Anti-inflammatory drugs are often used as well. Although, the evidence concerning the effectiveness of CPM remains poor [31], it remains a useful adjunct postoperatively to enable patients to move their Palbociclib molecular weight knees and encourage flexion [27]. Care must also be taken to monitor and encourage extension movement of the knee. Cryotherapy is beneficial in allowing patients to manage pain and swelling independently both. It combines focal intermittent compression with cold to provide optimal control of swelling, oedema, haematoma, haemarthrosis and pain and has been shown to be useful

in PWH [32]. This is used regularly through the day and is controlled by the patient. Active ROM is encouraged immediately, with passive stretching added by the therapist to

the end of available range. It is acknowledged that this can be very painful for the patient and it is only carried out alongside sufficient pain relief. Active muscle strengthening is commenced initially with static contractions and progressing quickly to concentric activity with mobilizing with crutches. The focus is on the individual to sense their knee and feel comfortable and confident to move it as much as possible. Mobilizing the patella is an important aspect in regaining knee ROM. Patello-femoral joint (PFJ) mobility is significantly reduced by the presence of fibrosed tissue in both the lateral and medial gutters, as well as between the patellar tendon and anterior tibia. This alters the position of the patella (medial and distal translation) CHIR-99021 clinical trial and limits knee flexion [28], as well as increasing contact pressure, which can lead to PFJ pain in later years. Using the Maitland grading scales, Grades III–IV pressures are recommended (for relief of stiffness) with sustained holds at the end of range to stretch fibrotic tissue. Patients or their relatives can be taught to do this at home. As an outpatient, patients are maintained on a higher regime of factor replacement MCE公司 for 2–3 weeks following surgery and as rehabilitation progresses they return to a regular

prophylactic regime for at least six weeks. If pain remains an issue, the patient is required to take adequate analgesia prior to the session. Physiotherapy is intensive, usually three times a week with the focus being on continued mobilization, strengthening and stretching of the knee. Occasionally, some patients can be provided with serial splints for the knee to be worn at night to aid extension. Stretching (under cover of factor replacement) is applied to the joint using a combination of both sustained and oscillatory movement. Hydrotherapy is a useful adjunct in enabling the individual to work on gait re-education, strengthening and proprioception. It is particularly beneficial for individuals who have multiple affected arthropathic lower limb joints, as the buoyancy of the water decreases weight-bearing stress through the joints, yet allows the knee to improve strength and function [33].