Effects of low-intensity pulsed ultrasound on pain and recovery of range of motion after total knee arthroplasty: preliminary study

Introduction: Pain and limitation in knee range of motion (ROM) during the immediate postoperative period are the common outcomes after total knee arthroplasty (TKA) procedure. Low-intensity pulsed ultrasound in combination with cryotherapy is a promising physiotherapy intervention which has been shown to help in relieving inflammation and improving recovery of joint function of patients with TKA. However, the documentation on the effects of combining low-intensity pulsed ultrasound in post-operative rehabilitation programme is limited. Therefore, this study was conducted to determine the effects of low-intensity pulsed ultrasound as in-addition to conventional physiotherapy on pain and knee ROM in patients with TKA. This study also aimed to assess the relationship between the recovery of knee ROM and pain following the combined intervention. Method: This was an assessor-blinded quasi-experimental study among patients with TKA at the Universiti Kebangsaan Malaysia Medical Centre. Participants were alternately allocated to receive either pulsed ultrasound-added conventional physiotherapy (n=10, experimental group) or conventional physiotherapy alone (n=10, control group) for 3 weeks. Visual analogue scale and goniometer were used to assess post-operative pain and active knee ROM, respectively. The outcomes were evaluated at baseline (post-operative day 2), week 1 and week 4 after TKA. Mixed model ANOVA and Spearman’s rho were used to analyze the data. Result: This study showed a significant time and group effects for pain and knee ROM following interventions. The pain score decreased (p0.05). Discussion and Conclusion: The findings from this study provide physiotherapists and other healthcare providers knowledge regarding the effects of combining low-intensity pulsed ultrasound in post-operative rehabilitation following TKA. The combined intervention demonstrated more promising results in pain alleviation and recovery of knee motion following TKA. Further study with larger sample size is needed to establish this study findings. Keywords: low-intensity pulsed ultrasound, physiotherapy, total knee arthroplast

The mid term functional outcomes of NexGen legacy posterior stabilized flex fixed bearing total knee replacement in primary osteoarthritis

Introduction: To evaluate the midterm functional outcomes of patients who had undergone total knee replacement (TKR) using posterior stabilized (PS) fixed bearing system from January 2005 until April 2006 for primary osteoarthritis of the knees. Methods: A retrospective study was done on forty-six patients, 87% female (n= 40) and 13% male (n=6), aged 54 to 81 years old (mean 69 ± 5.69) who had undergone primary TKR using the NexGen LPS-Flex Zimmer Warsaw. The patients were followed up for at least five years. A medial parapatellar approach and cemented posterior stabilized fixed bearing TKR system were used performed by one of two arthroplasty surgeons. All patients followed the same rehabilitation protocol post-operatively. Assessments were done using Oxford-12 knee scoring questionnaire to evaluate knee function and SF-36 to assess quality of life outcomes. Results: Oxford knee score revealed patients had lower (better) than average scores in terms of function (score 14.35 ± 4.21 out of 35) and pain (score 9.28 ± 3.01 out of 25). Analysis on the quality of life outcome score with SF-36 revealed a higher (better) score for mental component summary (MCS) relative to physical component summary (PCS). Patients had the highest score for role emotional (RE), followed by mental health (MH), and social functioning (SF). Conclusions: The NexGen LPS-Flex TKR produced a good functional outcome with minimal pain in the operated knee with better mental compared to physical health of patients in the midterm period post-total knee replacement

Clinical pathways: development and implementation at a tertiary Hospital in Malaysia

Clinical pathways have been implemented in many healthcare systems with mix results in improving the quality of care and controlling the cost. CP is a methodology used for mutual decision making and organization of care for a well-defined group of patients within a well-defined period. In developing the CPs for a medical centre, several meetings had been carried out involving expert teams which consist of physicians, nurses, pharmacists and physiotherapists. The steps used to develop the pathway were divided into 5 phases. Phase 1: the introduction and team development, Phase II: determining the cases and information gathering, Phase III: establishing the draft of CP, Phase IV: is implementing and monitoring the effectiveness of CP while Phase V: evaluating, improving and redesigning of the CP. Four CPs had been developed: Total Knee Replacement (TKR), ST Elevation Myocardial Infarction (AMI), Chronic Obstructive Airways Diseases (COAD) and elective Lower Segment Caesarean Section (LSCS). The implementation of these CPs had supported the evidence-based medicine, improved the multidisciplinary communication, teamwork and care planning. However, the rotation of posts had resulted in lack of document ownership, lack of direction and guidance from senior clinical staff, and problem of providing CPs prior to admission. The development and implementation of CPs in the medical centre improved the intra and inter departmental communication, improved patient outcomes, promote patient safety and increased patient satisfaction. However, accountability and understanding of the CPs must be given more attention

Effects of low-intensity pulsed ultrasound on knee range of motion of patients with total knee arthroplasty after controlling for postoperative pain

Background: Low-intensity pulsed ultrasound is a physiotherapy treatment modality that has shown positive effect on the recovery of knee range of motion (ROM) after total knee arthroplasty (TKA) other than helps to relieve inflammation and improve joint function. However, whether the recovery of knee ROM of post-TKA following the low-intensity pulsed ultrasound is influenced by the recovery of postoperative pain or not, is still unknown. Purpose: This study aimed to examine the effect of low-intensity pulsed ultrasound on the recovery of knee flexion range of post-TKA after controlling for postoperative pain following the intervention. Methodology: This was an assessor-blinded quasi-experimental study. Thirty-two post-TKA patients at the Hospital Canselor T uanku Muhriz Universiti Kebangsaan Malaysia were alternately allocated to an experimental group (n = 16, received low-intensity pulsed ultrasound and conventional physiotherapy) and a control group (n = 16, received conventional physiotherapy alone). Intervention was administered for 3 weeks (postoperative week 1 had 4 sessions/week, postoperative week 2–3 had 1 session/week). Pain and active knee flexion range were assessed using visual analogue scale and goniometer respectively: at baseline (postoperative day-2) and 1-week follow-up after the intervention. Data was analyzed using independent t-test and one-way ANCOVA. Results: The postoperative pain following the intervention was significantly different between the groups (meanSD = 1.641.40 vs 3.401.50, p < 0.01). After controlling for the postoperative pain following the intervention, there was a statistically significant effect of the intervention on the active knee flexion range (F(1,29) = 13.50, p = 0.001, p2 = 0.32), where the participants in the experimental group showed significantly greater knee flexion range than the control group. Conclusion: Low-intensity pulsed ultrasound as an adjunct to conventional physiotherapy provides better effect in the recovery of active knee flexion range of patients with TKA

Effects of low-intensity pulsed ultrasound as an adjunct to conventional physiotherapy on post-operative pain and functional ability of total knee arthroplasty patients

Introduction Low-intensity pulsed ultrasound as an adjunct treatment modality for acute management has shown bene cial for recovery of in ammation and joint function of patients after total knee arthroplasty (TKA). However, there is limited documentation on the effects of combining low-intensity pulsed ultrasound in TKA rehabilitation. This study aimed to determine the effect of low-intensity pulsed ultrasound as an adjunct to conventional physiotherapy on the recovery of post-operative pain and functional ability after TKA. Methodology This assessor-blinded quasi-experimental study was conducted among TKA patients at a university medical center. Participants were alternately allocated to receive either low-intensity pulsed ultrasound-added conventional physiotherapy (n = 16, experimental group) or conventional physiotherapy alone (n = 16, control group). The intervention was conducted for 12 weeks (4 times for the rst week post-TKA, once a week for the following 2 weeks, and once in every two weeks for another 9 weeks). The low-intensity pulsed ultrasound in the experimental group was conducted at the rst 3 weeks of post-operation. Visual analogue scale and Lower Extremity Functional Scale were used to assess pain and functional ability respectively: at post-operative day 2 (baseline assessment for pain and functional ability), week 4 of intervention (to assess pain) and week 12 of intervention (to assess functional ability). Collected data was analyzed using mixed model ANOVA. Results The study showed a signi cant interaction between time and group for pain (p 0.05, 2 = 0.11). Conclusion Integration of low-intensity pulsed ultrasound and conventional physiotherapy provides better effect in pain alleviation following TKA

Type II Collagen-Conjugated Mesenchymal Stem Cells Micromass for Articular Tissue Targeting

The tissue engineering approach in osteoarthritic cell therapy often requires the delivery of a substantially high cell number due to the low engraftment efficiency as a result of low affinity binding of implanted cells to the targeted tissue. A modification towards the cell membrane that provides specific epitope for antibody binding to a target tissue may be a plausible solution to increase engraftment. In this study, we intercalated palmitated protein G (PPG) with mesenchymal stem cells (MSCs) and antibody, and evaluated their effects on the properties of MSCs either in monolayer state or in a 3D culture state (gelatin microsphere, GM). Bone marrow MSCs were intercalated with PPG (PPG-MSCs), followed by coating with type II collagen antibody (PPG-MSC-Ab). The effect of PPG and antibody conjugation on the MSC proliferation and multilineage differentiation capabilities both in monolayer and GM cultures was evaluated. PPG did not affect MSC proliferation and differentiation either in monolayer or 3D culture. The PPG-MSCs were successfully conjugated with the type II collagen antibody. Both PPG-MSCs with and without antibody conjugation did not alter MSC proliferation, stemness, and the collagen, aggrecan, and sGAG expression profiles. Assessment of the osteochondral defect explant revealed that the PPG-MSC-Ab micromass was able to attach within 48 h onto the osteochondral surface. Antibody-conjugated MSCs in GM culture is a potential method for targeted delivery of MSCs in future therapy of cartilage defects and osteoarthritis

Human platelet lysate promotes proliferation but fails to maintain chondrogenic markers of chondrocytes

Traditionally, foetal bovine serum (FBS) is used as a serum supplement for stem cell expansion in vitro. However, it is associated with xenoimmunisation and the transmission of animal pathogens, which may cause harm to stem cell recipients. As a safer alternative, human platelet lysate (HPL) has been introduced for propagating stem cells. Chondrocytes are expanded in vitro for cartilage repair via autologous chondrocyte implantation (ACI). In this study, we compare the efficacy of HPL prepared from expired platelet concentrates with that of FBS for promoting the proliferation and maintenance of the chondrogenic markers of primary human chondrocytes expanded in vitro. Chondrocytes were cultured in F12:Dulbecco’s modified Eagle’s medium (DMEM) supplemented with 5% HPL, 10% HPL and 10% FBS. The cell morphology, viability and growth rate were examined from passage 1 (P1) to P3. RNA was isolated from P3 cells for quantitative polymerase chain reaction (qPCR) to determine the gene expression level of the chondrogenic, dedifferentiation and hypertrophic markers. HPL promoted chondrocyte proliferation without compromising cell viability. In addition, the chondrocytes cultured with HPL were smaller. However, HPL failed to maintain the chondrogenic markers, except SOX 9 (SRY-box transcription factor 9), which was upregulated, but not significantly. Nonetheless, HPL also suppressed the expression of type X collagen (Col X), a chondrocyte hypertrophic marker. In summary, we demonstrate the benefits of HPL supplementation in human chondrocyte culture, where it enhances cell proliferation and suppresses chondrocyte hypertrophy. In the future, HPL can be used for the large-scale expansion of chondrocytes for ACI