Reaching for the sun by Maia Waye
Local Sequim, WA artist
Knee pain study
Loraine Lovejoy-Evans, DPT, and Kathie Hummel-Berry, PT, PhD.
As part of my Doctoral program at the University of Puget Sound in Tacoma, Washington, I had to do a research project. Since I had been treating patients with significant swelling (edema) such as those who had cancer and developed lymphedema, I thought these treatment techniques would be interesting to study. I began applying these treatments with specialized bandages made in Germany and using a type of massage called Manual Lymphatic Drainage (MLD) to those with orthopedic injuries, such as knee pain.
Working with patients who had recently undergone surgery to replace the knee (total knee replacement or total knee arthroplasty), the results were very promising. A patient came in a week after the surgery to the hospital's outpatient physical therapy department where I was working. After doing the Clinical Manual Lymphatic Drainage (MLD) massage technique for 15 minutes, the pain reduced from 9/10 to 2/10 (with 0 being no pain and 10 being the worst pain imaginable). This was really exciting to me and shocking to the patient. All of my patients who had a knee replacement were then treated with this protocol. It was exciting to see these patients have less pain and moving the knee better and their bodies easier in a much speedier fashion than I had ever seen before with standard physical therapy approaches.
Wow, was I ever enthused by these impressive results? Doctors were pleased that their patients were moving better with less pain and the patients were happy to be getting better so fast. When I opened my private practice, Independence Through Physical Therapy, I continued to work on people using these treatment protocols on anyone that I felt had a swelling component as part of their complaints. Several patients over the years had previously undergone a total knee replacement but still had knee pain. One such patient was so miserable she told me she wished she had never had the surgery done and in fact stated she wished she were no longer alive. She was in a wheelchair and was unable to walk and needed help moving in and out of the chair including using the bathroom. After treating her with specialized bandages from Germany and Clinical Manual Lymphatic Drainage (MLD) massage technique, her pain decreased dramatically. She was able to get out of the wheelchair and return to walking.
Cause of knee pain
Since her knee pain improved by addressing the swelling, it made me wonder if the knee pain was actually caused by the bone-on-bone osteoarthritis or arthritis that resulted in her having a metal knee implanted to replace the damaged bone. She now had a metal knee so the arthritic knee was no longer present. How could she still have pain? I wondered, could the knee pain be coming from the swelling?
In pursuit of this question, I began treating patients with knee pain who had not undergone knee replacement surgery using these techniques to treat swelling. The same results were demonstrated in these patients by using specialized bandages and MLD. The knee pain was improving without surgery despite arthritis in the knee.
As part of my study at the University of Puget Sound, I worked with Dr. Hummel-Berry, on developing an idea. Lena Sadovikov PT, Valerie Strickland SPT, and Takeo Sumitomo helped with the study and wanted to work on swelling using the bandages and MLD techniques used in treating lymphedema. I encouraged the group to question if we could reduce knee pain and possibly prevent knee replacement surgery by addressing swelling in the leg before the leg is obviously swollen by using easier techniques? I encouraged our team to consider chronic venous insufficiency as part of the cause of knee pain.
Knee pain study in a nutshell
We recruited 29 patients who had knee pain and asked them several questions especially what activity caused them the most pain and what was their pain level on a scale of 0-10/10 when they did this activity. Most of the patients said that their pain walking through Costco (a large warehouse store) increased to 8/10. Then we determined that the best objective measurements would be girth or size of the leg, and range of motion of the knee or how well the knee bent and straightened. After establishing a baseline on each patient, they were put through three different treatment sessions lasting 2 weeks each.
For the first two weeks, I taught the patients to do strengthening exercises and stretches, a typical approach used in physical therapy. After this phase of the study, the measurements and questionnaires were repeated. Most of the patients noted no change in their pain and I could not measure much difference in their range of motion or girth.
During the next two weeks, the patients were given 3 pairs of 20-30mmHg knee-high compression stockings and were instructed to perform a simplified version of Manual Lymphatic Drainage massage to be done 4 times a day. After this phase of the study, the measurements and questionnaires were repeated. Most of the patients noted that their pain level walking through Costco reduced from 8/10 to 2/10 and I could measure that their girth at the ankle and calf reduced and the range of motion improved.
In the final two weeks of the study, the patients were instructed to withhold treatment, or stop doing the MLD and stop wearing the compression socks. Following this phase of the study, the measurements showed that girth increased and the range of motion decreased. The pain level in most of the patients increased from 2/10 to 6/10.
One of the patients was a young man who found such good improvements with the socks and massage that he did not want to stop. His wife begged him to not wear the socks or do the massage or it would ruin my study. He was able to finish the study but after the last two weeks of witholding treatments, he went back to wearing the socks and doing the massage. He found that he was able to hike and play basketball without pain now and he did not want to give that up.
One of the interesting things I found in the study was that everyone in the study wore the compression socks on both legs, even the one without the knee pain. The findings demonstrated that even the leg without the knee pain got smaller and the knee moved better.
This study showed that by addressing swelling problems in the lower leg, knee pain can be reduced. The earlier swelling problems are treated the less treatment is needed. I recall a patient telling me that her physician told her "you do not need to see Loraine yet". This indicated to me that the physician was recommending that she wait until her swelling was so bad she needed to be treated with bandages and tighter compression stockings. By treating swelling earlier, it requires a lighter compression sock and less of the Manual Lymphatic Drainage massage they need to do. Now I try to treat people earlier with socks and massage even if they do not show obvious signs of swelling problems. I find that typically in these patients, I can see early warning signs of swelling such as the petechia noted in chronic venous insufficiency. Petechiae are little brown or red dots on the skin without obvious irritation causing them.
If I wear my compression stockings, I do not get knee pain. But by not wearing my compression socks in the summer, I have seen an increase in my leg swelling and I have been having knee pain again. Silly choice, but it was definitely a choice. I do not like knee pain. It is time to put the socks back on!
Releasing Joint Restrictions
Another cause of knee pain I have found can be an abnormal alignment of the skeleton. With the pelvis out of place, even a little bit, this makes one leg longer than another. One leg would be climbing a mountain and the other leg stepping in a hole with every step. This is what I think causes arthritis or break down of the joint to begin with.
When I get a new patient to treat, I always start by using Releasing Joint Restrictions (RJR) or Strain and Counterstrain (SCS) treatment technique. This is a highly specialized stretching protocol that helps improve the alignment of the skeleton so the bones fit together the right way and the muscles can work their best. This commonly reduces knee pain. I had a patient yesterday who told me she had bone-on-bone in her knees and her pain level in standing was 8/10 in both knees. After doing the treatment in her recliner, she put the left leg out to the side, bent the knee and dropped the knee in toward the other knee for 90 seconds her knee pain reduced in standing to 4/10. It only took 90 seconds and the knee pain was cut in half. Even pain medications take 30 minutes and rarely do they cut the pain in half.
Starting with the RJR technique helps determine quickly if the knee pain is coming from the poor alignment. I have them work on doing this RJR technique 2 times a day and any time the pain increases. I then teach them to fire the inner core/pelvic floor to maintain the improved alignment. Finally, I teach them about swelling and use of socks and MLD. I try to change one thing at a time to make sure to learn what treatment changes their symptoms.
This helps people to manage their knee pain with these simple tools. The sooner they start doing these treatments, the less they have to do.