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Influence of physiotherapy on knee joint pain after arthroscopy
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/locate/kontakt 1 2 3
Original research article
Influence of physiotherapy on knee joint pain after arthroscopy
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Marek Zeman a,*, Pavlína Princová b a
University of South Bohemia in České Budějovice, Faculty of Health and Social Sciences, Institute of Physiotherapy and Selected Medical Disciplines, České Budějovice, Czechia b Tábor Hospital JSC, Department of Rehabilitation, Tábor, Czechia
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article info
abstract
Article history:
The article deals with the topic of the influence of physiotherapy on arthroscopic treatment
Received 18 September 2016
of the knee joint. The goal is to verify whether the selected methods of kinesiotherapy using
Received in revised form
physical therapy will lead to a decrease in pain and stability of the knee joint in patients who
2 January 2017
have undergone arthroscopy. The sample group consisted of 50 patients who underwent an
Accepted 20 January 2017
arthroscopic surgical operation of the knee joint. They were divided into two groups. The
Available online xxx
control group consisted of patients who were not recommended a post-operative phy-
Keywords:
group consisted of patients who underwent ten therapies. To prove the influence of
siotherapeutic treatment. They were discharged for home treatment. The intervention Arthroscopy
physiotherapy on pain and the stability of the knee joint, selected standardized question-
Physiotherapy
naires were used. They were filled in immediately after the operation and four weeks later.
Pain
Initial and final kinesiology assessments were carried out, including aspection, palpation,
Knee joint
goniometric and anthropometric measurement and examination of muscle strength. The
Meniscus
results show that the selected physiotherapeutic methods decrease pain of the knee joint and improve its stability in patients who have undergone arthroscopy. They also eliminate swellings, and have a positive effect on the strength and mobility of the operated limb. They help patients to quickly return to a fully active daily life. It is important to choose physiotherapy methods for each patient individually because individual dispositions and possibilities are not the same. Positive results can be reached combining various physiotherapy methods. Nevertheless, these results cannot be reached without the patient's active collaboration. © 2017 Faculty of Health and Social Sciences of University of South Bohemia in České Budějovice. Published by Elsevier Sp. z o.o. All rights reserved.
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* Corresponding author at: University of South Bohemia České Budějovice, Faculty of Health and Social Sciences, Institute of Physiotherapy and Selected Medical Disciplines, B. Němcové 585/54, 370 01 České Budějovice, Czechia. E-mail address: [email protected] (M. Zeman). http://dx.doi.org/10.1016/j.kontakt.2017.01.006 1212-4117/© 2017 Faculty of Health and Social Sciences of University of South Bohemia in České Budějovice. Published by Elsevier Sp. z o. o. All rights reserved.
Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006
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Introduction
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Lower limbs enable the most natural kind of locomotion – walking. Their significance in the support and movement of the erect body on two legs is major, which is the reason for our robust limbs having strong groups of muscles [1]. Great overexertion of articular facets and pressure are the reason the knee joint is predisposed to degenerative changes and injuries. The knee joint belongs to the most frequently injured joints of all. The reasons for the increasing percentage of injured young people are problems connected to injuries in sports, such as tennis, football, skiing, snowboarding and hockey [2]. Most of these patients are forced to seek medical help due to the symptoms of an injury, such as pain, swellings, knee joint instability and others. What is most important are the right diagnostics and the recognition of the type of pain because it can be grounded in various causes [3]. To set the right diagnostics, we use different depictive methods, such as X-ray, MRI, ultrasound and arthroscopic examinations, which enable an operation from 2 min openings [4]. A large number of people suffering from knee joint injury report pain, problems with stability, swellings, and partially limited mobility. They also report bad or very low level of information [5]. Most patients are discharged after the arthroscopy operation on the same day, and the next time they see their doctor is the day of the extraction of the stitches. Many of these patients are not informed enough about the possibilities of the following physiotherapy, which helps them to reach better stability and shortens their convalescence.
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Arthroscopy and the examination of the knee joint
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Arthroscopy is a modern diagnostic and surgical method with minimum invasion. It is a method after which a very small scar remains and the patient can soon return to a normal life [6]. The operation begins with a small incision of about 1 cm, where an endoscope probe called an arthroscope is inserted. At the end of the metal tube, a small camera with a cold light is installed, which televises the operation. The arthroscopy tube or a stand-alone intake cannula with a sterile physiological solution is inserted. A thin surgical tool is inserted in the other side of the joint, which not only enables a view of the inside of the joint, but also of the articular cartilage, meniscus, ligaments and the whole articular case. The tool may enable an operation [7,8], whose length depends on its seriousness but it most often takes 30–60 min. After a standard arthroscopy, the patient can be discharged immediately. In more complicated cases, they are hospitalized for 3–4 days. A systematic assessment of the whole knee and an internal examination must precede the operation [9]. Arthroscopy is carried out in the whole or spinal anaesthesia. All inner articular changes in the knee joint are an indication for treatment. We assign some types of fractures and arthritic changes to arthroscopy operations, as well as the reconstruction of the anterior cruciate ligament, treatment of torn ligaments, damaged cartilages (chondromalacia), the removal of the inflammatory inner articular epithelium (synovectomy) and a partial or full meniscectomy of the damaged meniscus [10].
Kinesiotherapy methods and physical therapy After a surgical operation, kinesiotherapy treatment with timely mobilization and verticalization is ideal. Frequent neglect and the wrong treatment of such injuries can lead to a quicker emergence of arthrosis or joint instability [11]. Exercising muscles for joint stabilization plays an important role. Our attention is focused on the prevention of muscle shortening and atrophy. We use positioning to prevent contractures with limited mobility [12]. We further focus on extensor knee muscles because insufficient treatment causes patellar and femoral arthrosis or insertion difficulties [13]. Passive and active exercise: passive movements are performed without the activity of the patient during the first postoperative days with regard to swellings, pain and the possibilities of the operated limb. Active exercise is performed under the therapist's supervision, where they help or control the movements so that they are performed in the best way possible. Active exercise uses other isometric contractions as well [14]. Soft and mobilization techniques: they help preserve the free mobility of these tissues. Mobilization is performed in joints, but it can be used in all mobile structures connected to the motor system [15]. Functional limitations of the joint mobility (blocks) are usually connected to so-called trigger points. These points are one of the main causes of blocks and that is why, in mobilizations, neuromuscular techniques are used so that the muscles are relaxed at the same time. The techniques are, for example, PIR – post-isometric relaxation and IR – reciprocal inhibition. PIR enables reaching a greater range of joint movement and relaxing shortened muscles through inhaling and exhaling [16,17]. Kinesiotaping: it is a kind of fixing bandage (often used in sports) and it belongs to the gentlest technique because it preserves blood circulation. It belongs to the so-called functional techniques of the prevention of the treatment of the muscular skeletal system instead of the former fixation plaster bandage [18]. It is easier to prevent the consequences connected to the fixation treatment. Taping shortens the treatment and increases the feeling of security. ‘‘Taping’’ can be used long term, for a few weeks, but also short term during a one-time load. The fixation also strengthens the chronically weakened ligaments after acute injuries, because it stabilizes and fixes the joint for the stabilization of functionality [16]. Exercising with balls and elastic tensions: small or big balls (so called over balls) are used for mobilization and stretching exercises, but also for toning exercises in order to strengthen the weakened muscles and improve co-ordination. Exercises with elastic tensions use rubber bands which are about 15 cm wide. The tensions are used for strengthening and influencing hypertonic and shortened muscles by influencing articular mobility and training co-ordination [19]. Exercising in closed and opened kinematic series: while exercising in opened series, the terminal body segment is loose, which results in the exercising of individual muscles in isolation. While exercising in closed series, all of the muscle series are activated, thanks to which it is necessary to activate multiple joint muscles and co-contract agonists and antagonists. The therapy should first include exercises from the closed series, especially in the first phases of physiotherapy,
Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006
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due to exercising the stability of the knee joint and the correct co-contraction of m. quadriceps femoris and the so-called hamstrings. The ideal neuromuscular control is reached through a combination of both types of series [20]. Senzomotoric stimulation: the method emphasises the increase of afferentation, especially from the face of the foot and deep nape muscles. It uses proprioception from deep receptors in the muscles, joints and ligaments. The aim of the exercise is the recovery of the correct muscle co-ordination and balance, influencing the disorder of the proprioceptive perception and the acceleration of the commencement of muscle contraction [21]. The patient exercises barefoot due to the maximum utilization of afferentation from the face of the foot. One of the means of facilitating the face of the foot is the activation of the muscles which support the arch of the foot by creating the socalled ‘‘little foot’’. It enables the improvement of the position of all leg joints and also the change in the tension in ligaments and muscles, which influences the proprioceptive signalization in the improvement of stability. Physical therapy: physical therapy increases or changes the afferent information, which helps to activate self-reparative mechanisms in the organism. Hydrotherapy is a frequently chosen physical therapy in knee disorders due to its antiswelling effects, phototherapy for its biostimulatory and analgesic effects, magnetic therapy for its trophotropic effects and electrotherapy for its analgesic effects [22,23]. Mechanic therapy enables the use of lymphatic drainage. Hydrotherapy, specifically cryotherapy, also called the cooling treatment, is a frequent means of pain treatment, especially of acute injuries. Cooling causes a decrease in the metabolic activity of the tissues, and decelerates the neural net, which affects swellings, pain and inflammation. The treatment is individual and it depends on the particular condition of the patient and their response to the negative thermotherapy [23,24]. Phototherapy combines photochemical and biostimulatory effects by applying electromagnetic radiation. The most frequent is laser, which helps heal tissues better. The advantage of the laser is the possibility of using it before the extraction of stitches because it is a non-contact method [16]. Its effects are analgesic, anti-swelling, anti-inflammatory and biostimulatory. It is the reason why tissues heal and regenerate better [23]. We use the Maestro Biostimul laser with CCM laser probes (wavelength of 830 nm), which penetrates deeper (approx. up to 1.5 cm). The power of the probe is set to 300 nW, the energetic density from 2 up to 5 J/cm2 and the frequency to 8.9 Hz.
Materials and methods The aim of the research is to monitor whether the selected kinesiotherapy methods combined with physical therapy applied soon after arthroscopy influence the speed of pain relief and the improvement of articular stability. The visual analogue scale (VAS) was used to assess the subjective intensity of pain. The Lysholm Knee Scoring Scale, which is used for disorders of the meniscus, ligaments and cartilage, was used to assess the function of the stability of the knee. The questionnaires were used at the beginning and at the end of the therapy.
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The visual analogue scale is simple and understandable and that is why it belongs to the most frequently used methods. Pain is set on a 10-centimetre line segment, where the points at the beginning of the scale (on the left side) signify a fully painless condition. Every other centimetre shows a higher intensity of pain; number 10 is the most severe pain that the patient can imagine. The line segment is numbered from 0 to 10 from left to right. Points 1–3 signify low pain, 4–7 mild pain, and 8–10 severe pain. The Lysholm Knee Scoring Scale enables a subjective assessment of the function of the knee. It comprises, for example limping, the need for a walking support, possible knee blocks, swellings, the possibility of using the stairs, squatting, pain and instability. The lower number of points shows the insecurity, instability and the functionality disorders of the knee; the higher number of points shows an improved stability of the knee. The maximum number of points is 100, where 95– 100 signify an excellent stability, 84–94 a good stability, 65–83 a satisfying stability, 64 and lower a dissatisfying stability [25]. A total of 50 patients who underwent arthroscopy of the knee joint were involved in the research group. The patients underwent the operation between March and September 2015 in the České Budějovice Hospital Inc. The group, who underwent a partial meniscectomy, consisted of patients with a lesion on a part of the meniscus. These patients were randomly divided into two groups – the control group and the intervention group – and they were monitored for four weeks from the first day of discharge to home treatment after the operation. After a thorough examination, the patients from the intervention group were set up with an individual physiotherapy plan, which depended on their problems (see below). The patients from the intervention group completed a complex kinesiotherapy programme, including physical therapy (laser). The four-day programme consisted of ten therapies. In the first two weeks, the 50-minute exercise unit was performed in three therapies per week; the third and fourth week comprised two exercise units. The control group underwent the therapy based only on the instructions and recommendations of a doctor.
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Physiotherapy plan
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1st post-operative week
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The first day after the operation: early verticalization and walking exercise using the French crutches, with a 50% load. The application of cryotherapy with cryobags, respecting anti-embolic regulations (compressive stockings, positioning, keep-fit of lower limbs). Therapy aimed at keeping the level of movement and activation of m. quadriceps femoris; passive and active exercise. Treating and relaxing soft tissues with myofascial techniques including the care of the scar, relaxing the patella, informing about the possibilities of individual therapy.
2nd post-operative week Treating and relaxing soft tissues with myofascial techniques, mobilization of the patella and the tibiofibular
Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006
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articulation, of the trophic of the scars and the whole knee joint area. 20-minute ride on a stationary bicycle (the requirement is reaching a 908 flexion of the knee joint). Manual lymphatic drainage aimed at the reduction of postoperational swelling, application of the lymphatic tape. Post-izometric relaxation of the hamstring muscle and the m. quadriceps femoris. Using the laser of a wavelength of 830 nm in 6–8 procedures. The probe was set to 300 mW, the energetic density to 2 up to 5 J/cm2 and the frequency to 8.9 Hz. Exercising mostly in closed kinematic series due to more stable movements. Senzomotoric stimulation – exercising a supervised sitting and standing position following the exercise of the so-called ‘‘little foot’’.
3rd and 4th post-operative week Exercising in open and closed kinematic series to strengthen the dynamic knee stabilizers. Aimed correction of the basic movement patterns, such as the standing position and walking. After managing the supervised standing position – exercising the standing position on one foot. Exercising the correct walking. Senzomotoric stimulation using unstable surfaces (a tubeshaped segment, dynair and walking in balance sandals).
Results The total of 50 patients comprised 14 women and 36 men. The age of the patients was between 25 and 50 years. The control group included 9 women (n = 36%) and 16 men (n = 64%). The intervention group included 5 women (n = 20%) and 20 men
(n = 80%). The average age of the patients in the control group was 39.6 years, and in the intervention group it was 35.6 years.
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Pain assessment
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We assumed that the intervention group would record a lower degree of pain in the operated joint. To assess pain, the visual analogue scale with points from 0 to 10 was used. The preliminary average assessment of pain in the intervention and control group was similar, but, after therapy, the final assessment of pain in the intervention group was lower. The intervention group recorded an average of 4.32 points in the preliminary examination and 0.28 points in the final examination. The control group recorded an average of 4.48 points in the preliminary examination and 1.16 points in the final examination. For better clarification, the chart of the pain assessment in all compared groups of patients has been added below (Charts 1 and 2). The statistical comparison of the final results was carried out with a two-choice t-test, which compares the final results of the VAS in both groups. The results of the test are shown in Table 1. Considering the established values, it is possible to claim that, comparing the control and intervention group, the intervention group reached a statistically significant lower degree of pain.
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Assessment of the joint stability
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We further assumed seeing a greater difference between the preliminary and final values of the Lysholm Knee Scoring Scale (which is the marker of the knee joint stability) in patients in the intervention group compared to the control group. At the beginning, the intervention group reached an average of 56.16 points and at the end 96.28 points. The control group showed the values of 53.8 and after 4 weeks 83.8 points. The statistical comparison of the results in the t-test assessed the difference
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Chart 1 – Illustration of the preliminary and final assessment of pain of VAS in the intervention group. Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006
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Chart 2 – Illustration of the preliminary and final assessment of pain of the VAS in the control group.
Table 1 – Statistical assessment of post-therapy pain in both groups.
Intervention group Control group
Average
DD
t
p
0.28 1.16
0.46 0.80
–4.77
0. 0000085
t – test criterion; DD – decisive deviation; p – significance level.
Table 2 – Statistical assessment of the differences of the Lysholm Knee Scoring Scale between the preliminary and final examinations in the intervention and control groups.
Intervention group Control group
Average
DD
t
p
40.12 30
8.10 8.96
4.19
0. 00006
t – test criterion; DD – decisive deviation; p – significance level.
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between the preliminary and final results in every patient, from which the average for each group was calculated. The average values in the intervention group were 40.12 points and 30 points in the control group. The results of the test are shown in Table 2. Considering the established values and comparing the control and intervention group, it is possible to claim that the intervention group reached a greater difference between the preliminary and final values of the Lysholm Knee Scoring Scale.
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Discussion
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This paper studies the effect of the kinesiotherapy methods in patients who underwent minimum invasive arthroscopy of the knee joint. As the term ‘‘minimum invasive’’ suggests (i.e.
a less limiting post-operational condition), we chose a fourweek research period because the patients return to work much sooner than patients who underwent an operation of the anterior cruciate ligament, due to fewer limitations. The main aim of our research was to assess the effects of timely physiotherapy treatment on the pain of the knee joint. In the process, we monitored whether the selected kinesiotherapy methods combined with physiotherapy, specifically laser, have an influence on the decrease in soreness and improve the stability of the joint. The problem we face in clinical practice lies in the issue of post-operative physiotherapy in patients who underwent arthroscopy of the knee joint because very few patients are prescribed a post-operative physiotherapy treatment at all. Patients are often discharged with home treatment and they are not well informed. It is obvious that the medical means and the capacity of physiotherapists are not unlimited. All patients cannot be recommended physiotherapy treatment due to a greater number of more serious surgical procedures. The available resources in literature surprised us in terms of the lack of information on the post-operative rehabilitation of patients who underwent arthroscopy, especially patients who underwent meniscectomy. Most available resources are foreign and they are aimed at doctors. None of the materials exactly described physiotherapy methods or manuals containing exercises for patients who underwent arthroscopy. Our research focused on patients operated on for a damaged part of the meniscus, because this is one of the most frequent types of knee joint disorder. All monitored patients underwent meniscectomy – a surgical procedure during which the damaged part of the meniscus is removed so that the healthy part is preserved. The authors Paša [26] and Gregg and Bosco [27] agree that due to the removed part of the meniscus, the contact pressure through the articular cartilage is increased proportionately to the removed part. Higher pressure leads to the gradual overexertion and narrowing of
Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006
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the articular knee slot and cartilage, which causes its degeneration and fragmentation due to the development of arthritic changes. That is one of the reasons patients should be more informed about the possibilities of articular physiotherapy so that they have the possibility to regain the full functionality of a joint. Peterson [28] points out the improvement of the articular stability, for which not only the functionality of ligaments is important. In such cases, the role of stabilization is played by the muscles around the joint, such as flexors and extensors of the knee joint. It is for this reason that setting up individual therapies must not omit exercises for better co-activation between the flexor and extensor muscle groups of the knee joint. The therapy for the patients from the intervention group was arranged individually and made up of various methods used in the following therapy: at the beginning, it included passive and active exercises, soft tissue and mobilization techniques, exercises with elastic tensions and balls. The third and fourth week added exercises in a closed and opened kinematic series and senzomotoric stimulation using unstable surfaces. To relieve symptoms such as pain and swelling, the therapy included a cooling of the operated knee, manual lymphatic drainage, physical laser treatment (6–8 procedures) and the supportive method for swellings – kinesiotaping. For the pain assessment, the VAS with values from 0 to 10 was used. The average preliminary pain assessment in the intervention and control group was similar, but the therapy helped the final values of the intervention group to be lower. The intervention group recorded an average value of the preliminary assessment of 4.32 points and a final value of 0.28 points. The average value of the preliminary assessment of the control group was 4.48 points and the final value reached 1.16 points. The statistical comparison of the final assessments, which was carried out by a two-choice t-test, was assessed as statistically significant (t = –4.77, p = 0.0000085). The intervention group evidently recorded a lower degree of pain in the operated joint than the control group. Ghazaly [29] reaches even lower values on the VAS in 71 patients who underwent arthroscopy or meniscectomy. The symptomatic treatment in physical therapy aimed at swellings, without the following physiotherapy, reached a pre-intervention value of 7.4 and, after eight weeks, 1.9. The positive influence of physical treatment was evident, as well as the limited functionality and the range of the operated joint because no methods of kinesiotherapy were used. In conclusion, we agree with the author that only physical treatment is not sufficient for full recovery, but combining it with other methods is desirable. We also assumed seeing a greater difference between the preliminary and final examination in the intervention group with the Lysholm Knee Scoring Scale, which assessed the (in) stability of the operated joint. In the preliminary assessment, the intervention group reached 56.16 points at the beginning and 96.28 points at the end. The control group reached the values of 53.8 points and 83.8 points after four weeks. The statistical comparison of the results from the two-choice t-test assessed the difference between the preliminary and final results in every patient. An average was calculated for each
group. The average values of the intervention group were 40.12 points and the control group reached a value of 30 points. The difference in the reached stability was assessed as statistically significant (t = 4.19, p = 0.00006). In the annual study of Haviv [30], a group of 201 patients was monitored. Similarly to our control group, the patients were not recommended a postoperational physiotherapy treatment. The results were assessed in the period of 1.5–2 months after operation, when the patient began to feel relief from pain along with increased articular stability. The author used the Lysholm Knee Scoring Scale to assess the therapy. The score increased from 68 to 82.6 after 1.5 months. We would like to point out the long convalescence period, which could be shortened by postoperational physiotherapy, because most patients return to work 3–4 weeks after arthroscopy.
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Conclusion
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The aim of this paper was to verify whether the selected kinesiotherapy methods combined with physical treatment would lead to a lower degree of pain and stability of the knee joint in patients who underwent arthroscopy. The research group consisted of 50 patients who underwent arthroscopy of the knee joint. The patients were divided into two groups – the control and intervention groups, who were monitored from the first post-operative day, when they were discharged for home treatment, for four weeks. The patients from the intervention group underwent a complex kinesiotherapy programme, including physical therapy (laser). The control group underwent the therapy based only on the instructions and recommendations by their doctor. To assess the subjective pain level, the visual analogue scale (VAS) was used, and the Lysholm Knee Scoring Scale, which is used for disorders of the meniscus, ligaments and cartilage. The testing was carried out at the beginning and the end of the therapy. In the preliminary assessment, the intervention group recorded an average degree of pain of 4.32 points and, in the final assessment 0.28 points, according to the VAS. The control group recorded the average preliminary value of 4.48 points and the final 1.16 points. Considering the values, we can claim that, when comparing the groups, the intervention group reached a statistically lower degree of pain than the control group. In the Lysholm Knee Scoring Scale, the intervention group reached 56.16 points at the beginning and 96.28 at the end. The control group reached 53.8 points and 83.8 points after four weeks. Considering these values, we can claim that when comparing the groups, the intervention group reached a higher difference between the preliminary and final values of the Lysholm Knee Scoring Scale. The results show that the influence of kinesiotherapy in patients who underwent arthroscopy of the knee joint relieves pain and positively affects the stability and function of the knee joint and helps patients to reach a full return to a normal and active daily life. It is important to choose methods for each patient individually because the possibilities and predispositions of individuals are not always the same.
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Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006
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Conflict of interest
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The authors have no conflict of interest to disclose.
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references
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[1] Bartoníček J, Heřt J. Základy klinické anatomie pohybové aparátu. Praha: Maxdorf; 2004. [2] Brukner P, Khan K. Clinical sports medicine. Sydney: McGraw Hill Medical; 2010. [3] Gross JM, Fetto J, Rosen E. Vyšetření pohybového aparátu. Praha: Triton; 2005. [4] Bartušek D. Diagnostické zobrazovací metody pro bakalářské studium fyzioterapie a léčebné rehabilitace. Brno: vydavatelství MU; 2004. [5] Chaloupka R. Vybrané kapitoly z LTV v ortopedii a traumatologii. Brno: IVDPZ; 2001. [6] Sosna A, Vavřík P, Krbec M, Pokorný D. Základy ortopedie. Praha: Triton; 2001. [7] Miller M, Chabra AB, Safran MR. Primer of arthroscopy. Philadelphia: Saunders Elsevier; 2010. [8] Dungl P. Ortopedie. Praha: Grada Publishing; 2005. [9] Cooper N. Anterior cruciate ligament reconstructions, the debate continues – with another response by Assoc. Prof. Hooper. J N Z Med Assoc 2011;124(1334):115–7. [10] Žvák I. Traumatologie ve schématech a rtg obrazech. Praha: Grada Publishing; 2006. [11] Runer M. The anterolatel ligament of the knee: a dissection study. Knee 2015;50(11):33. [12] Dvořák R. Základy kinezioterapie. Olomouc: Univerzita Palackého; 2003. [13] Véle F. Kineziologie. Praha: Triton; 2006.
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[14] Konvičková S, Valenta J, Mareš T. Biomechanika svalstva člověka. Praha: Nakladatelství ČVUT; 2007. [15] Dylevský I, Kubálková L, Navrátil L. Kineziologie, kinezioterapie a fyzioterapie. Praha: Manus; 2001. [16] Kolář P. Rehabilitace v klinické praxi. Praha: Galén; 2009. [17] Lewit K. Manipulační léčba. Praha: Nakladatelství sdělovací technika; 2003. [18] Frost R. Aplikovaná kineziologie – základní principy a techniky. Olomouc: Fontána; 2013. [19] Pavlů D. Speciální fyzioterapeutické koncepty a metody. Brno: Cerm; 2003. [20] Mayer M, Smékal D. Měkké struktury kolenního kloubu a poruchy motorické kontroly. Rehabil fyz lék 2004;10(3):111–7. [21] Haladová E, Nechvátalová L. Vyšetřovací metody hybného systému. Brno: Národní centrum ošetřovatelství a nelékařských zdravotnických oborů; 2010. [22] Zeman M. Základy fyzikální terapie. České Budějovice: ZSF JU; 2013. [23] Poděbradský J, Poděbradská R. Fyzikální terapie – manuál a algoritmy. Praha: Grada Publishing; 2009. [24] Rokyta R, Kršiak M, Kozák J. Bolest. Praha: Tigis; 2006. [25] Lysholm's J. Evaluation of knee ligament. Summary results with special emphasis on use of a scoring scale. Am J Sports Med 1982;10(3):150–3. [26] Paša L. Transplantace hluboce mražených menisků. Acta Chir Orthop Traumatol Cech 2008;75(1):40–5. [27] Gregg J, Bosco J. Meniscal repair and reconstruction. Bull NYU Hosp Jt Dis 2010;68(2):62. [28] Peterson L. Sport injuries. New York: Informa Healthcare; 2011. [29] Ghazaly E. Arthroscopic partial meniscectomy is superior to physical rehabilitation in the management of symptomatic unstable meniscal tears. Int Orthop 2015;39(4):5. [30] Haviv B. Which patiens are less likely to improve during the first year after arthroscopis partial menisectomy? Knee Surg Sports Traumatol Arthrosc Off J ESSKA 2015;23(10):1–3.
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kontakt xxx (2017) e1–e7
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/locate/kontakt 1 2 3
Original research article
Influence of physiotherapy on knee joint pain after arthroscopy
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Marek Zeman a,*, Pavlína Princová b a
University of South Bohemia in České Budějovice, Faculty of Health and Social Sciences, Institute of Physiotherapy and Selected Medical Disciplines, České Budějovice, Czechia b Tábor Hospital JSC, Department of Rehabilitation, Tábor, Czechia
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article info
abstract
Article history:
The article deals with the topic of the influence of physiotherapy on arthroscopic treatment
Received 18 September 2016
of the knee joint. The goal is to verify whether the selected methods of kinesiotherapy using
Received in revised form
physical therapy will lead to a decrease in pain and stability of the knee joint in patients who
2 January 2017
have undergone arthroscopy. The sample group consisted of 50 patients who underwent an
Accepted 20 January 2017
arthroscopic surgical operation of the knee joint. They were divided into two groups. The
Available online xxx
control group consisted of patients who were not recommended a post-operative phy-
Keywords:
group consisted of patients who underwent ten therapies. To prove the influence of
siotherapeutic treatment. They were discharged for home treatment. The intervention Arthroscopy
physiotherapy on pain and the stability of the knee joint, selected standardized question-
Physiotherapy
naires were used. They were filled in immediately after the operation and four weeks later.
Pain
Initial and final kinesiology assessments were carried out, including aspection, palpation,
Knee joint
goniometric and anthropometric measurement and examination of muscle strength. The
Meniscus
results show that the selected physiotherapeutic methods decrease pain of the knee joint and improve its stability in patients who have undergone arthroscopy. They also eliminate swellings, and have a positive effect on the strength and mobility of the operated limb. They help patients to quickly return to a fully active daily life. It is important to choose physiotherapy methods for each patient individually because individual dispositions and possibilities are not the same. Positive results can be reached combining various physiotherapy methods. Nevertheless, these results cannot be reached without the patient's active collaboration. © 2017 Faculty of Health and Social Sciences of University of South Bohemia in České Budějovice. Published by Elsevier Sp. z o.o. All rights reserved.
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* Corresponding author at: University of South Bohemia České Budějovice, Faculty of Health and Social Sciences, Institute of Physiotherapy and Selected Medical Disciplines, B. Němcové 585/54, 370 01 České Budějovice, Czechia. E-mail address: [email protected] (M. Zeman). http://dx.doi.org/10.1016/j.kontakt.2017.01.006 1212-4117/© 2017 Faculty of Health and Social Sciences of University of South Bohemia in České Budějovice. Published by Elsevier Sp. z o. o. All rights reserved.
Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006
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Introduction
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Lower limbs enable the most natural kind of locomotion – walking. Their significance in the support and movement of the erect body on two legs is major, which is the reason for our robust limbs having strong groups of muscles [1]. Great overexertion of articular facets and pressure are the reason the knee joint is predisposed to degenerative changes and injuries. The knee joint belongs to the most frequently injured joints of all. The reasons for the increasing percentage of injured young people are problems connected to injuries in sports, such as tennis, football, skiing, snowboarding and hockey [2]. Most of these patients are forced to seek medical help due to the symptoms of an injury, such as pain, swellings, knee joint instability and others. What is most important are the right diagnostics and the recognition of the type of pain because it can be grounded in various causes [3]. To set the right diagnostics, we use different depictive methods, such as X-ray, MRI, ultrasound and arthroscopic examinations, which enable an operation from 2 min openings [4]. A large number of people suffering from knee joint injury report pain, problems with stability, swellings, and partially limited mobility. They also report bad or very low level of information [5]. Most patients are discharged after the arthroscopy operation on the same day, and the next time they see their doctor is the day of the extraction of the stitches. Many of these patients are not informed enough about the possibilities of the following physiotherapy, which helps them to reach better stability and shortens their convalescence.
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Arthroscopy and the examination of the knee joint
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Arthroscopy is a modern diagnostic and surgical method with minimum invasion. It is a method after which a very small scar remains and the patient can soon return to a normal life [6]. The operation begins with a small incision of about 1 cm, where an endoscope probe called an arthroscope is inserted. At the end of the metal tube, a small camera with a cold light is installed, which televises the operation. The arthroscopy tube or a stand-alone intake cannula with a sterile physiological solution is inserted. A thin surgical tool is inserted in the other side of the joint, which not only enables a view of the inside of the joint, but also of the articular cartilage, meniscus, ligaments and the whole articular case. The tool may enable an operation [7,8], whose length depends on its seriousness but it most often takes 30–60 min. After a standard arthroscopy, the patient can be discharged immediately. In more complicated cases, they are hospitalized for 3–4 days. A systematic assessment of the whole knee and an internal examination must precede the operation [9]. Arthroscopy is carried out in the whole or spinal anaesthesia. All inner articular changes in the knee joint are an indication for treatment. We assign some types of fractures and arthritic changes to arthroscopy operations, as well as the reconstruction of the anterior cruciate ligament, treatment of torn ligaments, damaged cartilages (chondromalacia), the removal of the inflammatory inner articular epithelium (synovectomy) and a partial or full meniscectomy of the damaged meniscus [10].
Kinesiotherapy methods and physical therapy After a surgical operation, kinesiotherapy treatment with timely mobilization and verticalization is ideal. Frequent neglect and the wrong treatment of such injuries can lead to a quicker emergence of arthrosis or joint instability [11]. Exercising muscles for joint stabilization plays an important role. Our attention is focused on the prevention of muscle shortening and atrophy. We use positioning to prevent contractures with limited mobility [12]. We further focus on extensor knee muscles because insufficient treatment causes patellar and femoral arthrosis or insertion difficulties [13]. Passive and active exercise: passive movements are performed without the activity of the patient during the first postoperative days with regard to swellings, pain and the possibilities of the operated limb. Active exercise is performed under the therapist's supervision, where they help or control the movements so that they are performed in the best way possible. Active exercise uses other isometric contractions as well [14]. Soft and mobilization techniques: they help preserve the free mobility of these tissues. Mobilization is performed in joints, but it can be used in all mobile structures connected to the motor system [15]. Functional limitations of the joint mobility (blocks) are usually connected to so-called trigger points. These points are one of the main causes of blocks and that is why, in mobilizations, neuromuscular techniques are used so that the muscles are relaxed at the same time. The techniques are, for example, PIR – post-isometric relaxation and IR – reciprocal inhibition. PIR enables reaching a greater range of joint movement and relaxing shortened muscles through inhaling and exhaling [16,17]. Kinesiotaping: it is a kind of fixing bandage (often used in sports) and it belongs to the gentlest technique because it preserves blood circulation. It belongs to the so-called functional techniques of the prevention of the treatment of the muscular skeletal system instead of the former fixation plaster bandage [18]. It is easier to prevent the consequences connected to the fixation treatment. Taping shortens the treatment and increases the feeling of security. ‘‘Taping’’ can be used long term, for a few weeks, but also short term during a one-time load. The fixation also strengthens the chronically weakened ligaments after acute injuries, because it stabilizes and fixes the joint for the stabilization of functionality [16]. Exercising with balls and elastic tensions: small or big balls (so called over balls) are used for mobilization and stretching exercises, but also for toning exercises in order to strengthen the weakened muscles and improve co-ordination. Exercises with elastic tensions use rubber bands which are about 15 cm wide. The tensions are used for strengthening and influencing hypertonic and shortened muscles by influencing articular mobility and training co-ordination [19]. Exercising in closed and opened kinematic series: while exercising in opened series, the terminal body segment is loose, which results in the exercising of individual muscles in isolation. While exercising in closed series, all of the muscle series are activated, thanks to which it is necessary to activate multiple joint muscles and co-contract agonists and antagonists. The therapy should first include exercises from the closed series, especially in the first phases of physiotherapy,
Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006
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due to exercising the stability of the knee joint and the correct co-contraction of m. quadriceps femoris and the so-called hamstrings. The ideal neuromuscular control is reached through a combination of both types of series [20]. Senzomotoric stimulation: the method emphasises the increase of afferentation, especially from the face of the foot and deep nape muscles. It uses proprioception from deep receptors in the muscles, joints and ligaments. The aim of the exercise is the recovery of the correct muscle co-ordination and balance, influencing the disorder of the proprioceptive perception and the acceleration of the commencement of muscle contraction [21]. The patient exercises barefoot due to the maximum utilization of afferentation from the face of the foot. One of the means of facilitating the face of the foot is the activation of the muscles which support the arch of the foot by creating the socalled ‘‘little foot’’. It enables the improvement of the position of all leg joints and also the change in the tension in ligaments and muscles, which influences the proprioceptive signalization in the improvement of stability. Physical therapy: physical therapy increases or changes the afferent information, which helps to activate self-reparative mechanisms in the organism. Hydrotherapy is a frequently chosen physical therapy in knee disorders due to its antiswelling effects, phototherapy for its biostimulatory and analgesic effects, magnetic therapy for its trophotropic effects and electrotherapy for its analgesic effects [22,23]. Mechanic therapy enables the use of lymphatic drainage. Hydrotherapy, specifically cryotherapy, also called the cooling treatment, is a frequent means of pain treatment, especially of acute injuries. Cooling causes a decrease in the metabolic activity of the tissues, and decelerates the neural net, which affects swellings, pain and inflammation. The treatment is individual and it depends on the particular condition of the patient and their response to the negative thermotherapy [23,24]. Phototherapy combines photochemical and biostimulatory effects by applying electromagnetic radiation. The most frequent is laser, which helps heal tissues better. The advantage of the laser is the possibility of using it before the extraction of stitches because it is a non-contact method [16]. Its effects are analgesic, anti-swelling, anti-inflammatory and biostimulatory. It is the reason why tissues heal and regenerate better [23]. We use the Maestro Biostimul laser with CCM laser probes (wavelength of 830 nm), which penetrates deeper (approx. up to 1.5 cm). The power of the probe is set to 300 nW, the energetic density from 2 up to 5 J/cm2 and the frequency to 8.9 Hz.
Materials and methods The aim of the research is to monitor whether the selected kinesiotherapy methods combined with physical therapy applied soon after arthroscopy influence the speed of pain relief and the improvement of articular stability. The visual analogue scale (VAS) was used to assess the subjective intensity of pain. The Lysholm Knee Scoring Scale, which is used for disorders of the meniscus, ligaments and cartilage, was used to assess the function of the stability of the knee. The questionnaires were used at the beginning and at the end of the therapy.
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The visual analogue scale is simple and understandable and that is why it belongs to the most frequently used methods. Pain is set on a 10-centimetre line segment, where the points at the beginning of the scale (on the left side) signify a fully painless condition. Every other centimetre shows a higher intensity of pain; number 10 is the most severe pain that the patient can imagine. The line segment is numbered from 0 to 10 from left to right. Points 1–3 signify low pain, 4–7 mild pain, and 8–10 severe pain. The Lysholm Knee Scoring Scale enables a subjective assessment of the function of the knee. It comprises, for example limping, the need for a walking support, possible knee blocks, swellings, the possibility of using the stairs, squatting, pain and instability. The lower number of points shows the insecurity, instability and the functionality disorders of the knee; the higher number of points shows an improved stability of the knee. The maximum number of points is 100, where 95– 100 signify an excellent stability, 84–94 a good stability, 65–83 a satisfying stability, 64 and lower a dissatisfying stability [25]. A total of 50 patients who underwent arthroscopy of the knee joint were involved in the research group. The patients underwent the operation between March and September 2015 in the České Budějovice Hospital Inc. The group, who underwent a partial meniscectomy, consisted of patients with a lesion on a part of the meniscus. These patients were randomly divided into two groups – the control group and the intervention group – and they were monitored for four weeks from the first day of discharge to home treatment after the operation. After a thorough examination, the patients from the intervention group were set up with an individual physiotherapy plan, which depended on their problems (see below). The patients from the intervention group completed a complex kinesiotherapy programme, including physical therapy (laser). The four-day programme consisted of ten therapies. In the first two weeks, the 50-minute exercise unit was performed in three therapies per week; the third and fourth week comprised two exercise units. The control group underwent the therapy based only on the instructions and recommendations of a doctor.
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Physiotherapy plan
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1st post-operative week
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The first day after the operation: early verticalization and walking exercise using the French crutches, with a 50% load. The application of cryotherapy with cryobags, respecting anti-embolic regulations (compressive stockings, positioning, keep-fit of lower limbs). Therapy aimed at keeping the level of movement and activation of m. quadriceps femoris; passive and active exercise. Treating and relaxing soft tissues with myofascial techniques including the care of the scar, relaxing the patella, informing about the possibilities of individual therapy.
2nd post-operative week Treating and relaxing soft tissues with myofascial techniques, mobilization of the patella and the tibiofibular
Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006
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articulation, of the trophic of the scars and the whole knee joint area. 20-minute ride on a stationary bicycle (the requirement is reaching a 908 flexion of the knee joint). Manual lymphatic drainage aimed at the reduction of postoperational swelling, application of the lymphatic tape. Post-izometric relaxation of the hamstring muscle and the m. quadriceps femoris. Using the laser of a wavelength of 830 nm in 6–8 procedures. The probe was set to 300 mW, the energetic density to 2 up to 5 J/cm2 and the frequency to 8.9 Hz. Exercising mostly in closed kinematic series due to more stable movements. Senzomotoric stimulation – exercising a supervised sitting and standing position following the exercise of the so-called ‘‘little foot’’.
3rd and 4th post-operative week Exercising in open and closed kinematic series to strengthen the dynamic knee stabilizers. Aimed correction of the basic movement patterns, such as the standing position and walking. After managing the supervised standing position – exercising the standing position on one foot. Exercising the correct walking. Senzomotoric stimulation using unstable surfaces (a tubeshaped segment, dynair and walking in balance sandals).
Results The total of 50 patients comprised 14 women and 36 men. The age of the patients was between 25 and 50 years. The control group included 9 women (n = 36%) and 16 men (n = 64%). The intervention group included 5 women (n = 20%) and 20 men
(n = 80%). The average age of the patients in the control group was 39.6 years, and in the intervention group it was 35.6 years.
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Pain assessment
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We assumed that the intervention group would record a lower degree of pain in the operated joint. To assess pain, the visual analogue scale with points from 0 to 10 was used. The preliminary average assessment of pain in the intervention and control group was similar, but, after therapy, the final assessment of pain in the intervention group was lower. The intervention group recorded an average of 4.32 points in the preliminary examination and 0.28 points in the final examination. The control group recorded an average of 4.48 points in the preliminary examination and 1.16 points in the final examination. For better clarification, the chart of the pain assessment in all compared groups of patients has been added below (Charts 1 and 2). The statistical comparison of the final results was carried out with a two-choice t-test, which compares the final results of the VAS in both groups. The results of the test are shown in Table 1. Considering the established values, it is possible to claim that, comparing the control and intervention group, the intervention group reached a statistically significant lower degree of pain.
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Assessment of the joint stability
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We further assumed seeing a greater difference between the preliminary and final values of the Lysholm Knee Scoring Scale (which is the marker of the knee joint stability) in patients in the intervention group compared to the control group. At the beginning, the intervention group reached an average of 56.16 points and at the end 96.28 points. The control group showed the values of 53.8 and after 4 weeks 83.8 points. The statistical comparison of the results in the t-test assessed the difference
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Chart 1 – Illustration of the preliminary and final assessment of pain of VAS in the intervention group. Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006
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Chart 2 – Illustration of the preliminary and final assessment of pain of the VAS in the control group.
Table 1 – Statistical assessment of post-therapy pain in both groups.
Intervention group Control group
Average
DD
t
p
0.28 1.16
0.46 0.80
–4.77
0. 0000085
t – test criterion; DD – decisive deviation; p – significance level.
Table 2 – Statistical assessment of the differences of the Lysholm Knee Scoring Scale between the preliminary and final examinations in the intervention and control groups.
Intervention group Control group
Average
DD
t
p
40.12 30
8.10 8.96
4.19
0. 00006
t – test criterion; DD – decisive deviation; p – significance level.
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between the preliminary and final results in every patient, from which the average for each group was calculated. The average values in the intervention group were 40.12 points and 30 points in the control group. The results of the test are shown in Table 2. Considering the established values and comparing the control and intervention group, it is possible to claim that the intervention group reached a greater difference between the preliminary and final values of the Lysholm Knee Scoring Scale.
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Discussion
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This paper studies the effect of the kinesiotherapy methods in patients who underwent minimum invasive arthroscopy of the knee joint. As the term ‘‘minimum invasive’’ suggests (i.e.
a less limiting post-operational condition), we chose a fourweek research period because the patients return to work much sooner than patients who underwent an operation of the anterior cruciate ligament, due to fewer limitations. The main aim of our research was to assess the effects of timely physiotherapy treatment on the pain of the knee joint. In the process, we monitored whether the selected kinesiotherapy methods combined with physiotherapy, specifically laser, have an influence on the decrease in soreness and improve the stability of the joint. The problem we face in clinical practice lies in the issue of post-operative physiotherapy in patients who underwent arthroscopy of the knee joint because very few patients are prescribed a post-operative physiotherapy treatment at all. Patients are often discharged with home treatment and they are not well informed. It is obvious that the medical means and the capacity of physiotherapists are not unlimited. All patients cannot be recommended physiotherapy treatment due to a greater number of more serious surgical procedures. The available resources in literature surprised us in terms of the lack of information on the post-operative rehabilitation of patients who underwent arthroscopy, especially patients who underwent meniscectomy. Most available resources are foreign and they are aimed at doctors. None of the materials exactly described physiotherapy methods or manuals containing exercises for patients who underwent arthroscopy. Our research focused on patients operated on for a damaged part of the meniscus, because this is one of the most frequent types of knee joint disorder. All monitored patients underwent meniscectomy – a surgical procedure during which the damaged part of the meniscus is removed so that the healthy part is preserved. The authors Paša [26] and Gregg and Bosco [27] agree that due to the removed part of the meniscus, the contact pressure through the articular cartilage is increased proportionately to the removed part. Higher pressure leads to the gradual overexertion and narrowing of
Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006
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the articular knee slot and cartilage, which causes its degeneration and fragmentation due to the development of arthritic changes. That is one of the reasons patients should be more informed about the possibilities of articular physiotherapy so that they have the possibility to regain the full functionality of a joint. Peterson [28] points out the improvement of the articular stability, for which not only the functionality of ligaments is important. In such cases, the role of stabilization is played by the muscles around the joint, such as flexors and extensors of the knee joint. It is for this reason that setting up individual therapies must not omit exercises for better co-activation between the flexor and extensor muscle groups of the knee joint. The therapy for the patients from the intervention group was arranged individually and made up of various methods used in the following therapy: at the beginning, it included passive and active exercises, soft tissue and mobilization techniques, exercises with elastic tensions and balls. The third and fourth week added exercises in a closed and opened kinematic series and senzomotoric stimulation using unstable surfaces. To relieve symptoms such as pain and swelling, the therapy included a cooling of the operated knee, manual lymphatic drainage, physical laser treatment (6–8 procedures) and the supportive method for swellings – kinesiotaping. For the pain assessment, the VAS with values from 0 to 10 was used. The average preliminary pain assessment in the intervention and control group was similar, but the therapy helped the final values of the intervention group to be lower. The intervention group recorded an average value of the preliminary assessment of 4.32 points and a final value of 0.28 points. The average value of the preliminary assessment of the control group was 4.48 points and the final value reached 1.16 points. The statistical comparison of the final assessments, which was carried out by a two-choice t-test, was assessed as statistically significant (t = –4.77, p = 0.0000085). The intervention group evidently recorded a lower degree of pain in the operated joint than the control group. Ghazaly [29] reaches even lower values on the VAS in 71 patients who underwent arthroscopy or meniscectomy. The symptomatic treatment in physical therapy aimed at swellings, without the following physiotherapy, reached a pre-intervention value of 7.4 and, after eight weeks, 1.9. The positive influence of physical treatment was evident, as well as the limited functionality and the range of the operated joint because no methods of kinesiotherapy were used. In conclusion, we agree with the author that only physical treatment is not sufficient for full recovery, but combining it with other methods is desirable. We also assumed seeing a greater difference between the preliminary and final examination in the intervention group with the Lysholm Knee Scoring Scale, which assessed the (in) stability of the operated joint. In the preliminary assessment, the intervention group reached 56.16 points at the beginning and 96.28 points at the end. The control group reached the values of 53.8 points and 83.8 points after four weeks. The statistical comparison of the results from the two-choice t-test assessed the difference between the preliminary and final results in every patient. An average was calculated for each
group. The average values of the intervention group were 40.12 points and the control group reached a value of 30 points. The difference in the reached stability was assessed as statistically significant (t = 4.19, p = 0.00006). In the annual study of Haviv [30], a group of 201 patients was monitored. Similarly to our control group, the patients were not recommended a postoperational physiotherapy treatment. The results were assessed in the period of 1.5–2 months after operation, when the patient began to feel relief from pain along with increased articular stability. The author used the Lysholm Knee Scoring Scale to assess the therapy. The score increased from 68 to 82.6 after 1.5 months. We would like to point out the long convalescence period, which could be shortened by postoperational physiotherapy, because most patients return to work 3–4 weeks after arthroscopy.
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Conclusion
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The aim of this paper was to verify whether the selected kinesiotherapy methods combined with physical treatment would lead to a lower degree of pain and stability of the knee joint in patients who underwent arthroscopy. The research group consisted of 50 patients who underwent arthroscopy of the knee joint. The patients were divided into two groups – the control and intervention groups, who were monitored from the first post-operative day, when they were discharged for home treatment, for four weeks. The patients from the intervention group underwent a complex kinesiotherapy programme, including physical therapy (laser). The control group underwent the therapy based only on the instructions and recommendations by their doctor. To assess the subjective pain level, the visual analogue scale (VAS) was used, and the Lysholm Knee Scoring Scale, which is used for disorders of the meniscus, ligaments and cartilage. The testing was carried out at the beginning and the end of the therapy. In the preliminary assessment, the intervention group recorded an average degree of pain of 4.32 points and, in the final assessment 0.28 points, according to the VAS. The control group recorded the average preliminary value of 4.48 points and the final 1.16 points. Considering the values, we can claim that, when comparing the groups, the intervention group reached a statistically lower degree of pain than the control group. In the Lysholm Knee Scoring Scale, the intervention group reached 56.16 points at the beginning and 96.28 at the end. The control group reached 53.8 points and 83.8 points after four weeks. Considering these values, we can claim that when comparing the groups, the intervention group reached a higher difference between the preliminary and final values of the Lysholm Knee Scoring Scale. The results show that the influence of kinesiotherapy in patients who underwent arthroscopy of the knee joint relieves pain and positively affects the stability and function of the knee joint and helps patients to reach a full return to a normal and active daily life. It is important to choose methods for each patient individually because the possibilities and predispositions of individuals are not always the same.
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Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006
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The authors have no conflict of interest to disclose.
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references
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Please cite this article in press as: Zeman, M., Princová, P., Influence of physiotherapy on knee joint pain after arthroscopy. Kontakt (2017), http://dx.doi.org/10.1016/j.kontakt.2017.01.006