Use of an App-Controlled Neuromuscular Electrical Stimulation System for Improved Self-Management of Knee Conditions and Reduced Costs.

Patients suffering from quadriceps muscle weakness secondary to osteoarthritis or after surgeries, such as total knee arthroplasty, appear to benefit from the use of neuromuscular electrical stimulation (NMES), which can improve muscle strength and function, range of motion, exercise capacity, and quality of life. Several modalities exist that deliver this therapy. However, with the ever-increasing demand to improve clinical efficiency and costs, digitalize healthcare, optimize data collection, improve care coordination, and increase patient compliance and engagement, newer devices incorporating technologies that facilitate these demands are emerging. One of these devices, an app-controlled home-based NMES therapy system that allows patients to self-manage their condition and potentially increase adherence to the treatment, incorporates a smartphone-based application which allows a cloud-based portal that feeds real-time patient monitoring to physicians, allowing patients to be supported remotely and given feedback. This device is a step forward in improving both patient care and physician efficiency, as well as decreasing resource utilization, which potentially may reduce healthcare costs.

Impact of Neuromuscular Electrical Stimulation (NMES) on 90-Day Episode Costs and Post-Acute Care Utilization in Total Knee Replacement Patients with Disuse Atrophy.

INTRODUCTION: This study evaluated differences in: 1) total episode payments, 2) probability of hospital readmission, 3) probability of inpatient rehab facility (IRF) and utilization, and 4) probability of skilled nursing care facility (SNF) utilization in patients who had disuse atrophy and underwent a total knee arthroplasty (TKA) and either did, or did not, receive preoperative home-based neuromuscular electrical stimulation (NMES) therapy. MATERIALS AND METHODS: We used the Medicare limited dataset for a 5% sample of beneficiaries from 2014 and 2015 to construct episodes-of-care for TKA (DRG-470) patients with disuse atrophy who underwent a TKA during the 30 days prior to hospital admission and 90 days post-discharge. Patients were stratified into those who either did or did not receive pre- and postoperative NMES therapy. An ordinary least square (OLS) model was used to estimate the impact of NMES on total episode. Linear probability models were used to estimate the impact of NMES on SNF or IRF utilization and readmission. RESULTS: A $3,274 reduction in episode payments for patients who used preoperative NMES versus those who did not (p<0.001) was demonstrated. The probability of readmission was 12.7% lower for those who used preoperative NMES therapy versus those who did not (p=0.609). The probability of utilizing IRF and SNF was 56.7% (p=0.061) and 46.4% (p=<0.001) lower for those who used pre- and postoperative NMES versus those who did not, respectively. CONCLUSION: Significant reduction in total episode payments and SNF utilization for TKA patients with disuse atrophy who had NMES therapy was demonstrated.

Innovative Multi-Modal Physical Therapy Reduces Incidence of Manipulation Under Anesthesia (MUA) in Non-Obese Primary Total Knee Arthroplasty.

INTRODUCTION: Patients may experience knee stiffness following total knee arthroplasty (TKA). Non-operative measures, such as more physical therapy and special splints are warranted in such cases. In the event of failure of these measures to restore knee range of motion, more invasive procedures with higher risks, such as manipulation under anesthesia (MUA) or repeat surgery, can be utilized. Thus, it becomes essential to optimize their non-operative measures in order to avoid more invasive, riskier options. Therefore, the purpose of this study was to evaluate and compare: 1) range of motion, and 2) the rate of MUA in patients who either underwent a multi-modal physical therapy regimen (IMMPT) or standard-of-care post-operative therapy (standard) following primary total knee arthroplasty. MATERIALS AND METHODS: We analyzed all non-obese patients who underwent primary TKAs between January 2013 and December 2014 at our institution who started an outpatient physical therapy program within six weeks of their surgery (n = 127 knees). There were 86 women and 41 men who had a mean age of 67 years (range, 42 to 88 years). This cohort was stratified into those who underwent an IMMPT regimen at our institution (n= 47) and those who underwent standard therapy at an outside institution (N = 80). The range of motion and rate of manipulation between the two groups was compared by using Chi-square and Student's t-test, as appropriate. RESULTS: There were similar proportions of those who had an optimal range of motion (≥110 degrees flexion and ≤5 degrees extension) in the IMMPT group as compared to the standard physical therapy cohort (81% vs. 82%). The IMMPT cohort had a significantly lower proportion of patients who underwent MUA as compared to the standard therapy cohort (2% vs. 13%). CONCLUSIONS: This study shows an IMMPT protocol utilizing Astym® therapy (Performance Dynamics, Inc. Muncie, Indiana) is able to significantly reduce the rate of manipulation following a total knee arthroplasty. Furthermore, this IMMPT approach was also able to achieve similar range of motion to the standard physical therapy group while reducing the rate of manipulation, which may indicate similar efficacy in restoring range of motion. Comparative randomized studies are needed to determine the true benefit of this IMMPT protocol.

A Meta-Analysis of Transcutaneous Electrical Nerve Stimulation for Chronic Low Back Pain.

OBJECTIVE: Transcutaneous electrical nerve stimulation (TENS) may provide a safe alternative to current side-effect-heavy narcotics and anti-inflammatories utilized in chronic low back pain. Therefore, we performed a meta-analysis to evaluate the efficacy of TENS for the treatment of chronic low back pain. MATERIALS AND METHODS: We included randomized controlled trials (RCTs), cohort studies, and randomized crossover studies on TENS for the management of low back pain. We utilized a visual analogue scale (VAS) for pain as our primary outcome. Effectiveness of treatment was quantified using improvement in outcome scores for each study. Of the studies that met the criteria, 13 allowed for calculation of weighted mean differences in pain reduction. We used a random model effect to evaluate changes in pain produced by the intervention. RESULTS: Included were nine level I and four level II, encompassing 267 patients (39% male) who had a mean follow-up of seven weeks (range; 2 to 24 weeks). The mean duration of treatment was six weeks (range; 2 to 24 weeks). The standardized mean difference in pain from pre- to post-treatment for TENS was 0.844, which demonstrated significant improvement of TENS on pain reduction. When subdividing treatment duration, patients that were treated for < 5 weeks had significant effects on pain, while those treated for > 5 weeks did not. CONCLUSION: Treatment of chronic low back pain with TENS demonstrated significant pain reduction. The application of TENS may lead to less pain medication usage and should be incorporated into the treatment armamentarium for chronic low back pain.

What Is the Efficacy of Repeat Manipulations Under Anesthesia to Treat Stiffness Following Primary Total Knee Arthroplasty?

BACKGROUND: Manipulation under anesthesia (MUA) can help post-total knee arthroplasty (TKA) patients who have knee stiffness regain range-of-motion. However, despite undergoing MUA, patients may have persistent knee stiffness. Often, this persistent knee stiffness is treated with a repeat MUA. Therefore, the purpose of this study was to evaluate repeat MUAs by assessing: (1) demographic characteristics, (2) range-of-motion, (3) clinical outcomes, and (4) rate of revision surgery in post-TKA patients with persistent knee stiffness who either underwent a single MUA or repeat MUAs. MATERIALS AND METHODS: One-hundred-and-sixty-seven post-TKA who had undergone an MUA between 2005 and 2011 at two institutions were reviewed. Patients were stratified into those who had a single-MUA (138 knees) and those who had a repeat MUA (29 knees). The mean follow-up period was 63 months (range, 36 to 90 months). The incidence of repeat MUA within this cohort was determined. Demographics and ROM were compared using Student t-test and Chi-square as appropriate. Functional outcomes were assessed using Knee Society scores (KSS) and compared between the two cohorts. RESULTS: Among the 167 patients who underwent a MUA, 29 (17%) required repeat manipulations. The repeat MUA cohort was younger and more likely to have osteonecrosis as the underlying cause of knee disease. For the repeat MUA cohort, 17 patients (59%) had achieved satisfactory mean gains in ROM after their repeat MUAs. These patients had also achieved excellent mean Knee Society objective and functional scores. However, another seven knees (24%) had further persistent knee stiffness requiring arthrolysis of adhesions and five patients (17%) had undergone revision of the polyethylene spacer or patellar component to improve range-of-motion. CONCLUSION: In this study, the majority of patients who had undergone a repeat MUA were able to achieve improvements in flexion range-of-motion and functional outcomes. However, the remaining patients required more invasive procedure to treat persistent knee stiffness. In patients who have persistent knee stiffness after MUAs, a repeat MUA may be helpful to increase range-of-motion and function.

Nonpharmacologic Pain Management and Muscle Strengthening following Total Knee Arthroplasty.

Despite technological advances in total knee arthroplasty (TKA), management of postoperative muscle weakness and pain continue to pose challenges for both patients and health care providers. Nonpharmacologic therapies, such as neuromodulation in the form of neuromuscular electrical stimulation (NMES) and transcutaneous electrical nerve stimulation (TENS), and other modalities, such as cryotherapy and prehabilitation, have been highlighted as possible adjuncts to standard-of-care pharmacologic management to treat postoperative pain and muscle weakness. The aim of this review was to discuss existing evidence for neuromodulation in the treatment of pain and muscular weakness following TKA, and to shed light on other noninvasive and potential future modalities. Our review of the literature demonstrated that NMES, prehabilitation, and some specialized exercises are beneficial for postoperative muscle weakness, and TENS, cooling therapies, and compression may help to alleviate post-TKA pain. However, there are no clear guidelines for the use of these modalities. Further studies should be aimed at developing guidelines or delineating indications for neuromodulation and other nonpharmacologic therapies in the management of post-TKA pain and muscle weakness.

Decreased Opioid Utilization and Cost at One Year in Chronic Low Back Pain Patients Treated with Transcutaneous Electric Nerve Stimulation (TENS).

INTRODUCTION: Chronic low back pain (CLBP) may be treated without opioids through the use of transcutaneous electrical nerve stimulation (TENS). However, no study has evaluated its clinical effect and economic impact as measured by opioid utilization and costs. The purpose of this study was to evaluate patients who were given TENS for CLBP compared to a matched group without TENS at one-year follow-up, to determine differences between opioid consumption. MATERIALS AND METHODS: Opioid utilization and costs in patients who did and did not receive TENS were extracted from a Medicare supplemental administrative claims database. Patients were selected if they had at least two ICD-9-CM coded claims for low back pain in a three-month period and were then propensity score matched at a 1:1 ratio between patients who received TENS and those who did not. There were 22,913 patients in each group who had a minimum follow-up of one year. There were no significant demographic or comorbidity differences with the exception that TENS patients had more episodes of back pain. RESULTS: Significantly fewer patients in the TENS group required opioids at final follow-up (57.7 vs. 60.3%). TENS patients also had significantly fewer annual per-patient opioid costs compared to non-TENS patients ($169 vs. $192). There were significantly lower event rates in TENS patients compared to non-TENS patients when measured by opioid utilization (characterized by frequency of prescription refills) (3.82 vs. 4.08, respectively) or pharmacy utilization (31.67 vs. 32.25). The TENS group also demonstrated a significantly lower cost of these utilization events ($44 vs. $49) and avoided more opioid events (20.4 events fewer per 100 patients annually). DISCUSSION: Treatment of CLBP with TENS demonstrated significantly fewer patients requiring opioids, fewer events where a patient required an opioid prescription, and lower per-patient costs. Since TENS is both non-invasive and a non-narcotic, it may potentially allow physicians to be more aggressive in treating CLBP patients.