Device or Ice after total knee replacement: Frontline clinicians answer their own clinical question
Frontline physiotherapists frequently reflect on their clinical practice and query what is ‘best practice’ for a specific patient or patient population. Sometimes the answer is found in the literature; sometimes it isn’t.
Alison Hoens and Jo Moorhen (Physiotherapists)
At the end of 2007, an interdisciplinary clinical team (physiotherapist, occupational therapist and nurse) at St. Paul’s Hospital in Vancouver, BC, noted that some of the orthopaedic surgeons on their ward were starting to recommend continuous cold therapy compression devices for patients following Total Knee Arthroplasty (TKA). The usual care was intermittent application of ice in a bag. Patients and staff began asking the question “Which is best: device or ice?” A literature search in 2008 didn’t provide the answer. Consequently, the team decided to pursue the answer, but given that they had limited research training and experience, requested guidance from Alison Hoens (Physical Therapy Knowledge Broker and the Research, Education and Practice Coordinator for Physiotherapy at Providence Health Care). Undaunted by the absence of research funding, training and experience, the team embarked on a randomized control trial to address the question of whether consistent cooling using a device was more effective than intermittent cooling using an ice bag for 48 hours after TKA on influencing pain, range of motion, nausea/vomiting, blood loss and leg function.
The first hurdle for the team was the development of the research proposal and ethics submission. Support from the Providence Health Care Research Institute, such as in providing templates for consent forms, was essential to ensuring success. Designing the study to enable both scientific rigour and feasibility in a clinical setting was a challenge. Workflow in a busy hospital environment mandated creativity in study design. For example, as there was no possibility for hiring research assistants, frontline physiotherapists and occupational therapists, in addition to their existing obligations, were responsible for approaching potential subjects in the pre-admission clinic. Moreover, randomization of patients to device or ice had to occur in the operating room at the time of wound closure as the Circulation nurse selected an envelope disclosing the group to which the patient was allocated. The intervention group had the DonJoy IceMan™ applied immediately post-operatively but was removed after the first hour of application and then every four hours thereafter to allow for the standardized nursing assessment to detect potential skin and nerve damage: The control group received cooling using an ice bag, at a frequency requested by the patient. The workflow ‘workarounds’ reflected the reality of research in a busy clinical setting. Typical of most studies, recruitment and data collection for the 80 subjects deemed necessary to ensure sufficient power for the study required more than three years to complete. During this time period the research team was beset with the challenges of changes in staff due to illness, vacation, maternity leave, etc. There were multiple periods when there were thoughts of abandoning the study. Nevertheless, passion, fortitude and humour prevailed and a celebration ensued when the data collection was complete.
Mary Cho (OT) and Michelle Bech (Nurse Practitioner)
The elation for the completion of the data collection was followed by the sombre reality of chasing down missing pieces and entering the data. The team was fortunate to obtain support from the Orthopaedic Research Department and the Center for Health Evaluation and Outcome Science. This support included participation in data entry and statistical analysis.
The analysis revealed that there was no significant difference in the primary outcome (pain intensity measured via the Numeric Pain Rating Scale) or in secondary outcomes of passive range of motion, nausea/vomiting, opioid use, blood loss, length of stay or function at 6 weeks between the device and ice groups. However, the device group was significantly more satisfied, used the device more consistently day and night and was more likely to recommend this method of cooling.
The next challenge was the preparation of a manuscript for submission to Physiotherapy Canada. The first time authors were struck by the extensive effort required to develop a manuscript worthy of publication. However, the arduousness of the entire process was quickly forgotten when the paper was accepted and published in Volume 67, winter 2015 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4403323/). But the celebrations were not yet over as the manuscript was subsequently selected as the winner of the Canadian Physiotherapy Association’s 2015 Silver Quill Award to honour excellence in scientific writing for Physiotherapy Canada in the area of knowledge translation.
The most important outcome of this project was that the results were used to direct clinical practice. Administrators and clinicians are now confident that given the increasing demands on shorter length of stays for most procedures, the extra costs and resources (time to refill and reapply) the cooling devices are not necessary for better patient outcomes following TKA. The choice on whether to use a cooling device or ice in a bag resides with the patient.
What an incredible journey. The team could have not have imagined when they started the project that the entire process would take almost five years to complete and ultimately result in an award-winning manuscript. This was a remarkable outcome given the highly unusual foundation of no formal research funding or training.
Alison Hoens, BScPT, MSc
Joanne Moorhen, BScPT
Linda Li, PhD