Wednesday, May 22, 2024

The Role of Compression Therapy in Managing Knee Pain: Insights from Singapore

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Knee pain is a common problem that has been affecting most of the population, with its prevalence increasing over the years to become a severe issue. It is a subjective indicator of damage in the knee, and its effects are more than just physiological. Knee pain has been known to affect the overall quality of life of an individual and to cause restriction in the ability to carry out functional activities. With the increasing number of knee pain patients coming to seek medical treatment, there is a need to investigate newer forms of medical management for it, focusing on cost effectiveness and quick results. One of the methods of management lies in the use of compression therapy, a method which is not commonly known to people. Compression therapy is a method of applying external pressure to the limb to promote more efficient blood flow to the extremities and is commonly in the form of compression bandages or stockings. This essay will look at the role of compressive bandages in managing knee pain, and we start by doing a literature review to find out the clinical effects and its popularity among knee pain specialist and patients.

Benefits of Compression Therapy for Knee Pain

The result is reduced hemorrhaging from the surrounding vessels into the tissue and also reduces joint swelling as joint edema is caused by the buildup of fluid in the tissue. By wearing a compression bandage on the shoulder, knee, and/or ankle joints, they can be prevented from becoming inflamed and swollen. It also aids in removing the buildup of synovial fluid from an inflamed joint, reducing the nagging feeling of stiffness. By minimizing the extent and length of swelling.

Vasoconstriction is the physiological constriction of the blood vessels, which means that the flow of blood in these areas is slowed. Since blood is mostly water and moves from an area of high pressure to low pressure, any swelling that has occurred in the knee joint will attempt to move towards the area of restricted flow. This is where the increased pressure of vasoconstriction prevents more liquid from entering the vessel from surrounding tissue and slows the movement of extra blood from the site of injury.

Reduction of swelling The cause of the pain relief is somewhat complex and explained through the gate control theory. However, during its passive aspect of relieving swelling and pain, the therapeutic benefits of knee compression are clearer. When an external force is applied from the outside of the body, the underlying vessels are compressed. This increases the pressure needed to force blood through them, vasoconstricts them.

Reduction of Swelling

Swelling of the knee generally results from intra-articular bleeding and takes place in both acute and chronic knee pain conditions. It is also associated with knee stiffness, leading to a decrease in the range of knee joint motion and muscle atrophy. High levels of pain are also associated with knee effusion. Limitation in function and delayed recovery in acute knee injury, such as a sprained ligament or muscle strain, may be partly due to high levels of swelling. In a systematic review of treatment of ankle injury, it was suggested that if swelling could be controlled, recovery could be accelerated. The most direct and obvious effect of compression therapy is in the reduction of swelling. In a study on the effects of cryotherapy and compression on tissue healing, it was found that compression was effective in minimizing the area and levels of bruising and in the prevention of haemarthrosis. This is supported by a study which found that a significant decrease in the number of blood cells in the synovial fluid of a traumatised joint could be achieved with a pressure of 40mmHg.

Pain Relief

The last point to consider is that of pain avoidance or pain-causing activity avoidance, which can lead to a decrease in fitness and weight gain, a known cause of arthritis. A study of people with arthritis using the WOMAC osteoarthritis index found that the use of a pain-relieving knee sleeve significantly increased the physical function score compared to a placebo sleeve. Though there was no change in the WOMAC index, the authors noted that the physical function score it comprised of is a good indicator for the progressive disability in the later stages of knee osteoarthritis.

A study on people with an athletic injury or muscle soreness found that people using a mentholated (pain relieving) gel had a significant increase in quadriceps muscle strength compared to a placebo group. The strength was measured by the ability to extend the knee against an applied force. This might suggest that pain relief provided by compression will allow for maintenance or increased muscle strength around the knee joint, which could be a key factor in prevention of further injuries.

One study on a knee with experimentally induced synovitis found that muscle reflex latency was not changed; however, the on and offset times of the vastus medialis oblique and vastus lateralis muscles were substantially delayed, indicating further rehabilitation for treatment of pain to prevent atrophy of these muscles around the knee. This can be a difficult task if we consider other treatment options such as NSAIDs (nonsteroidal anti-inflammatory drugs) and ice therapy, which is often short term and not always an option for drug treatment.

This section begins with which is generally a cause of concern for patients with arthritis or knee injury. This question is vital because it has been shown that inactivity, a common result for those suffering from knee injury, which is brought about by the pain caused by movement, exacerbates muscle atrophy and delayed muscle reflex, hence slowing down the support your muscles can provide for the knee joint. This ultimately leads to increased instability and likelihood of further injury for the knee.

Improved Blood Circulation

Leg stiffness is a well-documented consequence of knee joint injury and osteoarthritis that is particularly pronounced in the morning and after periods of inactivity. The supine position promotes venous drainage and increases cardiac output and stroke volume. Hydraulic pressure and gradient settings, which can be modified by the choice of garment and material, and by changes in posture, can stimulate venous return and enhance cardiac response. Status of surrounding muscles may have profound effects on the efficiency of venous return. Pumping action of the calf muscle on the venous system is well known, and it has been shown that increased knee joint effusion can cause inhibition or reflex suppression of vastus medialis obliqus (VMO) activity. This may lead to muscle atrophy and further destabilization or disuse of the knee joint. Focused pressure on the infrapatellar area and around the knee joint can aid oxyhemoglobin delivery to stimulate VMO hypertrophy and re-establish neuromuscular control of the joint. Peripheral arterial microcirculation, the nutritive endarteriole to capillary exchange system, and other delicate lymphatic and venous drainage structures are particularly vulnerable to edema-induced tissue pressure. Compression material and pressure are determinants of effectiveness. High static stiffness material is effective, provided the garment design does not cause tourniquet problems and impair tissue perfusion in cases where ankle joint edema is also present. The use of intermittent gradient pneumatic compression pumps can provide effective mechanical assist and can be of benefit in patients with poor mobility or in a management postoperative rehabilitation. Compression therapy effects on tissue perfusion and remodeling will provide an interesting ground for future quantitative research in the field of sports injuries, orthopedics, and pathophysiology.

Types of Compression Therapy

Compression Sleeves

Another disadvantage of the sleeve is that it provides little support in terms of stabilizing the knee joint or maintaining proper patella alignment, a feature that is most beneficial for someone with ligament injuries or patellar maltracking in the case that they need compression to get rid of swelling. An advantage of the sleeve, however, is that it is very simple to slip on and off and would not hinder one from certain activities where much flexibility of the knee is needed, although it does not provide the same compression and effect as other forms of compression therapy from doing too much at one time.

The compression sleeve is a great idea for someone trying to alleviate knee pain. Sleeves are generally made out of neoprene or a drytex material and usually come in different sizes to ensure one gets a proper fit. Sleeves are designed to provide maximum compression at the knee joint to help get rid of swelling. If the idea is to get rid of swelling, then the sleeve is the best option due to the fact that only the knee will be compressed, as opposed to a larger area with the bandage. However, given that most of the swelling is due to fluid accumulation in the area surrounding the knee, drawing that fluid away from that area and avoiding the build-up of the fluid at any one spot to cause swelling would be more effective for avoiding the cause of the swelling and not aggravating an inflammatory condition.

Compression Bandages

A downside of compression bandages is that it can be difficult to maintain accurate pressure over the treatment time. suggested the use of a foam pad under the bandage to help disperse the pressure evenly and minimize the pressure gradient. This may not be easily accomplished since the position of the knee during activity would cause shifting of the pad and there are limited types of foam pads available for this specific purpose. Compression bandages can also be easily loosened due to the normal activity of the patient, leading to inadequate pressure and loss of the compression bandage itself. This method is also considered more inconvenient and bulky in comparison to wearing stockings and sleeves, as explained by the need for cutting and measuring the bandage and difficulty of finding the appropriate type to fit the knee. mentioned some of his patients refusing to wear bandages and having little compliance toward this method.

Compression bandages are another popular type of compression therapy. They are simple to apply and adjustable to the level of compression required. It is known that excessive tightness will impede arterial flow, while moderate tightness will increase venous pressure and reduce edema. A well-known example of a compression bandage for the knee is the Tubigrip bandages. This is an elasticated cotton bandage which requires the patient to measure and cut the bandage according to the length required for the knee. The bandage is type 2 and provides moderate 10-15mmHg compression to the knee. The bandage is tight enough to restrict fluid buildup coming from the lower leg and has been shown to be much more effective in controlling swelling in the knee compared to the use of ice and elevation.

Compression Stockings

Graduated compression stockings (GCS) are a frequently used tool in the treatment of knee OA, due to their ease of use, relative comfort, and lower cost compared to alternative compression wraps. A well-fitting stocking remains in position, does not require re-wrapping each time it is removed, and provides consistent therapeutic compression to the lower limb. GCS also exert a higher pressure at the ankle, with decreasing pressure up the leg, providing a compression gradient which is thought to enhance venous return and prevent swelling, as well as potentially reducing the risk of DVT. This is in contrast to many bandaging systems which may apply similar pressure across the system, or indeed may become loose at the proximal end, effectively tourniquetting the knee and causing discomfort and possible further swelling. An offshoot of GCS are tubular compression bandages, that mimic the action of stockings but of which there is less evidence for their effect on knee OA.

Considerations for Choosing Compression Therapy

Proper fitting of the compression product to the knee would ensure effective management of a patient’s condition. Multi-component bandage systems have been shown to be effective in pressure control to simulate the effect of a 4-layer bandage system. However, if these bandages result in unequal pressure distribution, they could be less effective than a tubular elastic bandage that provides uniform pressure. Compression stockings may be effective for patients with rheumatoid arthritis. However, measuring the knee-to-ankle pressure of a knee-length stocking, as well as the effect on quadriceps function and joint position sense, should be considered in patients with venous or lymphatic diseases.

Applying compression therapy to the knee using bandaging or a tubular elastic bandage efficiently reduces pain and swelling. The use of cohesive bandages can be a more practical alternative to short-stretch bandages in the knee as they are lighter, less bulky, and easier to apply. The guiding principle is to exert mild to moderate pressure to minimize swelling but not compromise venous return. It is also necessary to teach the patient or caregiver the correct method of bandaging to ensure the best results. However, there are many types of compression products available in the market, and the effectiveness of each in managing knee pain may differ. Knowledge of the effects of these products is essential when considering the most suitable option for a patient.

Proper Fit and Sizing

A lot of research into compression therapy involves the use of multi-chamber pumps. These devices are capable of providing graduated and sequential compression. This means that there is higher pressure at the distal end of the limb, and the pressure slowly reduces as it goes proximally. Multi-chambered devices can provide more effective and comfortable therapy compared to single-chamber sleeves, as the latter applies even pressure throughout its length.

A suitable fit is essential for compression therapy to be effective. A sleeve that is too tight can cause more pain and damage, whereas loose sleeves may slip off or cause blistering at the skin interface. Prior to the commencement of compression therapy, a clinician will measure the patient’s limb. Then the clinician or patient can select a sleeve that is the right size. Off-the-shelf knee sleeves are convenient and cost-effective; however, some patients will suffer from size and shape abnormalities that make finding an appropriate off-the-shelf sleeve difficult. Custom-fitted sleeves are an alternative solution. They are more costly and less convenient, but for some patients, they may be the only means to have adequate compression therapy.

Material and Design

Material and design almost seem synonymous with compression and support when it comes to therapeutic knee braces. Materials range from neoprene rubber, synthetics, and natural fibers, and each has its own advantages. Neoprene is the most common material because it provides consistent compression and retains heat, which some clinicians believe can improve blood flow and metabolic function to promote healing. Neoprene supports the knee and also has a minimal effect on proprioception. However, some patients complain of allergic skin reactions and discomfort due to overheating. Neoprene knee braces can also sometimes be quite heavy, causing patients to fatigue quicker over the course of a day. Neoprene itself has many different forms and densities, and brace manufacturers may utilize different types depending on the specific application and level of support. Synthetic fibers are used in lighter braces, including many sleeves. These materials are quite strong and lightweight and allow for a less bulky net and a more contoured fit, but they do not breathe well and can cause an allergic reaction in some cases. Natural fibers have become less common but are still used in some braces. These braces are cooler and lighter than neoprene, but they are also generally less durable and provide less support. Brace design variables include the use of metal hinges, open/closed patella designs, and the specific method by which the brace applies compression to the knee. Hinged knee braces are usually used for protection after knee injury or surgery and offload some of the load that would normally act on the knee. However, some studies have indicated the use of a neoprene sleeve can actually create a similar pressure on the patellofemoral joint.

Compression Level

Compression therapy applies an external force to the area being treated, improving the dialogue of the underlying soft tissues. Control of compression level is vital, as it should maximize the effectiveness of the garment without making it uncomfortable or causing adverse effects. The optimal level of controlled external compression should safely range a dosage between the systolic and diastolic arterial pressures (20-30mmHg). At this value, there is increased venous blood flow, enhanced removal of fluid from the area, and minimal to no increase in the load on the heart. This is widely accepted as the pressure range at which blood flow is significantly increased, so the aim is to produce a garment that exerts this pressure on the limb of the patient, using gradient or ‘standard’ compression. An ideal bandage or stocking would exert the highest pressure at the ankle and gradually decrease up the limb. Unfortunately, there is a gap between the prescribed pressure and the pressure actually achieved by the patients, usually around half is achieved. This has led to the development of adjustable compression braces, which allow the patient to increase the pressure as symptoms develop, i.e., during activity, and decrease it in the event of continuous discomfort or pain. This method has been shown to be more reliable in the treatment of symptoms of those with early to mid OA.

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