CONTINUING PHYSIOTHERAPY EDUCATION
Year : 2022 | Volume
: 4 | Issue : 2 | Page : 164--168
Role of offload taping for total knee arthroplasty: A clinical educative pearl for physiotherapists
Deepak Kumar, Adhya Kumar, Tanmay Kumar
Capri Spine Clinic, New Delhi, India
Correspondence Address:
Dr. Adhya Kumar
Capri Spine Clinic, New Delhi
India
Abstract
This article intends to utilize offload rigid taping as an adjunct to pain management after total knee arthroplasty (TKA). TKA is a common orthopedic surgery. A dramatic rise in TKA surgeries is foreseen as TKA surgeries are projected to take place with an increasing rate of younger TKA recipients under 60 years of age. Approximately 40% of surgical patients usually experience severe to acute postoperative pain after TKA. A study by Scott F. Dye et al. suggests that most knee pain does not arise from the degenerated articular cartilage in osteoarthritic patients. Rather, the anterior fat pad is the main culprit behind the nociceptive stimuli. As an experimental clinical trial, offload taping was administered on the 2nd postoperative day after TKA to understand its effect on pain scores using the visual analog scale. It was found that the administration of offload taping resulted in a significant reduction in acute pain at rest and during ambulation in such patients.
How to cite this article:
Kumar D, Kumar A, Kumar T. Role of offload taping for total knee arthroplasty: A clinical educative pearl for physiotherapists.Indian J Phys Ther Res 2022;4:164-168
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How to cite this URL:
Kumar D, Kumar A, Kumar T. Role of offload taping for total knee arthroplasty: A clinical educative pearl for physiotherapists. Indian J Phys Ther Res [serial online] 2022 [cited 2023 Oct 1 ];4:164-168
Available from: https://www.ijptr.org/text.asp?2022/4/2/164/368052 |
Full Text
Introduction
Knee osteoarthritis (OA), also known as degenerative joint disease, primary OA, or age-related arthritis, is the second most common chronic rheumatic disease in the elderly.[1],[2] It affects about 22% to 39% of the Indian population.[1] It is found to affect women more than men.[3] Risk factors include sex, higher body mass index, previous knee injury, and comorbidities.[3]
It causes pain, stiffness, and restriction in the knee joint range of motion.[4] It affects the three compartments of the knee joint (medial, lateral, and patellofemoral), affecting daily life activities to a great extent.[2] The medial knee joint is affected the most, causing varus deformity at the knee.
In a normally aligned knee, the ground reaction forces are slightly medial to the center of the knee joint. Here, the compressive forces are around 70% [Figure 1] during weight bearing. However, with 5° of varus stress, compressive forces on the knee joint increase to about 90%. Hence, a slight varus stress causes significant compression on the medial knee joint while loading.[5]{Figure 1}
Earlier, it was believed that OA is caused due to the loss of articular cartilage only, but now, it is known to be multifactorial in origin. It is now considered a disease affecting all the tissues in the joint, impacting changes in the tissues' architecture, metabolism, and function.[6] However, the disease pathophysiology is still not clearly understood.[2]
Knee OA causes pain around the knee joint, which can be mild, moderate, or severe. It can be dull, sharp, constant, or intermittent. Symptoms of OA vary depending on the severity of the problem. Common problems may vary from a decrease in range of motion, effusion, locking, and giving way to muscle weakness, patellar malalignment, crepitus, etc., Patients presenting with knee arthritis complain of pain while walking, climbing stairs up and down, getting up from a chair, and squatting. They also report severe pain and stiffness after prolonged periods of rest or sitting. These problems ultimately lead to decreased quality of life, negatively impacting the person's psychological status.[2]
As discussed, the pain arising from OA is majorly related to the medial compartment of the knee. According to Kellgren and Lawrence's radiographic criteria for the assessment of OA [Figure 2], Grade 3 and Grade 4 are classified as moderate and severe OA impacting the articular cartilage. In Grade 3 OA, there is moderate joint space reduction. In Grade 4 OA, there is marked and severe joint space reduction in the medial compartment with subchondral sclerosis.[7]{Figure 2}
Total knee arthroplasty
The most common indication of total knee arthroplasty (TKA) is moderate-to-severe OA, greatly affecting an individual's daily function.
TKA/total knee replacement (TKR) is a common orthopedic surgery. It is commonly performed on older individuals above 60 years of age and women.[3] However, TKR surgeries are projected to take place with an increasing rate of younger TKR patients under 60 years, leading to dramatic increases in TKR surgery.[3]
TKR involves replacing the articular surface of femoral condyles and tibial plateau with smooth metallic highly cross-linked polyethylene plastic.[3] Approximately 40% of surgical patients usually experience severe to acute postoperative pain at rest and after ambulation post-TKR.[8]
Acute pain is usually observed during postoperative days 1–3. Pain is presented as aching and heaviness. Pain limits functional activities post-TKR. Walking, being an important functional activity, gets severely affected. Hence, intravenous analgesia is commonly used as a part of pain management for acute postoperative patients. Opioids, COX 2, and Non-steroidal anti-inflammatory drugs (NSAIDs) are the most commonly used treatments for acute pain management post-TKR. Even after administering the abovementioned treatments, some patients still report severe pain resulting in decreased ambulatory status posing a higher risk of developing comorbidities (deep vein thrombosis, embolism, bed sores, etc.). To decrease acute pain, and increase function, offload taping was applied as an adjunct to pain management in patients who have undergone TKR on the 2nd postoperative day. Before moving on to taping, it is important to understand fat pads and their role in the generation of pain in the knee joint.
Is the loss of articular cartilage the real culprit of knee pain? Or, the real issue lies in inflamed fat pads?
The anterior suprapatellar fat pad, posterior suprapatellar fat pad, and infrapatellar fat pad are the three anterior fat pads found in the knee. These fat pads are abundant in free nerve endings.[9]
The infrapatellar fat pad, also known as Hoffa's fat pad, is present between the patellar ligament and the anterior intercondylar area of tibia. It is a highly innervated structure.
To understand how to map the pain in the knee joint and from where exactly the knee pain originates, an interesting study was done by Dye et al.[10] The study was based on conscious neurosensory mapping of the internal structures of the human knee without intra-articular anesthesia.[10] The conscious neurosensory characteristics of the internal components of the human knee were documented by instrumented arthroscopic palpation without intra-articular anesthesia. With only local anesthesia injected at the portal sites, the dye had both knees inspected arthroscopically. Subjectively, he graded the sensation from no sensation (0) to severe pain (4), with a modifier of either accurate spatial localization (A) or poor spatial localization (B).
As in [Figure 3], the intra-articular structures are shown on two views of the knee joint: (a) coronal view and (b) sagittal view.{Figure 3}
The sensations of pain and discomfort are graded, ranging from no sensation to severe pain, as shown through shading (white to black) in the figure above.
In the study, the nature of the intra-articular structures was found to be variable. It was found that the anterior fat pad, synovium, and patellar tendon were excruciatingly painful marked as 4A (which means severe pain with accurate spatial localization) in [Figure 3]. The anterior cruciate ligament and posterior cruciate ligament ranged from 1 to 2B in the mid portion, while ranged from 3 to 4B at the insertion sites.[10] The sensation from the meniscal cartilages ranged from 1B on the inner rim to 3B near the capsular margins.[10] The sensation from the healthy articular cartilage ranged from 0, indicating that the healthy articular cartilage does not carry the nociceptive sensations. Hence, even if there is a loss of healthy articular cartilage in knee OA, the healthy cartilage is not a structure that generates pain. The healthy articular cartilage lacks nerve supply, rendering it free of nociceptive sensations. However, it should be noted that when the cartilage develops cracks and fissures (degeneration), fine nerve endings grow in the cracks, which can carry nociceptive sensations, causing pain in the knee joint. Although healthy cartilage is absolutely pain-free.
Therefore, it is mainly the anterior fat pad, a highly innervated structure that causes most of the pain, along with some pain generated by the cruciate ligaments, patellar tendon, roots of the meniscus, and the posterior capsule. Therefore, anterior fat pads can be called the real culprit behind the majority of knee pain.
Offload taping: Adjunct to pain management
Rigid taping[11] [Figure 4] has been used as a part of rehabilitative and prophylactic programs in managing musculoskeletal disorders. Taping has been used as a method in physical therapy to reduce pain. There are different types of taping techniques available. A rigid tape, which is a zinc oxide tape, is an inelastic adhesive tape. It is an easy, cost-effective, and useful treatment method for pain relief. Before applying the rigid tape, a protective under wrap is commonly used.{Figure 4}
Taping with tension increases the threshold of pressure pain perception and supports the injured soft tissues, including the muscles, tendons, and ligaments.[12] It provides optimal loading without causing stress on the healing soft tissues. It protects and supports the structures in a functional position. Stretch and compression caused by rigid taping with tension perturbs the nociceptive signal transmission and modifies the pain perception.[12]
Rigid tape applied in a diamond shape helps offload the underlying fat pad, which is already inflamed. Using these principles and evidence, offload taping was applied as an adjunct to reduce acute postoperative pain in patients post-TKR.
Method of application of offload rigid taping
Before the zinc oxide brown tape application, a protective under wrap is applied.
Under wrap is applied without any stretch or tension in a diamond shape as illustrated [Figure 5]. Four strips of under wraps are taken. The corner of another strip overlaps the corner of each strip. It is applied to prevent skin irritation to avoid rashes, itching, or other skin reactions.{Figure 5}
On the under wrap, zinc oxide rigid tape is applied. Four strips, each measuring about 10–15 cm (can vary depending on the thigh and leg circumference of the patient), are taken.
The first strip is applied starting from the anterior shin of the tibia to the posterolateral aspect of the knee joint. First, the tape is pasted at the central aspect of the tibia proximally without any stretch. Then, the soft tissues along the midline of the tape are lifted and offloaded, following which the corner of the tape is pasted on the posterolateral aspect of the knee joint. The second strip is applied in the same manner starting from the anterior shin of the tibia to the posteromedial aspect of the knee joint.
Applying two strips of tape will make the soft tissues at the inferior aspect of the knee joint creased and offloaded. There would be a feeling of softness in the skin around the inferior aspect of the knee.
After this, two strips are applied on the knee joint's superior aspect starting from the central aspect of the femur distally. The corner of one strip is placed on the superolateral aspect of the knee joint, and the corner of the other one is placed on the superomedial aspect of the knee joint. Both the strips are applied in the same fashion of offloading the soft tissues along the two tape strips.
After the application of all four strips, a diamond shape of tape is seen, and the soft tissues inside the tape give an appearance of a muffin top.
Mild corrugations can be seen on the under wrap and on the T-plus bandage [Figure 6], which indicates an adequate offload of soft tissues. The more corrugations, the better the offload. If the offload is done suitably, there is a marked reduction in pain, ultimately causing an improvement in function.{Figure 6}
As this technique of taping promotes instant and marked reduction in pain, it was applied as an experimental clinical trial on patients post-TKR complaining of acute pain postoperatively. It was applied on the 2nd postoperative day as by that time, the patient's crepe bandage was weaned off replacing it with a strip of T-Plus bandage. Care was taken to prevent any undue stretch/tension on the stitch line of the patient.
The tape was applied in a similar manner as explained above. Following the application, the TKR patients were made to ambulate. It was found that with the application of the tape, there was a significant improvement in pain as per the visual analog scale. They reported a decrease in heaviness and pain and felt that the tape could provide more support to the soft tissues of the knee, which helped them to walk with a significant reduction in pain scales.
To decrease the pain along the medial aspect of the knee, another strip can be placed medially starting from the posteromedial aspect of the knee joint, offloading the soft tissues present along the medial joint line [Figure 7]. This strip of tape acts as a reinforcement to decrease pain further in the medial aspect of the knee.{Figure 7}
Discussion and Conclusion
This shows that the application of offload tape resulted in positive changes in pain scores compared pre- and postapplication of taping. It is hypothesized that the significant decrease in pain occurred because the taping technique disperses stresses generated by muscle contraction, thereby reducing painful inhibition, and allowing the subject to function more easily.[13]
A possible model of the mechanism of action for offload taping post-TKR relates to its neurophysiologic effects on the nervous system, particularly the nociceptive system. In this neurophysiological model, the tape may exert an effect on pain by primarily altering the nociceptive perception, either locally at the knee by inhibiting nociceptors, facilitating large afferent fiber input into the spinal cord, and/or possibly by stimulating the endogenous processes of pain inhibition.[13]
Hence, it can be a useful adjunct to pain management in TKR patients to reduce postoperative pain.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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