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Carmichael J, Dennis D, Jennings J, Stevens-Lapsley J, Bade M. Feasibility and initial efficacy of a multimodal swelling intervention after total knee arthroplasty: A prospective pilot study with historical controls. Knee 2022; 35:25-33. [PMID: 35183923 DOI: 10.1016/j.knee.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/21/2022] [Accepted: 01/30/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Swelling after total knee arthroplasty (TKA) is often profound and persistent, increasing risks of DVT, infection, and wound dehiscence, and impairing rehabilitation. We investigated the feasibility and initial efficacy of a multimodal swelling control intervention (MSI), comprised of an inelastic adjustable compression garment (CG), manual lymph drainage (MLD) massage, and home exercise program (HEP) after total knee arthroplasty (TKA) compared to a control group. METHODS Sixteen individuals (mean age 64.7 ± 7.1y) performed MSI for three weeks after TKA, through day 21 (D21). Outcome measures included patient satisfaction, safety, patient adherence, and swelling measured by Single Frequency Bioimpedance Assessment (SF-BIA). All outcomes were measured preoperatively and at postoperative D4, D7, D14, D21 and, three weeks after discontinuing MSI, on D42. Efficacy of MSI was calculated with Hedge's g effect size estimates using the SF-BIA ratios for MSI versus CONTROL (N = 56; mean age 64.3 ± 9.3y) at key post operative time points. RESULTS Patient satisfaction was 93% with no adverse events. Adherence to CG, MLD, and HEP were 85%, 99%, and 97% respectively. Peak swelling reduction with MSI was at D21 (Hedges' g = 1.60 at D21 (95% CI 0.99, 2.21)). Minimal change in swelling was observed three weeks after cessation of MSI on D42. CONCLUSIONS The self-administered MSI program is feasible and demonstrated strong initial efficacy to control swelling after TKA. Minimal rebound swelling was observed once MSI was withdrawn at D21. Future studies should examine the efficacy of inelastic adjustable compression in a randomized controlled trial.
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Affiliation(s)
- Joel Carmichael
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Colorado Anschutz Medical Campus, 13121 E 17(th) Ave, Mail Stop C244, Aurora, CO 80045, USA.
| | - Doug Dennis
- Colorado Joint Replacement, 2535 Downing Street, Unit 100, Denver, CO 80210, USA.
| | - Jason Jennings
- Colorado Joint Replacement, 2535 Downing Street, Unit 100, Denver, CO 80210, USA; Department of Mechanical and Materials Engineering, University of Denver, 2199 S. University Blvd., Denver, CO 80218, USA.
| | - Jennifer Stevens-Lapsley
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Colorado Anschutz Medical Campus, 13121 E 17(th) Ave, Mail Stop C244, Aurora, CO 80045, USA; Geriatric Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, 1700 Wheeling Street, Aurora, CO 80045, USA.
| | - Michael Bade
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Colorado Anschutz Medical Campus, 13121 E 17(th) Ave, Mail Stop C244, Aurora, CO 80045, USA; Geriatric Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, 1700 Wheeling Street, Aurora, CO 80045, USA.
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Fischer DC, Sckell A, Garkisch A, Dresing K, Eisenhauer A, Valentini L, Mittlmeier T. Treatment of perioperative swelling by rest, ice, compression, and elevation (RICE) without and with additional application of negative pressure (RICE +) in patients with a unilateral ankle fracture: study protocol for a monocentric, evaluator-blinded randomized controlled pilot trial. Pilot Feasibility Stud 2021; 7:203. [PMID: 34772457 PMCID: PMC8588602 DOI: 10.1186/s40814-021-00944-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 11/01/2021] [Indexed: 11/28/2022] Open
Abstract
Background Edema is commonly seen after surgical fixation of ankle fractures. Rest, ice, compression, and elevation (RICE) is an established combination to prevent swelling but hardly able to stimulate lymphatic resorption. Recently, an epicutaneously applied negative pressure suction apparatus (LymphaTouch®) has been introduced to stimulate lymphatic flow. While postoperative recovery, soft tissue, and osseous healing as well as functional outcome are probably linked to the amount of postoperative swelling, estimates on this relative to prevention (RICE) or prevention + stimulated resorption (RICE+) of fluid are scarce. Methods and analysis This is a single-center, evaluator-blinded randomized pilot trial to investigate postoperative swelling in adults requiring surgical fixation of a closed unilateral ankle fracture. A total of 50 patients will be recruited and randomly assigned to RICE or RICE+ prior to surgery. All patients will undergo evaluator-blinded measurements of the ankle volume the day before surgery and subsequently from the evening of the 2nd postoperative day every 24 h until discharge. RICE will be initiated right after surgery and continued until discharge from the hospital in all patients. Additional application of negative pressure therapy (RICE+) will be initiated on the morning of the 2nd postoperative day and repeated every 24 h until the time of discharge from the hospital. Outcome measures are (i) the relative amount and the time course of the postoperative swelling, (ii) the demand for analgesic therapy (type and amount) together with the perception of pain, (iii) the rate of complications, and (iv) mobility of the ankle joint and the recovery of walking abilities during a 12-weeks follow-up period. Serum and urine samples taken prior to sugery and during postoperative recovery will allow to evaluate the ratio of naturally occurring stable calcium isotopes (δ44/42Ca) as a marker of skeletal calcium accrual. Ethics and dissemination The protocol was approved by the institutional Ethics Committee (Rostock University Medical Center, Rostock, Germany) in accordance with the Declaration of Helsinki (approval number: A 2020-0092). The results of this study will be actively disseminated through scientific publications and conference presentations. Trial registration DRKS, DRKS00023739. Registered on 14 December 2020
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Affiliation(s)
- Dagmar-C Fischer
- Department of Pediatrics, Rostock University Medical Center, Ernst-Heydemann-Str. 8, 18057, Rostock, Germany.
| | - Axel Sckell
- Department of Traumatology, Hand and Reconstructive Surgery, Rostock University Medical Center, Rostock, Germany
| | - Angelina Garkisch
- Department of Traumatology, Hand and Reconstructive Surgery, Rostock University Medical Center, Rostock, Germany
| | - Klaus Dresing
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University Medicine Göttingen, Georg-August-University, Göttingen, Germany
| | | | - Luzia Valentini
- Department of Agriculture and Food Sciences, Neubrandenburg Institute for Evidence-Based Dietetics (NIED), University of Applied Sciences Neubrandenburg, Neubrandenburg, Germany
| | - Thomas Mittlmeier
- Department of Traumatology, Hand and Reconstructive Surgery, Rostock University Medical Center, Rostock, Germany
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Klein I, Tidhar D, Kalichman L. Lymphatic treatments after orthopedic surgery or injury: A systematic review. J Bodyw Mov Ther 2020; 24:109-117. [PMID: 33218497 DOI: 10.1016/j.jbmt.2020.06.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 04/05/2020] [Accepted: 06/07/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Orthopedic injuries in conjunction with extensive damage to tissues, bones and blood vessels, usually require a long recovery. Associated consequences are pain, movement limitations, decreased function and occasionally, prolonged edema, which can delay or interfere with the healing process. Lymphatic and compression therapy have become increasingly common, intending to reduce edema and pain, thus, promoting the recovery process. AIMS To examine the efficacy of methods commonly used to reduce edema after orthopedic injury or surgery, i.e. decongestive therapy, manual lymphatic drainage, and compression bandaging. METHODS English literature search was undertaken in January 2019, in the following databases: Cochrane Library, MEDLINE, PEDro. INCLUSION CRITERIA randomized controlled or quasi-controlled trials in adults who have edema or pain after recent limb trauma or surgery. Two independent assessors rated study quality and risk of bias using the PRISMA recommendations and PEDro score. RESULTS We evaluated 71 papers. After excluding duplicated and irrelevant papers, 15 met the eligibility criteria (6 on lymphatic treatment and 9 on compression). Quality of papers ranged from 3 to 7 on PEDro score; of them, 13 were 1b Level of Evidence and two were 1c. CONCLUSION After elective surgeries, when the significant edema appears or persists beyond recovery time, complex decongestive therapy and manual edema mobilization should be recommended in addition to conventional physical therapy. In acute injuries such as ankle or distal radius fractures, lymphatic treatments and compression bandaging should be considered as part of the therapeutic protocol. Nine studies evaluated different compression modalities found that only multilayer and long stretch compression significantly reduce edema.
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Affiliation(s)
- Ifat Klein
- Department of Physical Therapy, Assuta Hospital, Tel Aviv, Israel.
| | - Dorit Tidhar
- Department of Physical Therapy, Maccabi Healthcare Services, Netivot, Israel.
| | - Leonid Kalichman
- Department of, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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Abstract
Lymphatic flow plays a notable role in the regulation of bone formation and remodeling. Chronic accumulation of the lymph fluid within tissues may lead to issues with proper bone healing after fractures, emphasizing the importance of proper management of lymphedema after trauma. Many associated risk factors place patients at risk for lymphedema, including previous surgery with nodal dissection, radiation therapy, infection, malignancy, family history of congenital lymphedema, and trauma. The benchmark imaging technique for the diagnosis of lymphedema is lymphoscintigraphy. Other modalities include duplex ultrasonography, CT, and MRI. First-line conservative treatment of lymphedema is compression. Complete decongestive therapy or complex physical therapy, also known as decongestive lymphatic therapy (DLT), has shown positive results in reducing lymphedema. Surgical interventions aim to either reconstruct and restore function of the lymphatic system or debulk and reduce tissues and fluids. Understanding the significance of lymphedema on bone healing and techniques available to recognize it are important factors in preventing delay in diagnosis and ensuring proper management of lymphedema after trauma.
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Faculty Survey on the Status of Lymphology Education in Professional Doctor of Physical Therapy Programs. REHABILITATION ONCOLOGY 2020. [DOI: 10.1097/01.reo.0000000000000227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pichonnaz C, Bassin JP, Lécureux E, Christe G, Currat D, Aminian K, Jolles BM. Effect of Manual Lymphatic Drainage After Total Knee Arthroplasty: A Randomized Controlled Trial. Arch Phys Med Rehabil 2016; 97:674-82. [DOI: 10.1016/j.apmr.2016.01.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 12/21/2015] [Accepted: 01/02/2016] [Indexed: 11/30/2022]
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Oremus M, Dayes I, Walker K, Raina P. Systematic review: conservative treatments for secondary lymphedema. BMC Cancer 2012; 12:6. [PMID: 22216837 PMCID: PMC3320521 DOI: 10.1186/1471-2407-12-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 01/04/2012] [Indexed: 11/20/2022] Open
Abstract
Background Several conservative (i.e., nonpharmacologic, nonsurgical) treatments exist for secondary lymphedema. The optimal treatment is unknown. We examined the effectiveness of conservative treatments for secondary lymphedema, as well as harms related to these treatments. Methods We searched MEDLINE®, EMBASE®, Cochrane Central Register of Controlled Trials®, AMED, and CINAHL from 1990 to January 19, 2010. We obtained English- and non-English-language randomized controlled trials or observational studies (with comparison groups) that reported primary effectiveness data on conservative treatments for secondary lymphedema. For English-language studies, we extracted data in tabular form and summarized the tables descriptively. For non-English-language studies, we summarized the results descriptively and discussed similarities with the English-language studies. Results Thirty-six English-language and eight non-English-language studies were included in the review. Most of these studies involved upper-limb lymphedema secondary to breast cancer. Despite lymphedema's chronicity, lengths of follow-up in most studies were under 6 months. Many trial reports contained inadequate descriptions of randomization, blinding, and methods to assess harms. Most observational studies did not control for confounding. Many studies showed that active treatments reduced the size of lymphatic limbs, although extensive between-study heterogeneity in areas such as treatment comparisons and protocols, and outcome measures, prevented us from assessing whether any one treatment was superior. This heterogeneity also precluded us from statistically pooling results. Harms were rare (< 1% incidence) and mostly minor (e.g., headache, arm pain). Conclusions The literature contains no evidence to suggest the most effective treatment for secondary lymphedema. Harms are few and unlikely to cause major clinical problems.
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Affiliation(s)
- Mark Oremus
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Hirschmüller A, Baur H, Braun S, Kreuz PC, Südkamp NP, Niemeyer P. Rehabilitation after autologous chondrocyte implantation for isolated cartilage defects of the knee. Am J Sports Med 2011; 39:2686-96. [PMID: 21602564 DOI: 10.1177/0363546511404204] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Autologous chondrocyte implantation for treatment of isolated cartilage defects of the knee has become well established. Although various publications report technical modifications, clinical results, and cell-related issues, little is known about appropriate and optimal rehabilitation after autologous chondrocyte implantation. This article reviews the literature on rehabilitation after autologous chondrocyte implantation and presents a rehabilitation protocol that has been developed considering the best available evidence and has been successfully used for several years in a large number of patients who underwent autologous chondrocyte implantation for cartilage defects of the knee.
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Affiliation(s)
- Anja Hirschmüller
- University Hospital Freiburg, Department of Orthopedic Surgery and Traumatology, Germany.
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Abstract
BACKGROUND To quantify the effect of a single immersion exercise session on uncomplicated dependent edema in pregnancy. METHODS Lower leg volume was measured by water displacement volumetry and limb circumference in nine women with marked dependent edema, but otherwise normal second or third trimester pregnancy, before and after upright water immersion exercise session (Aqua-Fit) for 45 min. Maternal heart rate was monitored continuously throughout the session. Blood pressure was measured before and after the session. RESULTS Mean left leg volume decreased by 112 ml from 1665 to 1553 ml, and right leg volume by 84 ml from 1665 to 1581 ml (P = 0.007). Cardiovascular parameters fluctuated within the normal range, well below the upper limits recommended in pregnancy. CONCLUSIONS A single immersion exercise session is a safe, effective, and enjoyable complement, or alternative, to compression stockings for reduction of gestational dependent edema. Further study is required to determine its duration of effect and the optimum interval between sessions.
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Affiliation(s)
- Sabine Hartmann
- Perinatal Physiology Research Unit, Department of Obstetrics, Zurich University Hospital, Frauenklinikstrasse 10, 8091 Zurich, Switzerland.
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