Alan Needle | Rewiring Recovery: Transforming Joint Injury Treatment

On this episode of Appalachian Excellence: Research, Scholarship, and Creative Activity, Karen Fletcher, Office of Research and Innovation, interviews Dr. Alan Needle, a professor in App State's Department of Public Health and Exercise Science and Department of Rehabilitation Sciences. Dr. Needle discusses his research that explores how brain stimulation techniques can be added into injury rehabilitation to improve patient function.

 

 

 

Show Notes

Connect with Dr. Alan Needle

 injurylab@appstate.edu

Links

injurylab.appstate.edu

 

 

Transcript

Fletcher:
Welcome to Appalachian Excellence, a show where we feature Appalachian State University research, scholarship, and creative activity that creates solutions and inspires change. We're here to bring you stories of incredible work happening right here in the Blue Ridge Mountains of North Carolina. I'm your host, Karen Fletcher, where my day job has me working in the Office of Research and Innovation here at App State, and I've got my producer, Dave Blanks in the studio with me.

Blanks:
Hello Karen. My day job has me in here, so here I am.

Fletcher:
And great to have you here. Thanks.

Blanks:
Yeah, I'm glad you're here.

Fletcher:
I'm excited to introduce our guest today, Dr. Alan Needle, the Appalachian State University 2024 Chancellor's Awardee for Excellence in Research, Scholarship, and Creative Activity. He is a professor in the Department of Public Health and Exercise Science and the Department of Rehabilitation Sciences. He's been at App State since 2013. Dr. Needle has a Bachelor's of Science in Athletic Training from Boston University, a Master's in Science in Exercise Science with a sports medicine concentration and a PhD in biomechanics and movement science, both from the University of Delaware, a certified and licensed athletic trainer, a certified strength and conditioning specialist, and a fellow of the National Athletic Trainers Association. Dr. Needle explores how joint injury, especially ankle sprains, affect the central nervous system and how that changes how we assess and treat these injuries. I've had numerous ankle sprains as I've gone through my running career, so I'm fascinated about so many parts of his work and so let's dive into meeting him. Hey Alan.

Needle:
Hey, thanks for having me.

Fletcher:
Yeah, it's great to have you here. I think anyone listening has probably had some kind of ankle sprain or joint injury, and so that's probably why they're tuning in, but how did you get interested in this research area?

Needle:
Funny thing, I mean, you'd say most people, and I mean that's technically right. I'm always fascinated there's 40% of people that have never sprained an ankle and I'm just like, "What are you guys doing that you've managed to never sprain your ankle?" So how I got into what I'm doing is, it's interesting, when I finished my undergraduate degree at BU, I wasn't really interested in research. To work as an athletic trainer, currently the entry level is a master's, but back then you could get your certification with a bachelor's degree and then you would typically get your master's while getting experiences in AT so you can get a competitive job.
And I ended up getting connected University of Delaware great program. And I knew I had to do a master's thesis that was going to involve research. And so one of the professors there did some work with ankle sprains and I was like, well, that's kind of cool. Yeah, I've sprained my ankle a bunch, I'd like to know more about it. And then I kind of followed that and I ended up working with a different faculty who ended up being my advisor who was more about the neurological side of things. And so I kind of married these two separate faculties lines of research to look at these neural changes and ankle instability and ended up where I kind of am now.

Fletcher:
Wow. And so you brought some research to App State or you started a new program with our program here? I know that athletic training program was the first one in the University of North Carolina system to be approved and it's here at App State and you're heavily involved in that.

Needle:
So I was hired into the athletic training program as faculty in that program here at App State. So I was the first faculty hired in that program since the program got moved into the Beaver College of Health Sciences or what's now the Beaver College of Health Sciences. Back then it was originally fine and applied arts, it moved over. The college was created, and you can fact check me on this, around 2010 there became a bigger emphasis on research. I was one of the hires kind of tasked with yes, we're faculty in this program and we're also establishing a research line in this area. And over the years that department has evolved. I was hired into health leisure and exercise science, which then became health and exercise science, which AT then moved to rehabilitation science. And so my position got split because I also work pretty heavily with the Master of Science and Exercise Science program as well.

Fletcher:
Great. Keeps you very busy.

Needle:
It does.

Fletcher:
So tell us a little bit about the research that you're doing.

Needle:
I'd say the thousand-foot view of my research is we look at how ankle sprains or other joint injuries, so there's some connections with ACL injury. We've tried to do some stuff with muscle injury, but how that changes the nervous system, that's kind of been the original question that we look at because the problem with all of these injuries is that they happen again, and again, and again, and again. The biggest risk factor for almost any injury is a previous one of those injuries. So trying to understand why an injury predisposes you to subsequent ones was the question here. So we started to look at all these changes in the nervous system and that started with my dissertation work at the University of Delaware, and then it carried here.
And so we continued to look at a bunch of these questions and then we've started to pivot more, especially in the past, oh seven years or so, to not only asking, all right, what's changing? We have some good research on that, but especially what can I do about it and what can a clinician do about it? I spend a lot of time giving talks at athletic training conferences to clinicians. I tell them, "Well, all these brain excitability changes happen," and they're just kind of glaze over, "All right, that doesn't mean anything. I'm never going to use that." We try to figure out, all right, what are the parallels that a clinician can use to actually understand that? What are some treatments they could do to potentially try to fix it?

Fletcher:
Do you work with those clinicians in your lab as well here at App State, or are you trying to find this out before you talk to them about it?

Needle:
It's a combination of both. I mean, I have a pretty close relationship with some of the athletic training staff here, which of course has changed over the years, but we've done some collaborative research there. I've talked to fair bit with the physical therapist over at BreakThrough, which is located here on App State's campus. I've talked to some folks over in other PT clinics in the area. So we have had those conversations, but we haven't quite gotten to doing the research in those settings. I think that's a long-term goal of mine of trying to figure out what we can do actually in the clinic. But right now it's more a matter of what is available and what information can I disseminate that they could readily use, instead of just this eight steps removed of like, okay, here's a central nervous system change, and they have to figure out what it means. It's more a matter of, okay, what is immediately actionable from their perspective?

Fletcher:
Yeah. So walk me through, if I have an ankle sprain, what can you do with that? What could it tell you?

Needle:
Well, I mean, we can start by just saying ankle sprains are highly, highly, highly variable as far as some people sprain their ankle it's super loose, have a great amount of what we call laxity. Other people, they actually get really stiff from that ankle sprain. So there's no consistent. I can't say everybody's going to react this way. What we start to look at, so probably around the time I started my masters, there was some research that showed that pain and swelling when you have an ACL tear would actually turn off your quad. It's something called arthrogenic inhibition. But basically the idea is that an acute injury, your body tries to protect itself and turns the muscle off. What happens is then it becomes really hard to turn back on. Where I picked up is during my dissertation, we started to look at the brain, and that was kind of an interesting process, because I had some skills as far as programming goes, lab programming.And I was brought in from another lab that did stroke research to help them out with one of the devices they use, a transcranial magnetic stimulator.
So basically something that stimulates the brain and measures the response in the muscle. And I was like, well, this is cool. This might have applicability to what I'm trying to do. And so I ended up using that in my own research and we kind of carried it from there. So what we started to show is that we've seen these changes in acute injury than with chronic injury. So what we call people with chronic ankle instability, the brain and the spinal cord all have a hard time turning back on after that initial injury. We call that inhibition. So we see these inhibitory changes, and that might explain why people have a hard time stabilizing themselves when they're going out for a hike, or going out for a run on unstable surfaces, or playing a sport with a lot of cutting in it. But then we actually went a little bit further, and this is not necessarily my own work, but those that are in my field, we've also seen a lot of dependence on other areas of the brain.
One of the biggest challenges here is we see the muscle gets better. We see that people get stronger and people can activate better when they do physical therapy, but then they still go out and re-injure themselves a few weeks later. So what we're seeing happening is that normal movement, that activation is coming from a whole bunch of other areas in your brain. Usually your brain barely has to light up when you're running or you're walking or you're doing anything like that. That's why you can walk and talk at the same time. But what we're seeing in these individuals with these chronic joint injuries is that their brain kind of... The part that's supposed to control their muscle turns off, and then you start recruiting all of these other things to help you out. So they're using their vision, and they're using their motor planning, and all these things that you don't usually need when you're doing simple stuff. But then when you're doing complicated stuff, that's when it becomes more of an issue.

Fletcher:
So your brain could essentially be overloaded because it's not activating the muscle that it's supposed to and then trying to figure out how to make other things work.

Needle:
I mean, I think the simplest way to say is the part of the brain that's supposed to control your joint isn't doing it anymore. So the way we fix that internally, this is without any interventions. The way we fix that internally is the part of my brain that's supposed to control my joint isn't doing it. Let's get these other areas to help out. But then you go back into the real world, and I love to talk about parking lot injuries. I know that from personal experience, anytime you go for a hike, I call them parking lot injuries, because usually the last half mile of that hike. You walked over all the unstable terrain that you possibly could and you know you're getting close to the parking lot.
And so you start to look around for those little signs, and that's usually when it happens because you're fatigued. It's harder for you to activate in general. Your vision is distracted. You're looking, you're trying to think if you're in the right area. And that's when we see that kind of breakdown in neuromuscular control. I like to always equate that to Rough Ridge. For those people that know that area, there's a bridge you cross right at the start, and so when you're coming back, you see that bridge, but right before the bridge, there's this rock garden and you can see the parking lot, and I have rolled my ankle at least three times on that rock garden.

Fletcher:
Should be danger signs.

Needle:
Yeah.

Fletcher:
I think you're in good company there with all of us have probably done that in that area. So when you're in the lab and you're activating the brain or working with brain stimulation as you are strengthening, say an ankle, is that a controlled environment so that the brain can focus on that? But again, when I'm out and hiking at Rough Ridge, that's when my brain's looking at all these other things, and so it doesn't quite remember what I was doing in the lab?

Needle:
Sort of. The brain stimulation might be getting a little ahead of ourselves for right now, but the idea is that when you're doing rehab in a clinic, you're usually not doing rehab out in the real world. You usually don't have a ton of detractors. And I'm going to give a lot of credit to the clinicians out there is that we've learned over the past 8 to 10 years, distractions or differential learning or things where we try to manipulate the environment, the task, what somebody's doing, that's become a lot more prevalent to try to prepare you for basically the unpredictability of the real world. We're always having to do things in controlled environments. We just try to do our best to simulate what we can outside of the world. What a lot of my research has tried to do is operate on the assumption that that's always going to have a limitation to it. So we try to figure out how we can enhance that a bit.

Fletcher:
Right. Is that the brain stimulation part that I jumped to?

Needle:
Yeah. Well, so I always have to clarify to people, because I've talked about one type of brain stimulation so far, where we basically provide a stimulus to somebody's brain and measure a response in their muscle. That's what we call diagnostic brain stimulation. We do that to see how good are the connections. I zap you and I look at the response I get and bigger responses, meaning you have better connectivity. That's probably the most lay way I can put that. What we've been doing lately over the past seven years now is we've been working with something called transcranial Direct Current stimulation, which is an electrical stimulation. And these are sponges, sponge electrodes that we put on different locations on the head corresponding with where certain parts of your brain are, and we use that to try to make your brain more adaptable. So it basically is increasing this property of plasticity.
Plasticity is your ability of your brain to change anytime you learn something, learn a new fact. That is brain plasticity in action. So we are taking that stimulation and trying to make people more plastic so that when we do that controlled rehab, even though we can't use an environment, maybe they're too injured that they can't really do complex tasks, but we can try to get the correct areas of their brain actually activating. So that's what we're trying to do is we're trying to basically turn on the areas of the brain that we know that they need.

Fletcher:
We're going to take a break, but when we come back, we'll talk about how Dr. Needle incorporates students into his research.

Blanks:
Mabry Watson, a graduate student at Appalachian State University in exercise science, initially aimed for a career in physical therapy, but discovered her true passion in research. Under the mentorship of Dr. Needle, Mabry shifted her focus to studying rehabilitation and neural impacts of injuries, exploring innovative techniques like transcranial direct current stimulation. Mabry shares a bit about her journey into the world of research and some campus resources you should check out if you think you might want to get involved in research at App State.

Mabry Watson:
I decided back in middle school that I wanted to go to physical therapy school. I mean like seventh grade, what was I, 12, 13. I had no business making that decision, but I held onto it. I had gone and I'd done shadowing and I was bored. I was just realizing it's a lot of the same thing over and over. I didn't feel like there was a ton of creativity at the time, maybe there's more now. I decided during my junior year that I wanted to get some research experience. I really liked the idea of the ankle study because it had to do with rehabilitation. It fit right in there with physical therapy. I completely changed what I thought I wanted to do based off of my experience doing research, which is kind of insane to think about. Physical therapy is great, it's just not where my specific interest is.
But with the exercise science research, it was like, you can look at just about anything. I didn't immediately start working on that ankle study. I very much got eased into research, thankfully, which I think made it a lot easier. Dr. Needle set me up helping with data collection with one of the grad students. So I was very familiar with a lot of the procedures, the equipment. I learned a lot. I thought I knew some things. I knew nothing, which is fine. It's very much a learning experience, and I think helping out with research taught me so much more than just what I learned in classes. I think it helped a lot more in terms of understanding learning application. I think the one thing that I did underestimate was writing the proposal and the thesis and all of that. Scientific writing is different, and I really do wish it was taught in school.
Once you get to a grad level, yes, that's being taught, but high school, there was no teaching that at all, and it is a different way of writing. There are some websites like Academic Phrasebank that helps with a little initial phrasing that that was a blessing to find. TikTok told me. I think the most interesting thing that I've learned doing or working on research with Dr. Needle would be injuries like ankle injuries, ACL injuries, a lot of those ligamentous type of injuries will have an effect on the brain. It's located nowhere near the brain, of course, but somehow it has this neural effect. I think it's very interesting to use transcranial direct current stimulation, a non-invasive brain stimulation to stimulate different parts of the brain. So essentially you can turn up this thing called cortical excitability with one side and turn it down with the other. There are different techniques you can use.
Essentially the idea of hebbian plasticity, "If you don't use it, you lose it," that type of thing. It's kind of like that, but thinking about applying that with an ankle injury, if I were to give advice to other students interested in getting involved in research, I would probably say number one, talk to your professors. Most professors, especially here at App, are either doing research or know of someone doing research, and they might know a little bit about their projects and they can go and mention your name to those other professors or tell you who to go talk to. The other thing I would do is go to the Office of Student Research website. They will often have a list of some of projects going on. Sometimes there's an article, like was in my case, and you can kind of see what all is going on.
Another thing I would suggest is a lot of the labs, not just within exercise science, but within App, have lab websites and oftentimes they'll have a list of what they're doing, what's their current ongoing projects, who's involved in the labs, some of the previous research they've done. You can also look up professors' names and see some of their citations and stuff, which can be cool to go look into. So specifically with exercise science, I would say do it. Do the research, get involved, and if you don't like it, ask about some other professors' research. You can be as involved or as uninvolved as you want. If you don't like it, I guarantee you there's another study going on that's more interesting or just as interesting. Yeah.

Blanks:
To learn more about research opportunities at Appalachian State, go online to osr.appstate.edu.

Fletcher:
How do you involve your students in your research?

Needle:
Yeah, it's a great question. So I'm fortunate that I've had students from several different programs that come and help through. So I've got students that are now... well, they used to be in the Bachelors of Athletic Training, but we no longer have that. It's Master of Science and Athletic Training. So I do have a couple of those students that help out in my lab. Those students are under a huge time crunch as far as getting their clinical hours, but they're kind of key for recruitment and some extra hands on deck. I work very closely with the exercise science program, and I have students from both the Bachelor of Science and Exercise Science, and especially the Master of Science and Exercise Science program that helped me out, and they take on a variety of roles. I kind of dichotomize them a little bit where I say, okay, we can start. It's just having you as a helper, a student researcher. You're coming in here and you're just helping with the studies, turn some dials, write some numbers down.
And most of that is just getting them used to the environment because I would say 95% of the students that come to me have no lab experience before. They're kind of interested in physical therapy school. They want to see what rehabilitation research looks like, and they just want to get the environment. And of course, that's usually the first goal. Then when it's my master's students or some of our undergrad students that just really do enjoy it, we get them more involved on their own projects. So we have a discussion to kind of match what the student project interests are compared to what I've been trying to show over the past year, or few years. So let's talk about different interventions, different combinations. We can do single session, multi-session and try to do some of it's proof of concept, but I let them run the show on that. So I'm of course there to support them and guide them along the way, but it is their thesis, their student projects, and they get to do some interesting stuff.

Fletcher:
Sounds like fun. A fun way to get introduced to the topic, and I believe I've seen some recruitment emails come out when you're recruiting people who have had some kind of ankle sprain or joint injury and you want to bring them into the lab so that you can have real-world people to work on. So what does that look like if I volunteered to come in and said, "Hey, I just was at Rough Ridge and I sprained my ankle?"

Blanks:
I want to come in because I roll my ankle all the time. I've done it for years, and it used to just be my right ankle. Now it's like both of them. I'm like, "What are you doing, left ankle? You were the one I could depend on." Yeah. The other day I was trying to open like a can and I was stepping in a... It was a familiar place. I wasn't paying any attention. It was not a weird environment, and I rolled my ankle so bad and I fell down a hill. It was ridiculous. My glasses flew off my head. I really want to volunteer. So yeah.

Needle:
Something really interesting about that is most of my career has been based on ankle sprains or what we call chronic ankle instability, which is what you're describing. Your ankle gives way and rolls on you. Maybe you didn't sprain it, but it gave out on you during activities. So a lot of that. But we've recently been doing a study because I'm like, let me see if this intervention we're doing works in other models, and we started to recruit for ACL injury, and that has been a difficult recruitment.
So if anybody's listening and is in the Boone area and interested in doing research, and you've had ACL surgery, reach out to me for that because ankles tend to be so much easier. ACL surgery, you had the injury, you got surgery, and you went through a long rehabilitation process, six, nine months. And you usually, maybe you don't feel a hundred percent, but you've done the process. A lot of people are accepting that. People with ankle instability don't recognize how big and common of an issue that is. I think that was the most common response I get from people. It's like, "Whoa, I'm not the only one dealing with this. Wait, there's stuff that [inaudible 00:21:20]?"

Blanks:
It makes me feel better. Yeah, because lately, particularly, I've been like, there's no hope. I'm just going to keep doing this for the rest of my life.

Needle:
And most people don't. Is it a big enough problem that I need to go ahead and start dishing out a couple hundred bucks to get physical therapy over a few months to fix? So you tell them they have a research study that we're going to try to fix that they get pretty excited.

Blanks:
Yeah, I'm excited.

Needle:
Yeah. If you reach out to us as far as being a subject, the way that works is, so our students, sometimes me and sometimes my graduate assistants, will go to different classes or put announcements out or go to communities. You might see our flyers at the rec center all around. If you express interests, you could either be directly emailing us or through filling out one of our forms. We have a little QR code that links you to that. One of us will reach out to you and basically ask you some qualification questions trying to confirm do you have the injury at the point that we want it?
So a good example is for somebody with chronic ankle instability, you technically don't have chronic ankle instability until a year from your first ankle sprain, because we don't know how you're doing yet. So once you're a year out, then we can do that. ACL injury. We wanted to make sure we had people in this timeframe, "Hey, you're fully recovered and you've been returned to sport for a month and you're within 10 years of your injury." So we make sure of that. The other thing that we make sure of, because we are doing some research that involves brain stimulation, is we need to make sure you don't have any of the things that would put you at risk if we did brain stimulation. The biggest factor here is if you have seizure disorders, but there's a few other questions that we ask to just make sure that we're doing everything as safely as we can.
But then once we've confirmed that you're interested and confirmed that you would fit our criteria, we go ahead and bring you into our labs. Our labs over at Levine Hall over across the street from the hospital here in Boone, and we have you come in usually multiple times. The first one, you fill out your consent. We explain everything that we're doing in that study. We collect a bunch of what are called patient report outcome measures. So surveys about not just how your ankle or knee feels, but also how is life. So we look at a lot of just general disablement, not just ankle-specific disablement. We look at how fearful are you of re-injuring yourself. And then we bring you through a battery of testing, which changes study to study, but we generally include some measures of maybe jumping and hopping performance. So some performance-based metric. Usually some balance-based metrics where we look at how you are able to balance and how your muscles behave when you balance. So we put some sensors on your muscles to look at that.
And then depending on the study, we might also get some measures of nervous system function to see is your brain talking to your muscle? Are you using the entirety of your muscle to stabilize yourself? So trying to get some of those measures out there as well. And so that's usually what a testing session looks like. And then if it's an intervention study, which a lot of ours are, we'll have you scheduled for the interventions and come back in and redo those test sessions. So that's probably the most common setup. We have a pretty good range of research that goes on. We had an undergraduate research project last year where it was just people coming in one time, took about 30 minutes. We put some markers on them, reflective markers that we could track biomechanics. We had them do some jumps and we threw some surprises at them while they did that to just see how they reacted when there was something unexpected that showed up.

Fletcher:
Can you divulge the surprises?

Needle:
Oh, yeah, sure. We presented it at some conference now we had a cannon that fired at them.

Fletcher:
Wow.

Blanks:
Like a projectile?

Needle:
Yep.

Blanks:
Oh, really?

Needle:
It was just a rag. So if it hit them, it wasn't an issue.

Blanks:
Who got to fire it?

Needle:
One of our grad students.

Blanks:
Awesome.

Needle:
Yeah, one of our grad students.

Blanks:
What a great gig.

Needle:
Yeah, that was the grad thesis. We had an undergrad thesis that was something similar where they just didn't know how high they were jumping off of. They didn't know where the ground was. So just trying to see. So that's a quick little, put some markers on you. We let them know what's happening, saying we're going to fire a projectile, you're expecting something to happen, but when it happened every time, it would be like, "What was that?"

Fletcher:
Sounds like a little fun over there too.

Needle:
Yeah, and I think a lot of my career has been like, "Is that a crazy idea? I think we could do it. Let's do it."

Blanks:
Yeah. I have so many things that I've thought to interrupt with, but y'all are in such a flow that I really haven't said any of them. But when you were talking about the transcranial... Say it again.

Needle:
We can call it TDCS, but transcranial direct current stimulation.

Blanks:
I was reminded of EMDR. So have you ever seen that? Eye movement disinsectization and reprocessing. It's for PTSD, it's like a treatment that people use.

Needle:
So this is my other secret here.

Blanks:
Okay.

Needle:
It's that all of these ideas that... I feel like I've had a pretty good impact on my fields from talking to colleagues and whatnot. But most of the ideas that I've had have been stolen in a way. I mean, I can't really... Reapplied. Reapplied is a good word.

Blanks:
There you go.

Needle:
Reapplied from stroke, Parkinson's disease. Actually, I worked very closely with the faculty here that does Parkinson's research and uses TDCS, traumatic brain injury. And then TDCS, and all of that really comes from psychology. Back... Oh God, what year was it? 2016-2017. I went to a conference in Chapel Hill that was hosted by their department of psychiatry in the med school. It was all about neuromodulation, which is what all of this is, things that change your nervous system. And oh man, there is a whole library of things that are neuromodulatory. They're looking at it in treating schizophrenia, in treating depression, in treating PTSD. These are the things that they're using it for. There's some people that expand to the motor side of things and are looking at stroke and Parkinson's. Again, it's just kind of weird. It's like, "Can I use this for ankle sprains?"

Blanks:
Can I use that?

Needle:
Yeah.

Blanks:
The only other thing I was going to ask is it my shoes? Is it my shoes, Alan?

Needle:
There's factors with shoes, but the answer is if you only sprain them in your shoes-

Blanks:
No, I don't.

Needle:
... it might be it.

Blanks:
I don't.

Needle:
Right. There's some good work. So I don't do a ton of what we'd call hardcore biomechanics where we're looking at these really minute changes in how you move, but there's been some really good work done. And a lot of what I'm doing is based on the fact that... Well, I'll back up a second. To sprain your ankle, it takes 50 milliseconds. There've been some studies where people have accidentally sprained their ankle in the lab. They're markered up. We have the data. We know it takes about 40 to 50 milliseconds for it to happen.

Blanks:
How did that happen?

Needle:
I mean just have somebody jump, fire a projectile at them and something... It does not happen in my lab, but it's when it happens, it's obviously unfortunate. However, it gives us some really interesting information. And so we know it's that fast, and there's been video analyses of ACL injury, and they estimate that that happens about that fast. The fastest you can react. So if you feel your ankle going on, you, the fastest you're able to react is about maybe 80 milliseconds if it's pure reflexive. But to actually generate a good amount of force to stop yourself from doing it, probably more like 200 milliseconds. So the bottom line here is reactions are not enough to actually stop you from injuring your joint. So what we've seen is it all comes down to planning. It all comes down to, oh, well, these people tend to land in a more vulnerable position. So when you step, you're more likely to step and land on the outside of your foot so that there's just such a smaller degree of error that you might just roll over.

Fletcher:
So we had talked earlier about how you talk to clinicians afterwards when whatever you're finding out, you have a way to say, "Hey, this is what's happening," and maybe even work with them on ways that they can work with their patients. What does that look like? As in, "Okay, here's some results that may help you, Dr. So and so." How does that transfer of information?

Needle:
I mean, that's the challenge. We're talking about translational research here. Things that I could take these basic science principles and apply them into a clinic, and it's a huge challenge, and it's probably one of my biggest motivators for, I could keep looking at all of these different ways, the nervous system changes, but I care more about what can affect a patient's function. So this is a mix of things. Usually the easiest way for me to do that is speaking engagements. I've spoken at the NATA, the National Athletic Trainers Association Annual Conference a bunch of times. I've given talks to our alumni base at App State to regional conferences. I'm going out next month and talking to the International Ankle Consortium, which the conference is the International Ankle Symposium, which is a mix of researchers and clinicians there. But we're just having those discussions and sometimes it hits, sometimes it doesn't. I have a lot of issues where I'm trying to tell clinicians, "Actually, all you got to do is this brain stimulation, and it's going to fix everybody."
I will say we just had... it was accepted a few weeks ago, maybe a month ago, I have a paper that is being published in the Journal of Athletic Training, so a very clinician accessible journal that was originally conceived. It's funny how it kind of took a turn on me, but I'm really proud of this one, that it's a clinical commentary. So it is designed to be for clinician, and it was meant to be a paper that talked about how to use TDCS and what the practical implications are. Where I say it took a turn is, we still talk about that, but it actually went far more broad. We actually talked about just all of these different ways that you could potentially make your treatment neuromodulatory. So what can you do to strengthen and to improve sensory function and to decrease fear of movement? How can we optimize changing your brain in that process without using brain stimulation? Because it's a nice option, but some people are going to be hesitant. Some patients are going to be hesitant on it.

Fletcher:
Sure. So you're saying there's actually possibly opportunity to do this without brain stimulation?

Needle:
Yeah. So my argument is that brain stimulation is going to help. So brain stimulation doesn't work on its own. You need to do something else with it. One of the things I described earlier is that brain stimulation makes you more plastic, more adaptable. You can still be doing those other things that might help. This is just something that might make it more efficient. As an example, strengthening. So when we think about strengthening in a rehab setting, we usually think about using a band, like elastic Band to strengthen something.
Well, one thing that we can do to make that strengthening better is we can do it eccentrically, which means we're going to actually push harder when you're trying to go back to that start position. So if you think about a squat, you go heavier on the way down and lighter on the way up. We know that by doing that, you're actually able to turn your motor cortex on a little bit. You're able to kind of reverse some of those changes in the brain just like that. But if I do that with this potentially brain stimulation, this TDCS, we can make that more efficient and make those changes happen faster and happen more durably, meaning that they last once you leave rehab, because that's a big concern we have is nobody's going to do rehab forever. Nobody wants to do rehab forever. So can I send you out of there and then bring you back a month later and you still look the same way?

Fletcher:
Right? I think that's everyone's goal.

Needle:
Yeah.

Blanks:
Is there a way you can replicate that on your own outside of the lab as me, as a person who wants to replicate the stimulation?

Needle:
The TDCS. So what's funny is I'll start by saying we use a research specific brain stimulation just because our device, for instance, we're able to double-blind. So we don't know what stimulation our patients are getting, and they don't know.

Blanks:
I know you can get TENS machines and use those.

Needle:
So what's interesting about TDCS is that right now it's primary marketing that if you go and want a biostimulator is for general, well-being energy. So basically non-clinical uses of the device. And so I actually have some of these, because when I give these talks, I like to show people, "Hey, look, here's a stimulator you can buy." It costs about $120 for this one specific brand. I don't want to mention a brand name on here. But for this one specific brand of brain simulator, it costs 120. You can find them for ranging anywhere from 100 to 600 depending on the types of parameters. So it's something that's really easy to do, and all these devices are designed for home use, but they're designed specifically to be put in these certain locations, usually along the forehead that are designed to help more with attention and things like that, wellbeing energy levels. But it's the exact same technology. There's nothing stopping you from trying to put it in the different locations and trying to work some rehab in with that.

Blanks:
Although we, on this podcast, don't recommend you do anything like that. I don't know how can we give ourselves an out there.

Needle:
So I think right now, putting in that paper, we are at the cutting edge of this. So we published the first paper that used TDCS and individuals with a musculoskeletal injury. So any musculoskeletal injury, we published that back in 2020. And since then it's been repeated. They've gotten very, very similar results to us, which is awesome, because every time we see those results, it's like, "Ah, we screwed up somewhere. This is going to get disproved." No, it's been kind of holding up, which is nice. But we're talking, I think my last check, there have been seven articles that have looked at just TDCS in individuals with these injury. And these articles are targeting different parts of the brain. They're targeting different exercises that you're pairing it with. They're targeting different outcome measures. And so we're seeing positive effects from it, but we don't know the magic recipe yet.
The article that I put out recently that gave a clinician guide, we talk about this issue, but we also look at all of these different rehabilitation tools that you can do. And these are options. We don't know what's going to be the most effective. We know some of these, there's evidence to show that strengthening somebody eccentrically makes their motor function better. There's other stuff. So we talked about doing things like action observation and motor imagery. We've had some master's students do projects that involve that, but it's very preliminary. We really aren't sure if things like that would work, and that's a cognitive tool. Can I picture somebody doing this? Picture myself doing this, and is that going to make this movement going to be better on me?

Blanks:
Gotcha. And then is there an ADHD component?

Needle:
Oh, that's a very interesting question. I mean, it's possible. I have not seen that link. And we struggle a little bit because when we look at our research that uses the diagnostic brain stimulation, a lot of ADHD meds are exclusionary. We can't do that measurement on individuals that are on ADHD meds because it raises their risk of having an adverse event. So it's a little harder for us to really come to that conclusion.

Blanks:
Interesting. Okay. That's all the interruptions.

Fletcher:
It's all good.

Needle:
My whole thing about this is I could look over potential questions and prepare, but honestly, I'm talking about the one thing that I know better than... I know what I do. I know my research, and I mean, we can talk ankles for another hour if you want.

Blanks:
Is there a more common injury?

Needle:
Ankle sprains across most populations are the most common injury. We're talking that it takes up about, I mean, it varies across sport to sport, but roughly 15% of injuries tend to be ankle sprains. Now, that includes different types of ankle sprains, but generally it's ankle sprains. And when I'm trying to seek out funding for my research, we really... So there was a paper that came out from a professor at UNC Charlotte. It was an editorial paper that I like to cite just for the tone of it, that it's like "Ankle sprains cause cancer." But the idea is-

Blanks:
Is that clickbait? It sounds like a clickbait title.

Needle:
But her point on that is that we see these issues that, all right, so 60% of the population, we've seen that across a [inaudible 00:36:34], 60% of people sprain their ankles. About half of them or so will go on to develop ankle instability. So we're talking about 30% of the population is rolling their ankles when they're doing physical activity, which is all well and good when you're young. But as you start to get older, that makes you less likely to do certain types of physical activity. And there's been studies in college-age kids, there's been studies in rats that show when you sprain your ankle, you do less physical activity.
And on top of that, your ankle is also at increased risk of arthritis. So you combine all of that, you end up with people that are doing less physical activity and fearful of doing certain types of activity because of their ankle. And we all know that physical activity, if you're not doing it leads to death. It's a precursor for many, many diseases. So that's usually the argument that we're talking about here, is that if I can fix these ankle sprains, then maybe I can stop arthritis and maybe I can make sure that these people can stay active for a longer portion of their life.

Blanks:
Save the world. Yeah. Wow. Butterfly effect from your ankle.

Needle:
Yep.

Fletcher:
I've just got one more question. So what are the next steps or future directions for your research?

Needle:
Yeah, so I mentioned right now we've done a bunch with the ankle and have that research that's come out. We've currently been working on this study with ACL injury, but I can see myself moving back to ankle just from a recruitment perspective. But that being said, we're trying to figure out the recipe here. So we're really trying to figure out where are the optimal targets to try to fix this? What are the best things to pair this types of brain stimulation with to improve people's outcomes? Is there maybe a predictor? Can I look at how people move, do an evaluation on them and figure out which treatment they're going to respond best to? So can I maybe individualize this? Because everything I'm talking about, I'm trying to paint with a broad brush, and we all know that that's not real life.
So these are all things that we're trying to do because all of this comes down to the fact of the research is telling me, not just my own, what I'm seeing published is that this is a intervention that could potentially have a pretty good impact. Has potential to improve function in a lot of people, but there's a lot of hesitation. There's the talk of the FDA, right? Because right now this is being used under general labels. It's off-label use. But if the FDA works towards approving something like that, that would go a long way to see this. And it's kind of hard to figure out what my role in that would actually be. But all I know is that if I can continue to produce research that shows that it's safe and efficacious, then we're moving in that direction.

Fletcher:
Well, I'm excited to see where this leads. And thank you so much for being here and creating solutions and inspiring change through your joint injury research and letting us know a little bit about what you're doing here at App State's campus. Can you let us know and the listeners out there, how they might contact you if they're interested in getting involved?

Needle:
So if you're interested in being involved with research, whether it's helping us perform the research, if you're a student here at App or if you are interested in participating, probably the easiest way is to reach out to injurylab@appstate.edu. We also have a website injurylab.appstate.edu that has some of our information there. We're updating it as we go. I also like to make all of my papers that I can make available there. I like to make them available if you're interested in that. But yeah, injury lab@appstate.edu, injurylab.appstate.edu are probably the easiest ways to reach us.

Fletcher:
Okay, thank you. If you like what you've heard and are interested in learning more about the work being done at App State, tune in next time to hear from Dr. Will Canu, Appalachian State University's 2024 Provost's Awardee for Excellence in Research, Scholarship and Creative Activity, and professor in the Department of Psychology whose research focuses on ADHD. This is Karen and Dave saying thank you for listening to Appalachian Excellence featuring Appalachian State University Research Scholarship and Creative Activity Creating Solutions Inspiring Change.

Blanks:
Bye, Karen.

Fletcher:
Bye. Dave.

Needle:
I've been getting a lot of emails from you.

Fletcher:
I know. I've been like every day.

Blanks:
Oh my God, Karen, geez.

Fletcher:
Well, he's so important and great, so I keep like... I need you to do this for us. Nice.

Blanks:
By the way, there were so many puns in this that I didn't say. You were like, can you just walk us through this? And I was like, God.

Needle:
You can always go with the, you're really on a roll right now.

Blanks:
There's so many. You were like, "Yeah, but it took a turn." God, so many good ones.

Needle:
Yeah. I'm going to be at an ankle conference in two weeks where it's just like, "Oh, TALUS." Which tell us is one of the... It gets bad.

Blanks:
God, there's so many.

Needle:
Yeah.