Use of Neuromuscular Electrical Stimulation During Physical Therapy May Reduce the Incidence of Arthrofibrosis After Total Knee Arthroplasty.

INTRODUCTION: Arthrofibrosis remains a major complication following total knee arthroplasty (TKA) that negatively impacts patient outcomes and exhausts healthcare resources. The use of neuromuscular electrical stimulation (NMES) has demonstrated the ability to facilitate quadriceps muscle recovery and reduce pain. Therefore, the purpose of this study was to compare TKA patients who received physical therapy (PT) and adjuvant NMES therapy versus physical therapy alone in terms of: 1) rates of manipulation under anesthesia (MUA) to treat arthrofibrosis; and 2) post-therapy range of motion (ROM). MATERIALS AND METHODS: This was a retrospective review of TKA patients from multiple institutions who underwent physical therapy versus physical therapy and adjuvant NMES therapy following primary TKA. A total of 206 patients were reviewed in the two cohorts that either received PT alone (n=86) or PT and adjuvant NMES therapy (n=120). Data regarding the requirement of MUA postoperatively for treatment of arthrofibrosis were collected for every patient. Additionally, pre- and post-therapy knee ROM data was also collected. Outcomes in both cohorts were then compared and analyzed. RESULTS: Lower rates of arthrofibrosis requiring MUA were recorded in patients who used NMES therapy and PT when compared to PT alone (7.5% vs. 19.8%; p=0.009). Log regression analysis revealed lower odds of needing MUA in patients who utilized NMES therapy in adjunct with PT (odds ratio [OR]=0.36; 95% CI: 0.115 to 0.875; p=0.023). Patients who received the NMES therapy were shown to have a statistically greater mean improvement in ROM when compared to those patients who did not receive NMES (+2.63, p=0.04). Log regression analysis also demonstrated that post-PT ROM decreased the odds of receiving MUA with a larger ROM (OR=92; 95% CI: 0.824 to 0.9855; p<0.001). CONCLUSION: This study demonstrated that the use of NMES during PT may reduce the incidence of arthrofibrosis and improve patient ROM. Prospective, randomized controlled, and larger-scale studies are needed to validate these results. Nevertheless, this novel report demonstrated the positive outcomes for a new application of the NMES therapy.

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.

Knee Osteoarthritis: Does Transcutaneous Electrical Nerve Stimulation Work?

Transcutaneous electrical nerve stimulation has been proposed as a nonoperative treatment for osteoarthritis. The purpose of this study was to evaluate the outcomes of a novel transcutaneous electrical nerve stimulation device compared with those of other standard nonoperative modalities for the treatment of osteoarthritis of the knee.

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.

Do the Effects of Transcutaneous Electrical Nerve Stimulation on Knee Osteoarthritis Pain and Function Last?

Transcutaneous electrical nerve stimulation (TENS) has been shown to decrease pain associated with knee osteoarthritis, which potentially leads to better function, improved quality of life, and postpones the need for surgical intervention. The purpose of this study was to perform a 1-year follow-up of a previous prospective group of patients with knee osteoarthritis, randomized to TENS or standard of care, who were asked to rate their changes in: (1) patient pain perception; (2) subjective medication use; (3) subjective functional abilities; (4) quality of life; (5) device use; and (6) conversion to TKA. A population of 70 patients were randomized to receive either a TENS device or a standard conservative therapy regimen. Patients were evaluated based on various subjective outcomes at minimum 1-year (mean, 19 months) follow-up. The TENS cohort had lower visual analog pain scores compared with the matching cohort. Subjective functional outcomes, as well as functional and activity scores, were also greater in the TENS cohort. Patients in TENS cohort showed significant improvements in their subjective and functional outcomes as compared with their initial status, while the control group did not show significant change. A majority of the TENS patients were able to reduce the amount of pain medications. Additionally, a large portion of the patients assigned to the TENS group continue to use the device, after completion of the trial. This study demonstrated the benefit of TENS for improving subjective outcomes in patients with pain due to knee osteoarthritis, compared with standard conservative treatments. The results of the study suggest that TENS is a safe and effective adjunct as part of the spectrum of current nonoperative treatment methods for knee osteoarthritis.

Use of Transcutaneous Electrical Nerve Stimulation Device in Early Osteoarthritis of the Knee.

Some have proposed the use of transcutaneous electrical nerve stimulation (TENS) as an adjunct to the current standard of care in treatment of osteoarthritis knee pain. The purpose of this study was to evaluate the effects of TENS on the following issues in patients who have early-stage osteoarthritis of the knee: (1) pain reduction; (2) subjective and (3) objective functional improvements; (4) quality-of-life (QOL) measure improvements; and (5) isokinetic strength. A prospective, randomized, and single-blinded trial was performed on 23 patients who were randomized to either novel TENS device or standard of care. Metrics analyzed included stair-climb test; timed-up-and-go test (TUGT); 2-minute walk test; 20 times, single leg 6-inch step test; five-repetition chair-rise test; active and passive range-of-motion (ROM) score; short form health survey-36 scores (SF-36) score; Knee Society Score (KSS); lower extremity functional scale (LEFS); visual analog scale (VAS); and isokinetic quadriceps and hamstring strength. In objective functional scores, TENS had significant improvements in TUGT and objective KSS when compared with the matching cohort. Subjective functional and QOL outcomes patients had a significant improvement of their LEFS and SF-36 physical component with the use of TENS brace. The TENS device significantly improved the quadriceps strength when compared with standard therapy. In evaluation for improvement within the TENS cohort, patients had a significant improvement at 3-month follow-up in the TUG test, timed stair-climb test, 20-times single leg, KSS, LEFS, and SF-36 physical component compared to their initial visit. In addition, within the TENS cohort, patients had a significant reduction in pain via VAS at their 3-month follow-up. In conclusion, the use of TENS for 3 months has shown encouraging results to improve pain, function, and QOL in patients with painful osteoarthritic knees, and could positively contribute as an adjunct to current nonoperative treatment of knee arthritis. However, given our small sample size, larger randomized studies are needed to further evaluate these outcomes.

Post-operative blood management strategies for total hip arthroplasty.

Total hip arthroplasty is increasing in incidence due to our aging population. However, this procedure has a high potential for increased blood loss, with allogeneic blood transfusions commonly used. However, due to potential transfusion-related risks such as immunosuppression or infections, attempts have been made to reduce the amount of blood loss and minimize transfusions. Therefore, our aim was to provide a broad overview of the widely used methods for reducing post-operative blood loss after total hip arthroplasty. These include antifibrinolytic agents, autologous blood transfusion drains, avoiding the use of drains, and modifications in drainage techniques. In addition, lowering the transfusion threshold is another method used to decrease the rates of allogeneic blood transfusion. Current evidence suggests that the use of some of these strategies-either alone, or in combination-may reduce the amount of blood loss and the need for allogeneic transfusions. However, further research is needed to create new, more standardized guidelines.

Preoperative blood management strategies for total hip arthroplasty.

Total hip arthroplasty is associated with marked blood loss, with the potential for up to 90% of patients requiring allogeneic transfusions. Also, perioperative-induced anemia is associated with lower postoperative functional scores, increased mortality, increased cardiovascular risks, longer hospital stays, and postoperative infections. The purpose of this review was to analyze the recent evidence on preoperative blood management strategies utilized for total hip arthroplasty. Specifically, we evaluated the use of preoperative iron therapy, intravenous erythropoietin, and autologous blood donation. No single strategy was shown to be superior over another in reducing the need for allogeneic transfusions; however, a combination of these blood management strategies may result in improved blood loss outcomes. Larger prospective randomized studies comparing the individual strategies, as well as combination therapies, are needed to develop a concise statement on the most effective and efficient preoperative blood management treatment algorithms for total hip arthroplasty.

Preoperative blood management strategies for total knee arthroplasty.

Elective total knee arthroplasty is frequently associated with considerable blood loss and a concomitant decline in hemoglobin postoperatively. This often leads to high rates of allogeneic transfusions, with reports of up to 69%, to treat postoperative anemia. Allogeneic blood transfusions have been shown to be an independent risk factor for increased adverse outcomes, such as prolonged length of hospital stay and postoperative infections. Although multiple preoperative blood management strategies have been proposed, there are no concise guidelines, as few studies have compared the relative efficacy of these techniques. The aim of this review was to evaluate current evidence on the various preoperative blood management strategies for patients undergoing total knee arthroplasty and to provide an overview of the safety and efficacy of these practices. Specifically, we evaluated preoperative autologous blood donation, iron therapy, and intravenous erythropoietin. Current evidence suggests that these techniques independently may be effective at reducing the incidence of allogeneic blood transfusions, correcting preoperative, and preventing postoperative anemia. However, more studies are necessary to evaluate combination protocols, as well as the cost-effectiveness and safety of these practices as part of routine preoperative blood management for total knee arthroplasty.

Long-term outcomes of MUA for stiffness in primary TKA.

Knee stiffness following primary total knee arthroplasty (TKA) is a well-recognized problem which leads to poor patient outcomes and may limit patient activities of daily living. Manipulation under anesthesia (MUA) is one option for the treatment of knee stiffness. However, there has been controversy regarding the safety and long-term efficacy of this procedure. A systematic review of the literature was performed to identify studies that reported the clinical outcomes and measured range of motion for patients undergoing MUA. Fourteen studies (913 patients) reported range of motion results following MUA at up to 10-year follow-up. The mean premanipulation and final range of motion were 66 and 99 degrees, respectively. Compared with preoperative range of motion, the gain in the range-of-motion arc at 1-, 5-, and 10-year follow-up was 30, 33, and 33 degrees, respectively. Complications were rare with only two reported periprosthetic fractures, resulting in an incidence of 0.2%. MUA for a stiff primary TKA is an efficacious procedure to restore range of motion. Early gains in motion appear to be maintained at long term, and in some cases patients may gradually improve further at mid-term follow-up. The risk of periprosthetic fracture is low, making MUA a safe option for improving knee range of motion.

Clinical and economic impact of TENS in patients with chronic low back pain: analysis of a nationwide database.

This study evaluated patients who were given transcutaneous electrical nerve stimulation (TENS) compared with a matched group without TENS prior to intervention and at 1-year follow-up. Patients who were treated with TENS had significantly fewer hospital and clinic visits, used less diagnostic imaging (31 vs 46 events per 100 patients), had fewer physical therapy visits (94 vs 107), and required less back surgery (7.5 vs 9.2 surgeries) than patients receiving other treatment modalities. Total annual costs for chronic low back pain patients without neurological involvement were lower in TENS patients ($17,957 vs $17,986 for non-TENS), even when the cost of the device was taken into account.