Knee Study Science
My husband, Eric with Kiska inside whalebone sculpture in Port Angeles, WA
University of Puget Sound (UPS) Doctoral Study
by Loraine Lovejoy-Evans, MPT, DPT, CLT-Földi,
and Kathie Hummel-Berry, PT, PhD.
Managing Knee Pain Due To Venous And Lymphatic Congestion With A Home Program Of Manual Lymphatic Drainage And Over-the-counter Compression Stockings.
In 2006, I worked on obtaining a doctorate degree in physical therapy. As part of that effort, I did a study for a research project on managing knee pain. I had been working on managing edema for people who had cancer and had developed lymphedema. I started to apply the techniques I had learned in managing lymphedema, to my orthopedic patients such as those who had undergone a total knee replacement surgery. By applying treatments for lymphedema to these orthopedic cases, using skincare, Manual Lymphatic Drainage (MLD) massage, specialized compression bandaging, and exercise were making impressive improvements.
​
Patients who underwent these treatment protocols were showing an excellent reduction in girth (size of the limb), increase in the range of motion or ability to move the leg, increased functional mobility such as being able to walk, and especially reduction in pain. The worse the swelling is for people, the tighter compression they need to maintain the reduction of girth achieved using specialized compression bandages and the more frequently they need to do their Manual Lymphatic Drainage (MLD) massage technique.
These outcomes were pretty amazing. Especially remarkable were the outcomes in people who were still having knee pain a long time after the surgery. These people were so miserable before they underwent this treatment, they told me they wished they had never had the surgery. These cases still puzzle me.
Osteoarthritis, or arthritis as the cause of joint pain
The theory in medical care is that arthritis or a breakdown of the surface of a bone in a joint is what causes knee pain. Therefore, by removing the damaged bones and replacing them with metal components this should resolve the knee pain. This seems logical to me. However, as a physical therapist, for years I was seeing people that continued to have knee pain despite having a new metal knee. I was baffled by this and it made me begin to wonder about the true cause of the pain.
A hypothesis is formed
This made me think about starting even before the surgery to see if we could reduce knee pain by applying the same treatment methodology earlier which would, in theory, require less compression and less MLD. I worked with Dr. Kathie Hummel-Berry, chairman of the physical therapy department at the University of Puget Sound, in Tacoma, Washington, to develop a research project around this theory.
Hypothesis
Chronic venous and lymphatic congestion may contribute to knee pain. Complete Lymphedema Therapy (CLT) is used to manage lymphatic congestion. CLT includes: skincare, education, manual lymphatic drainage (MLD) massage, specific exercises, and compression bandaging until girth is reduced enough to keep swelling down with compression garments (surgical socks). Elements of CLT then may be effective to manage related knee pain and reduced function. Patient-directed interventions are useful due to limited health care resources.
Purpose
To investigate the effectiveness of exercise versus over-the-counter (OTC) compression garments and self-Manual Lymphatic Drainage (MLD) massage to reduce impairment and increase function among patients with knee pain related to venous and lymphatic congestion.
Number of subjects
Twenty-nine consecutive patients with knee pain and who were felt by the researcher to also have venous and lymphatic congestion. Ages ranged from 42-88, the majority of subjects, 12 of the 29, were aged 70-80.
Genders
Males - 12; Females - 17
Research Design
ABBA single-subject design with repeated enrollment was used with consecutive adult patients with venous and lymphatic lower extremity congestion and functionally limiting knee pain. Patients with contraindications to CLT were excluded.
Girth Measurement Reliability
I started doing a few studies to determine the reliability of girth measurements using a measuring tape. For the last study, I recruited friends and family to lend me their legs. I randomly measured each of their ankles, calves, and did a figure-of-8 measurement of the foot and ankle. I measured each of them a total of 5 times. The results of each measurement were hidden from me, as I called them out and had someone write them down. Then I moved onto the next leg. I continued to go to a different person, mixing up different legs until I had no idea which leg I was measuring. Needless to say, I could not remember the last time I measured that leg or what those measurements had been previously. The statistical outcome of this small study was found to be strong enough that the measurement technique could be used in the study.
Measurements
Taken at the beginning of the study and repeated at the end of each two-week phase of the study: Ankle, calf and figure-of-8 girth in cm; knee active range of motion using a goniometer (a protractor with long arms to measure angles) flexion (bend) and extension (straightening); body weight; pain intensity (visual analog scale); knee function (Lysholm score); and Quality of life (Medical Outcomes Study Short-Form 36). Girth and range of motion measurements were repeated on separate days until there were three measurements within 5 millimeters for girth and within 5 degrees for the active range of motion to establish a baseline.
The visual analog scale, Lysholm score, and Medical outcomes study short-form 36 are all questionnaires given to each subject to fill out. The visual analog scale is a line that is numbered from 0 to 10 indicating intensity or how bad the pain is. The Lysholm score is a series of questions specifically about knee function. The Medical outcomes study short-form 36 is a series of questions about the quality of life.
Each of these measurements was taken on every patient in the study before any treatments took place to establish a baseline. Then the measurements were all repeated after each phase of treatment. The measurements were written on a blank form that was created with spaces to fill in. I was given this blank form and I filled it out on each patient at each visit. Then the form was locked into a file box and I was not allowed access to these forms until the study was over.
​
Typically a different researcher would complete the measurements and a different one would treat the patients. But since my private practice was in a rural setting and I had no one available to assist me, we found that seeing different patients daily and not seeing the patient until the next treatment was applied, I was not able to recall their previous measurements. So it was not ideal, but we made it work.
Interventions: Two weeks of specific exercises (strength and flexibility). Two weeks of wearing 20-30mmHg Over-the-counter (OTC) knee-high compression stockings during all waking hours plus self-MLD (Manual Lymphatic Drainage) massage 4 times a day. In the final phase of the study, all treatment was withdrawn for two weeks.
​
Conclusions: After a home program including use of OTC compression garments with self MLD subjects demonstrated reduced knee pain intensity, reduced girth, and increased function and range of motion.
Sample Patient Response:
A 42-year-old male in the study complained of left knee pain during standing up from sitting rated at 6/10 with 10/10 being the worst imaginable. He showed common signs of venous insufficiency including hemosiderin staining of the leg. He also showed signs of swelling in both legs with indentations from socks and loss of hair in the lower leg.
42 year old male before study
42-year-old male after 2 weeks of socks and MLD
42-year-old male at baseline before study. His left knee flexion or how far he can bend was 122 degrees before the study.
​
42-year-old male after 2 weeks of exercise
After the first phase of treatment, exercising for 2 weeks, he reported that his pain level during sit to stand reduced from 6/10 to 5/10. Girth measurements of the left leg showed an increase in size by 0.5 cm at the ankle and a decrease by 1 cm in the calf. Left knee flexion, or bending improved from 122 to 131 degrees.
​
​42-year-old male after 2 weeks of wearing compression socks and doing MLD
After the second phase of treatment, wearing the compression stockings and performing the Manual Lymphatic Drainage (MLD) massage for 2 weeks, he reported that his pain level during sit to stand reduced from 5/10 to 3/10. Girth measurements of the left leg showed a reduction in size by 2 cm at the ankle and by 2 cm in the calf. Left knee flexion, or bending improved from 131 to 134 degrees.
​
42-year-old male after 2 weeks of withholding treatment showing increased signs of chronic venous insufficiency. After the final phase of treatment, withholding all treatments for 2 weeks, he reported that his pain level during sit to stand increased from 3/10 to 9/10. Girth measurements of the left leg showed an increase in size by 3.5 cm at the ankle and by 1 cm in the calf. Left knee flexion, or bending reduced from134 to 100 degrees.
​
This patient reports that during last phase of study withholding all treatments his wife had to beg him to not use the socks. If he wore them, it would ruin the study. He noted such good improvements with the socks and MLD massage that he wanted to resume using them.
​
Prior to study treatments, he had significant pain with basketball and exercise. But during socks and MLD he was able to take a strenuous hike without difficulty.
​
After socks and MLD, he reported an 80% improvement in left knee pain; however, after withholding treatment for 2 weeks he reported the socks and MLD treatment improved knee pain by 90%