's, you have to put them together sometimes. So, um, I, I dramatic, uh, results I think in my mind from the study and, you know, I'm sure 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 the literature that way. Right. But like, you know, I, I, again, I think it just, it shows you that like we, we have to do that. So, um, so. Terry, this was awesome. Uh, I really appreciate you sharing some of your new research and some of your thoughts on this. Um, I know that was super helpful to me. I learned a bunch. Uh, your students at Creighton are lucky to have you here, man. But, um, bef before I let you go quick, 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, what are you currently reading or, or doing for your own Con-Ed and your own professional development? What are you doing for yourself?

Terry: 39:44

Oh, good question. Uh, right now, one of the things that I'm reading is, uh, It's a, uh, it's a book called Attributes, and it's, and it's really looking at, you know, just sort of the underlying, uh, you know, psychological things that, 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. So, super great, uh, super great book that I'm into right now.

Mike: 40:09

I love it. That's awesome. There's been so many good book suggestions too, people, so please, if you're listening, like write these down. I, I go to Amazon and I'll just put'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've recently changed your mind about

Terry: 40:27

uh, changed my mind about.

Mike: 40:29

professionally?

Terry: 40:30

what. Yeah, I'll tell you what Professionally, 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 or what, and I think, you know, kind of initially, you know, sort of giggled or snickered at the idea or, or, or whatever else, but realizing like, To be able to disseminate information, has to go much more beyond, you know, writing a paper or doing a talk at a national meeting or whatever it is. And, and so I think, you know, being, you know, open and willing to, uh, you know, that that learning can occur a lot across a lot of different formats. And, and, uh, you know, as a, as a, as an educator and a researcher that, that I need to be more aware of, you know, what, what methods are out there beyond standing up in front of a classroom or, or, or in a, you know, a, a con ed session or at a national meeting. And I think this is, you know, things like a podcast. Great idea.

Mike: 41:23

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 of students there at Creighton. What's the best piece of advice that you like to give them?

Terry: 41:35

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 that I'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 that spot? So that's really one of the joys that I have in, in being able to have conversations with people early on in their career and, and realizing, you know, that five year plan can change, but it's about the process of getting there and the process for each individual may vary. There's no cookie cutter approach, but it's something that I think you should think about early on.

Mike: 42:16

That's huge. I, I, I, I love that one. That's one of my favorite ones so far. I, I think that's great. A lot of people are, they're just thinking about their end game or they're thinking about their next step. They don't realize that the process is so important and, you know, and, and sometimes, like you said, you don't evolve the way you think you are, but evolution is evolution, right? And, and it's just part of the, so, um, and I love that. So great answer. Uh, what's coming up next for you? Anything new in the works or anything we're building other than the podcast? You're about to start anything new.

Terry: 42:43

No, uh, no podcast. We're, uh, we're, I'll tell you what, we're, we're moving into a new health science building,

Mike: 42:49

Oh,

Terry: 42:50

and, uh, at, at Creighton And I, you know, I've spent a considerable amount of time, you know, 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 the lab. So I've learned a lot about construction and, uh, you know, working with contractors and, and, uh, and sort of serving as this, uh, person in the middle if, if you will. So that's kind of what's coming up next is, you know, just building out this wonderful space, uh, where I hope we're able to, you know, really come up with great ideas and help impact patient

Mike: 43:23

Yeah. Pump out some good research. That'd be great. Awesome. Well, uh, where can people learn more about you, Terry? Any place you wanna send them or obviously, you know, PubMed and look up all, all Terry's great works, but anything else you'd recommend?

Terry: 43:35

I think, you know, I, I'm on, uh, I, I am on PubMed and that's at least a kind of a historical 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 Twitter is probably where I would have more of the professional side of things. Facebook, kind of the more personal side of things, but, but sometimes they'll, uh, they'll, they'll, they'll blend, um, a little bit. But uh, that's just kind of another way as far as reaching out to me and, uh,

Mike: 44:03

Awesome. Yeah. Well, I'll, I'll put, I'll put some of those links in the, uh, in the show notes so people can find you. So, um, that'd be great. But yeah. But, uh, stay on top of Terry's research. It sounds like they're gonna have some great stuff coming out soon. Um, it's gonna be amazing. So, uh, Terry, great episode. Thank you so much for sharing all your knowledge with us. That was amazing. Uh, we'll have to have you on in the future to do even more, but thank you so much.

Terry: 44:25

Hey, thank you. And, and yeah, thanks for doing the podcast. Thanks for, uh, thanks for being a, a, a leader in the, in the sports academy and, and just the profession overall. So, yeah, it was an honor being here today.