ASSESSMENT

ASSESSMENT OF THE EFFICACY OF NEUROMUSCULAR TAPING IN REHABILITATION FOLLOWING KNEE REPLACEMENT SURGERY

University of Parma, Faculty of Medicine and Surgery,
Parma, Italy
31/3/2011

Objectives

Gonarthrosis is an evolving chronic arthropathy whose effects are severely disabling and limiting on the patient’s life during normal daily, social and work activities. Over the years many therapeutic techniques have been developed to limit damage from this pathology. Not least among these has been the option of surgically implanting a prosthesis to substitute the affected joint (TKR).

Carrying out the surgical procedure for implantation of a knee prosthesis means replacing the joint-covering surfaces comprised of the femoral condyles, the tibial condyles and the posterior surface of the kneecap. This makes the surgery extremely invasive. Along with the possible risks and complications that may arise from any surgical procedure, issues emerge following a TKR implant and subsequent enforced immobility, which may influence the effectiveness and duration of rehabilitation procedures. Pain, bruising and limited ROM may delay or even limit recovery of proper knee function.

Often, in a hospital environment, these aspects are overlooked during the post-acute phase of knee arthoprosthesis with concentration being placed on the recovery of the ability to walk. Once this objective has been achieved, the patient may be discharged. The principle aim of this study is to show how proper application of an elastic bandage during post-acute rehabilitation following TKR can contribute to improved joint articulation, diminished bruising and reduced knee pain.

For this study, no special category of patients was chosen on which to apply the rehabilitation technique in question. In spite of this, there was an attempt to create experimental and control groups that were evenly matched for certain specific parameters. This was done to optimize each individual evaluation and physical examination and in order to make the rehabilitative program fully applicable to each patient involved. Of thirty patients selected, fifteen were treated according to traditional rehabilitation procedures, (specifically the protocols laid down by Cameron, Brotzman and Wilk), making up the control group. The other fifteen patients received the same treatment with the addition of NeuroMuscular Taping. The patients involved in this research received rehabilitation treatment lasting approximately three weeks, a period coinciding with their post-acute hospitalization.

Methodology

Application of NeuroMuscular Taping

Phase 1 (from taking charge of the patient up to the removal of the stitches) During this initial period, the patient still had stitches and dressing on their surgical wound, which prevented any direct action on the knee. Our objective was to drain the quadriceps muscle and the popliteal fossa.

Tape on Quadriceps

Cut: the tape was cut in half lengthways, giving it a width of 2.5 cm.
Taping Length: from the dressing to the inguinal area
Application: four strips of tape were applied to the patient. The first laterally wrapped around the vastus lateralis. The second was positioned laterally on the rectus femoris and medially to the vastus lateralis. The third was located between the rectus and the vastus medialis. The fourth wrapped medially around the vastus medialis.
Joint Position: the tape was applied with the knee held in a position of maximum flexion.
Method: decompressive

Figure 1
Quadriceps Tape: front view

Popliteal Fossa Tape

Cut: fan shaped
Taping Length: 20 cm
Application: the tape was applied to the popliteal fossa. The anchor point was proximal and half of the tape should follow the line of the popliteal fossa. The five strips comprising the fan should cover the space behind the knee evenly. Indicatively, the first and fifth strips follow the gastrocnemius laterally and medially. The third strip descends straight toward the Achilles tendon. The last two fill the remaining space.
Joint Position: The tape was positioned with the joint extended.
Method: Decompressive

Figure 2
Popliteal Fossa Tape, posterior view
Figure 3
Quadriceps Tape and Popliteal Fossa, lateral view.

Anterior Tape N°1

Cut: fan shaped
Taping Length: 30 cm
Application: the middle of the tape should be located in a position corresponding to the center of the kneecap and the anchor point should be 1 cm to the left of the locating position for the femur. The first, third and fifth rays should pass along the tibial ridge, the center of the kneecap and the head of the fibula respectively. The other two were positioned in such a way as to fill the remaining spaces evenly.
Joint Position: the tape was applied with the knee flexed as far as possible.
Method: decompressive

Anterior Tape N°2

Cut: fan shaped
Taping Length: 30 cm
Application: the middle of the taping should be located in a position corresponding to the center of the kneecap and the anchorage should be 1 cm left of the indicative position of the femur. The first, third and fifth rays should pass along the tibial crest, the center of the kneecap and the head of the fibula respectively. The other two should fill the remaining spaces evenly.
Joint Position: The tape was positioned with the joint flexed as far as possible.
Method: decompressive

Figure 4
Fan-shaped tape on the knee, anterior view

Posterior Tape

Cut: fan shaped
Taping Length: 20 cm
Application: the tape was applied to the popliteal fossa. The anchor point was proximal and the middle of the tape should coincide with the line of the popliteal fossa. The five strips of the fan should cover the space behind the knee evenly. Indicatively, the first and fifth strips followed the gastrocnemius laterally and medially; the third strip descended straight toward the Achilles tendon and the other two strips filled in the remaining space.
Joint Position: the tape was positioned with the joint extended.
Method: decompressive

Figure 5
Popliteal Fossa Tape, posterior view
Figure 5
Fan-shaped tape and popliteal fossa, side view

Phase 3

(from the start of the functional phase, when emphasis is on regaining the ability to walk)
This application was functional and was used up until discharge of the patient. It should help to reeducate the patient’s functional movement, in walking. The bandage was made up of four tapes

Figure 6
Phase-3 Tape, anterior view

Knee Tape

Cut: Y shape
Taping Length: 25 cm
Application: the tape had a distal anchor point and its midpoint should correspond to the centre of the kneecap. The Y was positioned in such a way that it encircled the kneecap.
Joint Position: the tape was applied with the knee flexed as far as possible.
Method: decompressive

Tape Below Kneecap

Cut: The tape was cut in half lengthways, giving it a width of 2.5 cm.
Taping Length: 15 cm
Application: ideally, the width of the tape should be divided into three parts. The upper third should coincide with the lower third of the kneecap.
Joint Position: the tape was positioned with the joint flexed.
Method: compressive; the tape was stretched to 25% .

Medial Collateral Tape

Cut: the tape was cut in half lengthways, giving it a width of 2.5 cm.
Taping Length: 20 cm
Application: the tape was applied to correspond to the medial collateral ligament of the knee.
Joint Position: the tape was applied with the knee extended.
Method: compressive; the tape corresponding with the joint was applied with 50% tension but above and below the joint, it was given a 25% stretch.

Lateral Collateral Tape

Cut: the tape was cut in half lengthways, giving it a width of 2.5 cm.
Taping Length: 20 cm
Application: the tape was positioned to correspond to the lateral collateral ligament of the knee.
Joint Position: the tape was positioned with the joint extended.
Method: compressive; the tape corresponding with the joint was applied with 50% tension but above and below the joint, it was given a 25% stretch.

Assessment

The assessment parameters for the patients were: joint ROM, circumference of thigh and pain.
Degree of articulation was taken into consideration because hospital policy and reference texts maintain that the achievement of a 90° flexion is normally considered the minimum for a normal return to daily life and therefore usually leads to the patient’s discharge from the hospital. Thigh circumference, on the other hand, is important as it directly affects the other two parameters as well as the quality of the patient’s recovery. Pain is without doubt the one factor that most influences the patient’s approach to rehabilitation and to the post-operative period. Objective measurement of this parameter has always been problematic. Hence, for this study I opted to use the Visual Analogue Scale (VAS). The term ‘VAS’ usually refers to the quantitative logging of a qualitative clinical measure by means of asking the patient to indicate a point on a line with its ends corresponding to two extreme and opposite conditions. There are different kinds of VAS tests, ranging from analogue scales to verbal and numerical scales. A numerical scale was chosen for this study in that it is perhaps the easiest to understand for the patient, while it is the most practical for this kind of research. For the numerical scale (NRS), the patient was asked to gage the pain experienced over the previous week. The pain was given a numerical value between 0 and 10, where 0 represented absence of pain and 10 was the highest possible level of pain that the patient could experience.

Results

Reduction of Swelling
The two tables below contain the thigh circumference measurements (measured at 15 cm above the upper margin of the patella) of patients in the two groups were taken upon admission and discharge from the Rehabilitation Unit. Separate calculations were then made of the average reduction in swelling of the lower extremity for the patients in each group, which are compared schematically in the graph below.
Improvement in Knee Articulation
The two tables below contain values for joint ROM of the operated knee of patients in the two groups, taken upon admission and discharge from the Rehabilitation Unit. Separate calculations were then made of the average improvement in joint articulation (flexion-extension, passive-active) of the knee for patients in each group, which are compared in the table below.

Control Group Thigh Circumference

Experimental Group Thigh Circumference

Figure 7
Diagram Showing Changes in Joint ROM

Pain Improvement (VAS)

The two tables below contain values for pain experienced by patients in the two groups, taken upon admission and discharge from the Rehabilitation Unit. Pain was measured using a numerical Visual Analogue Scale (VAS), whose values range from 0 to 10. Separate calculations were then made of mean improvement in pain levels, which are shown in the diagram below, where differences found are highlighted.

Final Assessment

Comparing the results obtained from the two research groups over the period under consideration, it can be seen how the use of elastic bandaging, without departing from traditional rehabilitation procedures aimed at recovery of joint articulation and the reduction of swelling and pain, accelerates and optimizes the achievement of these aims. All the while this treatment avoids the establishment of compensatory processes, motor schemas and incorrect posture in the patient, which over the long term usually lead to certain secondary problems.

In comparing the results obtained, it is important not to overlook certain factors that may bear on their veracity. Specifically, the value of the use of the difficult to compare and assess the variable of pain as a subjective parameter is to be considered. Pain may be evaluated differently by different patients depending on their emotional state, their individual pain threshold and on the way in which pathologies associated with the surgical procedure are confronted. Therefore, comparison of this parameter measured in the two research groups appears to be of limited value, as it is an expression of different factors independent of the rehabilitation procedures applied. Nevertheless, the large difference in values between the two groups, with the experimental group favored strongly, may in any case indicate how using taping can help hospitalized patients during the post-operative period.

Reduction in Pain

Of much greater experimental significance, however, are the differences found in reduction of swelling and improvement in joint ROM. Regarding the first of these parameters, despite the interaction among various factors such as inflammation, the resulting stasis of liquids rich in catabolites and inflammation mediators and the trophic tone of each individual patient’s thigh, there was a remarkable difference between the experimental and control groups. In the literature there are articles in which the use of bandaging is indicated as an effective method for reducing post-operative edema and swelling. The counter-indication for this technique is the invasive nature of the bandaging, especially with patients who have just undergone surgery. NeuroMuscular Taping overcomes this objection through its being only slightly invasive, easy to apply and to remove as well as improved patient compliance and motivation.


Figure 8
Reduction in Pain

Improvements in ROM, were significantly greater in the experimental group than in the control patients. This difference was mainly found in active and passive flexion.

In conclusion, it may be affirmed that the application of elastic bandaging, using NeuroMuscular Taping during the post-acute phase after an FKR implant, provides undeniable advantages when used, together with traditional rehabilitation therapy. The method offers improvement in the overall condition of the patient and positively affects the specific parameters that are usually considered and measured for purposes of discharge from the Intensive Rehabilitation Unit. Along with these quantifiable data, increased patient compliance and motivation was also noted. The use of NeuroMuscular taping appeared to be much appreciated by patients from the outset and following initial measurements and corroboration of positive outcomes, they seemed to expect its application.

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