Postoperative Knee Rehabilitation Research Articles

Continuous Epidural Analgesia and Continuous Femoral Nerve Block for Postoperative Pain after Unilateral Total Knee Arthroplasty: A Prospective Cohort Study

Introduction: Total Knee Arthroplasty (TKA) surgeries are associated with moderate to severe postoperative pain. Inadequate analgesia leads to patient distress, suboptimal knee mobilisation and complications due to delayed rehabilitation. Peripheral nerve blocks and central neuraxial techniques are in the vanguard of various analgesic strategies to minimise pain after TKA. Aim: To compare the effects of Continuous Epidural Analgesia (CEA) and Continuous Femoral Nerve Block (CFNB) on postoperative analgesia, knee rehabilitation and adverse effects after TKA surgeries. Materials and Methods: A prospective cohort study was conducted among 90 patients undergoing unilateral TKA at the Government Medical College, Kozhikode, Kerala, India. They were divided into two groups of 45 each. CEA (Group E) and CFNB (Group F) were given for postoperative pain management. Effectiveness of postoperative analgesia was measured by Numerical Rating Scale (NRS) scores at 6, 12, 24, 48 and 72 hours and also by need for rescue analgesics during the first 48 hours. Postoperative knee rehabilitation indices were measured on 1st, 2nd and 3rd Postoperative Days (POD). Incidence of adverse effects in each group was also noted. Continuous variables were analysed using students t-test, categorical variables using Chi-square test and NRS scores using Mann Whitney U test. Results: NRS scores were similar in both CEA (E) and CFNB (F) groups. On POD 1, 75.6% of group E and 71.1% of group F (p=0.630), on POD 2, 71.1% of group E and 68.9% of group F (p=0.818) and on POD 3, 62.2% of group E and 66.7% of group F (p=0.66) achieved specific rehabilitation indices. There was no statistically significant difference in pain scores, rescue analgesic requirement and rehabilitation indices between the two groups. No significant adverse effects were noted in either group. Conclusion: CFNB is as effective as continuous epidural block for postoperative analgesia and knee rehabilitation after TKA without any significant side-effects.

Periarticular analgesia vs epidural analgesia in early post operative period of total knee arthroplasty

Modern view of perioperative pain is to view it as an impediment to recovery and various methods are used to facilitate rapid return to normal functional activity. Post operative pain relief after knee surgeries, especially total knee replacement, is a major concern. It is severe in 60% of patients and moderate in 30%. It causes undue distress and hinders early intense physical therapy, considered one of the most important factors for optimal postoperative knee rehabilitation. The present study compares the efficacy between periarticular cocktail and epidural analgesia in early post operative pain management following TKA. A total of 78 patients were included in the study. By simple randomization patients were divided into Group A in which 48 patients received a periarticular cocktail and Group B in which 30 patients received Epidural top up dose. Group -A patients received an analgesic cocktail of 0.125% Bupivacaine (2mg/kg body weight), Ketorolac (30mg), Adrenaline. This analgesic cocktail of 20 cc was infiltrated in the posterior capsule, medial structure, lateral structures and the cut quadriceps tendon before placing the implant. Epidural topup of 8cc of 0.125% Bupivacaine was given 6 hours after surgery in Group B patients. No drain was placed in patients of Periarticular infiltration group. A straight leg raise test was done to assess the VAS score at 12h, 24h, 48h, 72h. Epidural analgesia provides effective pain control despite the disadvantages of its invasiveness, late return of motor functions and more systemic side effects. Local infiltrative periarticular analgesia methods should be considered due to its ease of use, lower rates of systemic side effects and the fact that it does not extend the motor block or require systemic application of LA, while providing comparable pain relief and equal range of movements and ambulation in the immediate postoperative period

The Effect of Anti-Gravity Treadmill on Balance in Acute Phase of Post-Operative Knee Rehabilitation

Background: An anti-gravity treadmill has been used in orthopedic and neurological rehabilitation. However, little literature on its use in post-operative knee rehabilitation is available. Objectives: The purpose of this investigation was to study an effect of anti-gravity treadmill on balance in an early phase of post-operative knee rehabilitation. Methods: Forty-nine patients who underwent knee surgery participated in this study (study design: cohort study; level of evidence: level II). At one week post-operatively, each patient was tested for timed single leg stance (SLS) on surgical knee on a floor. Patients were placed onto either AlterG group (AG) or control group (CG) after the test based on their pain level. The patients in AG underwent a balance exercise on AlterG, with the pressure adjusted to a pain-free or minimal pain level, once a day at least 5 days a week. Those in CG underwent their balance exercise on a floor in the same manner. All patients were tested again for SLS at 2 week post-operatively. The lengths of SLS were recorded and analyzed. Results: The lengths of SLS were 38.8 seconds and 19.9 seconds for CG and AG, respectively, at 1 week post-operatively. They improved to 50.5 seconds (CG) and 35.0 seconds (AG) at 2 week post-operatively. There was statistically significant between-group difference at both 1 week and 2 week post-operatively. However, there was no significant between-group difference in improvement from week 1 to week 2. Conclusions: A use of anti-gravity treadmill may have a positive effect on balance in an acute phase of post-operative knee recovery in patients who had an increased level of pain during full weight-bearing immediately after knee operation.

Anti-nerve growth factor therapy increases spontaneous day/night activity in mice with orthopedic surgery-induced pain.

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are 2 of the most common and successful surgical interventions to relieve osteoarthritis pain. Control of postoperative pain is critical for patients to fully participate in the required physical therapy which is the most influential factor in effective postoperative knee rehabilitation. Currently, opiates are a mainstay for managing postoperative orthopedic surgery pain including TKA or THA pain. Recently, issues including efficacy, dependence, overdose, and death from opiates have made clinicians and researchers more critical of use of opioids for treating nonmalignant skeletal pain. In the present report, a nonopiate therapy using a monoclonal antibody raised against nerve growth factor (anti-NGF) was assessed for its ability to increase the spontaneous activity of the operated knee joint in a mouse model of orthopedic surgery pain-induced by drilling and coring the trochlear groove of the mouse femur. Horizontal activity and velocity and vertical rearing were continually assessed over a 20 hours day/night period using automated activity boxes in an effort to reduce observer bias and capture night activity when the mice are most active. At days 1 and 3, after orthopedic surgery, there was a marked reduction in spontaneous activity and vertical rearing; anti-NGF significantly attenuated this decline. The present data suggest that anti-NGF improves limb use in a rodent model of joint/orthopedic surgery and as such anti-NGF may be useful in controlling pain after orthopedic surgeries such as TKA or THA.

The Use of Continuous Passive Motion Following Knee Cartilage Defect Surgery: A Systematic Review

We evaluated the clinical evidence of using continuous passive motion postoperatively after treating articular cartilage lesions of the knee. We hypothesized that postoperatively, the use of continuous passive motion improves the outcomes of cartilage restoration procedures. Multiple medical databases (MEDLINE, EMBASE, CINAHL, PubMed, Sport-Discus, and Cochrane) were searched for Level I through IV evidence with specific study inclusion and exclusion criteria. The following key words were searched: microfracture, mosaicplasty, OATS, ACI, osteochondral autograft, osteochondral allograft, autologous chondrocyte implantation, autologous chondrocyte transplantation, CPM, continuous passive motion, motion therapy, postoperative knee rehabilitation, cartilage, knee. All studies were independently reviewed by the authors and the references were checked for any missed articles. Four Level III studies were identified that met inclusion criteria for our hypothesis. No randomized, controlled studies were identified. A meta-analysis could not be performed as a result of the heterogeneity of the procedures and outcome measures. Definitive conclusions regarding the benefits of continuous passive motion postoperatively in knee cartilage surgery could not be made secondary to this heterogeneity. Continuous passive motion is commonly used postoperatively following cartilage surgery. Unfortunately, the clinical evidence (only 4 studies) to support the use of continuous passive motion is lacking despite an overwhelming abundance of basic science support and the common clinical practice of continuous passive motion implementation postoperatively in knee cartilage restoration procedures. There is a great need for well-conducted, high-level evidence studies to address this void in our literature.

Comparison of the influences of continuous femoral nerve block and patient controlled intravenous analgesia on total knee arthroplasty

To assess the influences of continuous femoral nerve block (CFNB) and patient-controlled intravenous analgesia (PCIA) on postoperative pain scores,knee rehabilitation,and stress response after total knee arthroplasty (TKA). Totally 32 adult patients scheduled for elective total knee arthroplasty were equally randomized into CFNB group or PCIA group. Intraoperative hemodynamics and fentanyl dose were recorded. Pain was assessed at rest and during continuous passive motion (CPM) using a visual analog scale at post-anesthesia care unit (PACU) and 4, 8, 12, 24, and 48 hours postoperatively. Morphine consumption was also recorded. As indicators of stress and inflammatory response,the leukocyte count, serum lactic acid, blood glucose, serum C-reactive protein (CRP), and serum cortisol were determined on admission, to operation room, immediately after skin incision, before extubation,on post-operation day 1 (POD1), and on POD2. CFNB group showed significantly lower heart rate compared with PCIA group 60 minutes and 90 minutes intraoperatively (Pü0.05). Intraoperative consumption of fentanyl was significantly lower in CFNB group (137.5∓44.4) μg than in PCIA group (264.1∓67.1) μg (Pü0.01). The CFNB group showed significantly lower VAS scores both at rest and during CPM compared with PCIA group at all time points (Pü0.05). Morphine consumption was significantly lower in CFNB group than in PCIA group at different time points (Pü0.05 or Pü0.01). The maximal continuous passive motion amplitude of CFNB group were significantly larger than that of PCIA group on POD1 [(55.0∓9.4) vs.(44.6∓9.9), P[(76.3∓11.0) vs. (67.5∓10.3), P<0.05]. The incidences of somnolence and nausea/vomiting in CFNB group were 37.5% and 37.5%, respectively,which were significantly lower than those of PCIA group (75.0% and 81.3%) (Pü0.05). Patient satisfaction scores on anesthesia and post-operative analgesia was significantly higher in CFNB group than in PCIA group (93.1∓7.9 vs. 79.1∓11.9, respectively) (Pü0.05). After TKA,CFNB technique provides more stable intraoperative hemodynamics than PCIA, with better pain relief,faster postoperative knee rehabilitation,less side effects,and higher patient satisfaction.

Surface Electromyography Biofeedback Training to Address Muscle Inhibition as an Adjunct to Postoperative Knee Rehabilitation

Abstract Following a knee injury and surgery, pain-related and fear-related muscle inhibition can interfere with rehabilitation and may contribute to the development of chronic pain. Surface electromyography biofeedback can help patients identify and overcome muscle inhibition during physical therapy exercises, so that normal muscle strength and range of motion can be regained.

Effect of early active range of motion rehabilitation on outcome measures after partial meniscectomy

Range of motion (ROM) exercises are accepted as being an essential part of post-operative knee rehabilitation but there is little research to support this treatment. Our purpose was to determine whether a specific early, active ROM intervention using a bicycle ergometer equipped with an adjustable pedal arm offered measurable benefit to post-operative partial meniscectomy patients. Thirty-one subjects were randomly assigned to experimental or control groups. The experimental group rode a stationary bicycle equipped with the pedal arm device six times over 2 weeks post-operatively under the supervision of a physical therapist while the control group did not. Subjective measures of gait were significantly different with a positive experimental group response to the supervised exercise with improved gait performance at weeks 1, 2 and 4 after surgery (P < or = 0.05). Early, protected active ROM exercise on a bicycle ergometer equipped with an adjustable pedal arm demonstrated promising results in patients after partial meniscectomy.

Effects of Intravenous Patient-Controlled Analgesia with Morphine, Continuous Epidural Analgesia, and Continuous Three-in-One Block on Postoperative Pain and Knee Rehabilitation After Unilateral Total Knee Arthroplasty

In this study, we assessed the influence of three analgesic techniques on postoperative knee rehabilitation after total knee arthroplasty (TKA). Forty-five patients scheduled for elective TKA under general anesthesia were randomly divided into three groups. Postoperative analgesia was provided with i.v. patient-controlled analgesia (PCA) with morphine in Group A, continuous 3-in-1 block in Group B, and epidural analgesia in Group C. Immediately after surgery, the three groups started identical physical therapy regimens. Pain scores, supplemental analgesia, side effects, degree of maximal knee flexion, day of first walk, and duration of hospital stay were recorded. Patients in Groups B and C reported significantly lower pain scores than those in Group A. Supplemental analgesia was comparable in the three groups. Compared with Groups A and C, a significantly lower incidence of side effects was noted in Group B. Significantly better knee flexion (until 6 wk after surgery), faster ambulation, and shorter hospital stay were noted in Groups B and C. However, these benefits did not affect outcome at 3 mo. We conclude that, after TKA, continuous 3-in-1 block and epidural analgesia provide better pain relief and faster knee rehabilitation than i.v. PCA with morphine. Because it induces fewer side effects, continuous 3-in-1 block should be considered the technique of choice. In this study, we determined that, after total knee arthroplasty, loco-regional analgesic techniques (epidural analgesia or continuous 3-in-1 block) provide better pain relief and faster postoperative knee rehabilitation than i.v. patient-controlled analgesia with morphine. Because it causes fewer side effects than epidural analgesia, continuous 3-in-1 block is the technique of choice.

Effects of Intravenous Patient-Controlled Analgesia with Morphine, Continuous Epidural Analgesia, and Continuous Three-in-One Block on Postoperative Pain and Knee Rehabilitation After Unilateral Total Knee Arthroplasty

In this study, we assessed the influence of three analgesic techniques on postoperative knee rehabilitation after total knee arthroplasty (TKA).Forty-five patients scheduled for elective TKA under general anesthesia were randomly divided into three groups. Postoperative analgesia was provided with IV patient-controlled analgesia (PCA) with morphine in Group A, continuous 3-in-1 block in Group B, and epidural analgesia in Group C. Immediately after surgery, the three groups started identical physical therapy regimens. Pain scores, supplemental analgesia, side effects, degree of maximal knee flexion, day of first walk, and duration of hospital stay were recorded. Patients in Groups B and C reported significantly lower pain scores than those in Group A. Supplemental analgesia was comparable in the three groups. Compared with Groups A and C, a significantly lower incidence of side effects was noted in Group B. Significantly better knee flexion (until 6 wk after surgery), faster ambulation, and shorter hospital stay were noted in Groups B and C. However, these benefits did not affect outcome at 3 mo. We conclude that, after TKA, continuous 3-in-1 block and epidural analgesia provide better pain relief and faster knee rehabilitation than IV PCA with morphine. Because it induces fewer side effects, continuous 3-in-1 block should be considered the technique of choice. Implications: In this study, we determined that, after total knee arthroplasty, loco-regional analgesic techniques (epidural analgesia or continuous 3-in-1 block) provide better pain relief and faster postoperative knee rehabilitation than IV patient-controlled analgesia with morphine. Because it causes fewer side effects than epidural analgesia, continuous 3-in-1 block is the technique of choice. (Anesth Analg 1998;87:88-92)

Transcutaneous neural stimulation use in postoperative knee rehabilitation.

A prospective study of 100 patients who were oper ated on in 1979 and 1980 was performed to determine the effect of transcutaneous neural stimulation (TNS) on the patients' postoperative knee rehabilitation pro gram. The patients were then divided into four study groups. Fifty patients had a single incision arthrotomy with a meniscectomy. Of these surgical patients, Group A included 25 patients who were treated with a TNS unit postoperatively, and Group B includes 25 patients who did not use TNS. Fifty other patients had a total condylar-total knee replacement. Of these sur gical patients, Group C includes 25 patients who used TNS postoperatively and Group D includes 25 patients who did not use TNS. In the arthrotomy group the TNS patients (Group A) had a shorter average hospital stay (3.84 versus 5.40 days), initiated straight leg raises sooner (1.72 days versus 3.17 days) and began am bulation sooner (1.4 days versus 2.44 days) than the patients who did not use TNS (Group B). As compared to Group B, Group A had a reduction in number of meperidine injections of 42.75% and a reduction of meperidine dosage of 31.49%. In the total knee pa tients, the group treated with TNS (Group C) also had a shorter hospital stay (14.92 days versus 17.88 days) and performed straight leg raises sooner (4.92 days versus 7.54 days) than patients who did not use TNS (Group D). There was no difference in the ambulation times in Group C and Group D (4.96 days). There was a reduction of meperidine injections of 35.88% and a reduction of meperidine dosage of 44.48% in Group C. The use of TNS in postoperative knee patients improved their rehabilitation performance and shortened their hospital stay. No side effects were noted.