Massage Therapy for Post-Op Knee Pain

postoperative knee pain

The use of massage therapy has been shown to improve outcomes in post-operative patients.

The body of knowledge to support the use of massage therapy continues to grow, understanding the basic science behind what we do and the guiding principles of adaptability enable us to apply this work to a number of pathologies.

A comprehensive complementary post-operative treatment should incorporate a number of rehabilitation strategies based on patient-specific assessment findings including, but not limited to:
• Manual Therapy (neurodynamic mobilization, classic massage, joint mobilization)
• Acupuncture/electroacupuncture (local, segmental and distal stimulation sites)
• Education on psychosocial factors (eg. BPS framework of pain, fear avoidance)
• Remedial Loading Programs (eg. static stretching, concentric, eccentric, isometric)

Postoperative Pain Management

Massage therapy has a modulatory affect on peripheral and central processes via mechanoreceptors. Input from large sensory neurons activate spinal cord interneurons that prevents the spinal cord from amplifying the nociceptive signal (Bishop et al. 2015Vigotsky et al. 2015). This anti-nociceptive effect of massage therapy can help ease discomfort in post surgical patients (Mitchinson et al. 2007) .

Postoperative Range of Motion

A recent study published in The Journal of Knee Surgery looked at the effect that soft-tissue treatments with hand-held instruments have on post-surgical knee stiffness (Chunghtai et al. 2016). In the study soft-tissue treatments was shown to improve knee flexion deficits by 35° and knee flexion contractures by 12° in a small cohort of individuals who had failed to respond to traditional rehabilitation and manipulation under anesthesia. 



Postoperative Scar Management

Research is still in its infancy but there is evidence to suggest that in addition to managing pain massage therapy may improve healing after trauma and in some cases affect the development of postoperative fibrosis (Cholok et al. 2017). 




Fibrosis is a potential complication of surgery, it is characterized by the production of excessive fibrous scar tissue, which may result in decreased movement.

Understanding the cellular effectors and signaling pathways that drives the accumulation of fibrotic deposition, helps therapists optimize treatment protocols for patients suffering from post-surgical fibrosis and guide specific prophylactic treatments.

In the normal wound healing response, the cascade of biological responses is tightly regulated. Fibrotic development is characterized by a lack of apoptosis in the proinflammatory phase, resulting in an imbalance between synthesis and degradation. Persistent transforming growth factor-β (TGF-β) secretion and downstream responses are thought to contribute to a sustained inflammatory response (Cheuy et al. 2017).

Massage therapy is a promising strategy that is used to attenuate adhesion formation and minimize the loss of mobility due to fibrosis.

The mechanisms by which massage therapy interrupt the sequelae of pathological healing is most likely not in a single unified response, but as a collection of interconnected adaptive responses within the neuroimmune system and soft tissue structures.

Recent studies have looked at the effect of modeled massage therapy on tissue levels of TGF-β1 (Bove et al. 2016). In this study it was demonstrated manual therapy attenuated the increase of fibrosis and tissue levels of TGF-β1, this may play a role in scar development by reducing the contractile activity of myofibroblasts.

Summary Points

Massage therapists are uniquely suited to incorporate a number management strategies to help decrease postoperative pain and increase function. In addition to specific hands on treatment, treatments includes recommendations for activity modification, info on natural history, remedial exercise and self-care. 

The next step for researchers is to look into what sort of dosage and duration would be needed to optimize the effects of this non-pharmacological approach. 

More to Explore

As a massage therapist who works with post-surgical patients, this is a topic I am interested in so I will follow closely and keep readers updated as more research comes to light. Here are my current go to resources for post-operative protocols:
• Traumatic scar tissue management: Massage therapy principles, practice and protocols
• Clinical Orthopaedic Rehabilitation: a Team Approach
• Post-Surgical ACL Injuries 

Research Links

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