Total knee arthroplasty (TKA) is an important option in the management of severe osteoarthritis. Despite excellent long-term results following TKA, the immediate postoperative period is often associated with pain, bleeding, edema, and reduced range of movement. So, what can we do to assist in making rehab better than traditional post-surgery methods?
The aim of this article is to look at how cryotherapy may assist in rehabilitation of TKA.
Despite the encouraging results of TKA, the immediate postoperative period is often associated with significant issues such as pain, surgical blood loss, and localized edema resulting from tissue damage and the inflammatory response (1). These are considered crucial factors due to their influence on postoperative opiate use, requirement for blood transfusion and its associated risks as well as a negative impact on postoperative rehabilitation (2). This can result in increased length of stay in hospital, in turn creating increased cost and inconvenience to the patient (3).
Despite progress in anaesthesia and multimodal pain management, TKA remains a challenging procedure for many patients. This has led to the use of nonpharmaceutical management adjuncts such as cryotherapy to address the immediate postoperative concerns described earlier.
Physiology of action
Cryotherapy involves the application of a cold substance, such as ice, to the skin surrounding inflamed soft tissues and joints. The theoretical physiological benefits of clinical cryotherapy have been widely documented since its use in the 1960s and the effects of ice have been demonstrated in several animal and human studies (4,5).
The proposed mechanism of action is that a reduction in temperature reduces intra-articular temperature and limits pain through reducing nerve conduction velocity in addition to promoting immediate vasoconstriction, reducing vascular spasm and slowing down of blood flow, ultimately decreasing tissue edema (6).
Pain
Pain has been the most investigated outcome measure in studies involving cryotherapy post-TKA. Kullenberg et al, observed significantly better pain control and patient satisfaction in patients treated with cryotherapy compared to epidural anaesthesia in 86 patients following TKA (7). Ohkoshi et al, found that that continuous cold application resulted in greater than 50% reduction in analgesic demands (8).
Blood loss
Blood loss can be a significant problem post-operatively, requiring blood transfusions at times. Levy and Marmar (9), reported a significant reduction in post-operative blood loss in patients treated with cold therapy compared to controls in a cohort of patients who underwent 10 bilateral and 80 unilateral TKAs with similar findings also shared by Ni et al, (10) Desteli et al, (11) assessed the effect of cryoceutical treatment both pre- and post-TKA versus no intervention. Despite concluding that this approach was effective at reducing peri-operative and postoperative haemorrhage, they did not report a statistically significant difference in need for transfusion between groups.
Postoperative swelling
Cryotherapy was found to reduce the inflammatory processes thought to decrease macrophage infiltration and the accumulation of TNF-α, NF-κB, TGF-β and MMP-9 mRNA levels (12).
Range of motion
Restrictions in range of motion (ROM) can hinder early rehabilitation. Kullenberg et al, reported an increased range of flexion when cryotherapy was used post-TKA in their study of 86 patients (7).
Conclusion
Management of postoperative pain following TKA still poses a challenge. However, nonpharmaceutical adjuncts such as cryotherapy are becoming increasingly popular and have evolved from simple ice packs to more refined devices employing whole body cryotherapy and local cryotherapy treatments. The current research shows this adjunct treatment is benefiting many patients with little to no contraindications.
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