Kinesio-Taping

Post-Operative Pain & Wound Mangement

Kinesiodays in Demark
Prof. Dr. Hans-Michael Klein
Department of Cardio-Thoracic Surgery
University Hospital
Dsseldorf-Germany
 Agenda

Background and Introduction Pain management

Pain in the context of surgery In general
Postoperative Pain Management
Surgical approach
Thoractomy
Creating a Clinical trial
Sternotomy How to find the right tape application
VATS Study-design
Postoperative Pain Course of the study
Etiology Results
Pathophysiology Sensation of Pain & Postoperative Pain
Postoperative thoracotomy pain Analgesic consumption
syndrome
Subjective evaluation of breathing
Acute postoperative pain
Rating the Tape
Pathway of pain
Gate-control-theory Conclusion and Perspective
 Agenda

Background and Introduction

 Background and Introduction

Trauma - Sports trauma - Myofascial and

Neuropathic pain

(Pain lead to reduction of performance as well as QOL)

Kinesio taping
Kinesio Taping
 Sports trauma

No prospective randomized studies available,

showing the efficiency of KT after sports traumata
 Agenda

Pain in context of surgery

 Pain in the context of surgery

Surgical trauma

Acute pain (postoperative)

Chronic pain
 Pain in the Context of surgery

The pain that accompanies cardio-thoracic

surgery is notable for its intensity and
duration.

Gottschalk et al. Anesthesiology 2006; 104(3):594-600

 Pain in the context of surgery

Kinesio Taping

First experiences

Treatment of PTPS
 Pain in the context of surgery

Acute pain (postoperative)

Chronic pain
 Postoperative Pain

Definition of chronic postoperative pain:

Pain developing after surgery

Pain with a duration of at least 2 month
Exclusion of other reasons
Exclusion of the possibility for the same pain
preoperatively

Schnabel et al., Schmerz 2010; 24:517-533

 Postoperative Pain

Post thoracotomy pain syndrome PTPS

Incidence of 25-60% after thoracotomy (15-35% after sterotomy)

Up to 50% moderate to severe pain

Thoracotomy and sternotomy are, along with limb amputation,

considered to be the procedures that elicits the highest risk of
severe chronic postoperative pain

Kehlet et al. Lancet 2006; 367:1618-1625

 Postoperative Pain

Etiology

Myofascial and

Neuropathic origin of PTPS

Schnabel et al., Schmerz 2010; 24:517-533

 PTPS - Post Thoracotomy Pain Syndrome

Localisation of PTPS:

Pain most profound around the scar

Patients relate 82-90% of pain directly to the surgical side
Pain expands into other areas
scar > chest wall > sternum / costo-vertebral costo-sternal region >
shoulder > scapular region > spine

Wildgaard et al. Acta Anaesth. Scand. 2011; 55: 60-68

 Postoperative Pain

Anatomical distribution of pain

scar > thorax > sternum > shoulder > spine

Wildgaard et al. Acta Anaesth. Scand. 2011; 55: 60-68; Groosen et al., European Journal of Cardio-Thoracic Surgery 0 (2012) 192006, 367: 1618-25
 Postoperative Pain

Pathophysiology
tissue
nerve injury
damage

activation of peripheral
nociceptive, afferent neurons inflammatory mediators 1

nociceptive reversible modulation 2 reversible activation of

pain peripheral hypersensibility spinal and
primary hyperalgesia supraspinal neurons
irreversible modification of 3
the nociceptive system central sensibilisation
PTPS secundary hyperalgesia
Wildgaard et al., Acta Anaesth. Scand. 2011; 55:60-68, Reuben et al., J of Cardiothoracic and Vasc. Anesth 2008; 6:890-903
 Postoperative Pain

Consequences of PTPS
Reduction in quality of life
disabled, unemployed, helpless
Lower physical and mental health status
High costs for health care management
Sleep disturbances
 Postoperative Pain

PTPS

multifactorial genesis

multimodal pain management

 Postoperative Pain Management

Multimodal analgesia
Preventive analgesic techniques Additive methods
Central neuroaxial blockade TENS
(epidural) Physiotherapy
PCA Trigger point injections
Peripheral regional blockade
Intercostal, interpleural, paravertebral
Local anesthetic wound infiltration Kinesio taping
Cryoanalgesia
Systemic analgesics
Opioids, NSAIDs, NMDA
antagonists,
antikonvulsives and
antidepressants
 Agenda

Surgical approach
 Surgical Approach

Open thoracotomy: Sternotomy:

posterolateral Median sternotomy
traditional J-sternotomy
muscle sparing
Horizontal sternotomy
axillary
T-sternotomy
anterior

Video assisted thoracic

surgery VATS

Gottschalk et al. Anesthesiology 2006; 104(3):594-600

 Posterolateral Thoracotomy

1 posterolateral thoracotomy
2 anterior thoracotomy
 Posterolateral thoracotomy

1 M. pectoralis major
2 M. serratus anterior
3 M. latissimus dorsi
4 M. trapezius
 Posterolateral Thoracotomy

1 M. serratus anterior
2 M. latissimus dorsi
3 M. trapezius

Incision of the M. latissimus dorsi

vs.
muscle-sparing access
 Posterolateral Thoracotomy

Rib retractors potentially induce intercostal nerve damage

Anteriolateral Thoracotomy
 Sternotomy

A Median sternotomy
B anterior thoracotomy C J-sternotomy D lower hemisternotomy
 Median Sternotomy

Retractors potentially induce rib fractures and muscle damage

Median Sternotomy
VATS
 Agenda

Postoperative pain
 Pain in the context of surgery

Acute pain (postoperative)

Chronic pain
 Acute Postoperative Pain

Definition of acute pain

Duration is short lived less than 3 months;
Pain of varying intensety, initially severe than subsiding as healing takes
place;
Nervous system is usually intact
Reasons for pain can be pinpointed pain as caused by trauma, surgery,
etc.
Responds well to conventional analgesia opioids, local anaesthetics, etc.
Psychological problems such as depression are short lived if present at al

Acute pain is also known as nociceptive pain and can be divided into
visceral and somatic pain

Pain Community Centre 16.08.2015 Acute Postoperative Pain

 Postoperative Pain

Pain characteristics:
Pain immediately after surgery 81%
Chronic persistent pain 35%
Pain attacks with or without intermittend pain 65%
PTPS + pain from other locations 64%
Radiating pain 31%

Grosen et al. Eur. J. Cardio-Thorac. Surg 2012; 0: 1-9, Wildgaard et al, Acta Anaesth. Scand. 2011; 55: 60-68
 Postoperative Pain

Pain Associated symptoms in the painful area:

characteristics: tingling
burning pins and needles
painful cold Itching
electric shocks Allodynia
Hyper-, hypoaesthesia
aching
tender
numbness

Grosen et al. Eur. J. Cardio-Thorac. Surg 2012; 0: 1-9

 Postoperative Pain

Preoperative factors:
Younger patients Psychosocial factors
Preoperative anxiety
Women
Depression
Existence of preoperative pain Malignant disease
Genetics Social network and social status
 Postoperative Pain
Intraoperative factors:
Surgical procedure
Technique: open VATS
statistically no difference
Duration of operation
Incision: localisation
incision size closure
technique
Use of rib retractor
Nerve, muscle and rib
handling
Scope size and numbers
Anesthesia
Timing - preemptive analgesia
favorable? no advantage
Nerve block technique
Thoracic epidural analgesia
gold standard
Interpleural analgesia, paravertebral
block, intercostal block
Cryoanesthesia ???
General anesthesia
Possible difference between TIVA
and inhalational anesthesia
 Postoperative Pain

Other possible causes for pain:

Rib traction
Healing rib fracture
Frozen shoulder
Local infection
Costochondral dislocation
Previous pleural or chest wall lesions
Lung herniation
Retained foreign bodies, broken wires
Song et al. Eur. J. of Cardio-Thor. Surg 2012; 41: 1078-82, Gottschalk et al., Anesthesiology 2006; 104:594-600
 Postoperative Pain

Postoperative factors:
Acute postoperative pain
Adjuvant radio- and chemotherapy
Recurrence of malignancy
Reoperation
Non-elective surgery
 Pathway of Pain

Allan Gottschalk et al. m Fam Physician. 2001 May 15;63(10):1979-1985.

 Pathway of Pain

Woolf CJ, Chong MS Anesth Analg 1993, 77: 362-379

 Pathway of Pain - Central Sensitization

Woolf CJ, Chong MS Anesth Analg 1993, 77: 362-379

 Pathway of Pain Peripheral sensitization

Woolf CJ, Chong MS Anesth Analg 1993, 77: 362-379

Gate-control-Theory

Protopathic Pathway and

Proprioception:
- Pain
-Temperature
- Pressure
-Tactile sensation

-Conscious perception
of the movement apparatus

Starts peripheral at the different skin receptors !

 Gate-control-Theory

The gate control system modulates sensory input from the skin
before it evokes pain perception and response.

Modulation of pain transmission (at the level of spinal cord)

Pain modulation at Higher Centers (Gate control theory of pain)

Modulation of pain by Physical Therapy

Modulation of pain by Kinesio-Taping

 Postoperative Pain

Cardiovascular effects
increases heart rates
increases blood pressure
increases stroke volume
increases myocardial oxygen demands, reduces mycardial supply and possible
mycardial ischemia
Respiratory effects
Stimulation of respiration > initial hypocapnia and respiratory alkalosis
Diaphragmatic splinting and hypoventilation, atelectasis, hypoxia and ensuing
hypercapnia
Development of chest infection
Psychological effects
 Postoperative Pain

Metabolic effects
Raised blood sugar levels
Gastro intestinal effects
Delayed gastric emptying
Nausea
Reduced gastro - intestinal motility and ileus
Haemostasis
Immobility
Increased blood viscosity
Hypercoagulability and risk of deep vein thrombosis
Endocrine effects
Catabolic and anabolic changes
Decrease in insulin production
Reduction in testosterone levels
Fluid retention
 Agenda

Pain management
 Postoperative Pain Management

The goal in postoperative pain management is to mobilize

the person as early as possible, get them eating and
drinking as early as appropriate and ensure they are able to
cough and deep breathe.

Pain Community Centre 16.08.2015 Acute Postoperative Pain

 Postoperative Pain

The pain that accompanies thoracic surgery is notable for its

intensity and duration

Undertreatment of pain is common, and is experienced by all age

groups from neonates to the elderly

Pain can cause significant problems and delay postoperative

recovery

Gottschalk et al. Anesthesiology 2006, 104:594-600

 Postoperative Pain Management

Adequate pain control

Reduce the risk of adverse outcomes
Maintain functional ability, as well as psychological well-being
Enhance the quality of life
Shortened hospital stay and reduced cost

Pain management interventions should be offered ATC

Pain management is to provide continuous pain relief
Patient should be assessed for adequacy of pain control
 Postoperative Pain Management

Medical specialties Medications

Physical approach Mild pain
Mild to moderate pain
Physical medicine and rehabilitation
Moderate to severe pain
TENS
Opioids
Acupuncture Non-steroidal anti-inflammatory drugs
Light therapy Antidepressants and antiepileptic
Kinesio Taping drugs
Psychological approach Cannabinoids
Other analgesics
Cognitive behavioral therapy
Hypnosis
Interventional procedures
Mindfulness Meditation
 Pain in the context of surgery

Clinical scientistsaim is to find the best therapy for their

patientsproblems.

In medicine theses therapies need to be confirmed by

evidence based studies.
 Agenda

Creating a clinical trial

 Creating a Clinical Trial

In order to improve the postoperative pain management, a

clinical trial was organized.

The trial should investigate the influense of KT on the

patientspostoperative problems.
 Duesseldorf Trial

Pain-diminishing effects of Kinesio taping

after median sternotomy
Rabea Brockmann, Hans-Michael Klein
Department of Cardiovascular Surgery, Heinrich-Heine-University
Duesseldorf, Germany

Pain-diminishing effect of Kinesio taping in patients after sternotomy. Journal of Cardiothoracic Surgery 2015, 10(Suppl
1):A76.http://www.cardiosurgery.org/content/10/S1/A76
Pain-diminishing effects of Kinesio taping after median sternotomy. Journal of Physiotherapy Therory and Practice. UPTP-2016-
0190.R2, accepted for publication, March 2017
 How to find the right tape application

Possible applications of Kinesio tapes

M. latissimus dorsi
M. trapezius
M. serratus anterior
M. pectoralis major

shoulder
How to find the right tape application
 Agenda

Study - design
 Study-design

prospective randomised pilot-study

patients after surgery with access via sternotomy
test group [n = 25]
control group [n =25]
daily documentation of
sensation of pain
analgetic consumption
subjective evaluation of breathing
etc.
Sensation of Pain
 Agenda

Course of study
 Course of Study

4 dropouts (2 in each group)

taping on the first day after extubation
daily documentation of
sensation of pain
analgetic consumption
subjective evaluation of breathing
radiologic abnormality
consumption of antibiotics
adverse effects of tape
impaired healing
 Agenda

Results
Results
 Results - Sensation of Pain (p < 0.001)

Pain values
4

3,5
#

2,5
pain value

1,5

0,5

0
no tape tape
mean 3,29 1,68
 Results - Analgesic Consumption (p = 0.029)

Need for piritramide (mg/d)

4

#
3,5

2,5
Dipidolor (mg/d)

1,5

0,5

0
no tape tape
mean 3 1,55
 Results - Analgetic Consumption (p = 0.035)

Need for paracetamol (g/d)

1,6

#
1,4

1,2

1
Paracetamol (g/d)

0,8

0,6

0,4

0,2

0
no tape taoe
mean 1,33 0,93
 Results - Postoperative Pain

Rating the postoperative pain

12

10

8
number of patients

0
no pain very slight pain slight pain medium pain strong pain very strong pain
tape 0 3 11 8 1 0
no tape 0 0 2 9 6 6
pain
(no pain - very strong pain)

tape no tape
 Results
Subjective Evaluation of Breathing (P < 0.001)
Subjective evaluation of breathing
25

#
20
Number of patients

15

10

0
no tape tape
normal 5 22
impaired 18 1
 Results - Rating the Tape Application

Rating the treatment with the tape

16

14

12

10
number of patients

0
A B C D E F
Patient 8 14 1 0 0 0
Rating the treatment with the tape
A-F
 Agenda

Conclusion
 Conclusion

Kinesio taping after cardiac surgery does have positiv effects on:

Pain values
Pain killer consumption
Subjective breathing ability

Safety and feasability of kinesio taping after cardiac surgery is

given
 Conclusion

Postooperative pain
Perioperative pain management is important to prevent
postoperative pain
A multimodal analgesia concept is necessary
The combination of different analgesic concepts is effective
Kinesio- taping is a useful method to support invasive and
systemic analgesia
Kinesio- taping can be applied even in patient with
anticoagulation therapy
 Future Prospects

Development of sterile KT

Standardized use of KT after different surgeries in other medical sectors

Prospective randomized trials

Motivation

No progress without vision

 Dsseldorf University Hospital

Traumatic surgery

Prospective randomised trial 300 patients

Steril KT application intraoperative

Standardization of pain management PCA (patient-controlled analgesia)

GCP(good clinical Practice)

 Traumatology
Locking plate osteosynthesis
for fractures of the proximal humerus
 Traumatology

Plate osteosynthesis ankle fracture

 Traumatology
(Per)-Trochanteric fractures PFN(proximal femur nail)
 Perspective

Vision without action is merely a dream.

Action without vision just passes the time.

Vision with action can change the world.

Joel A. Barker
First enrollment

Department for Traumatic Surgery

University Hospital
Duesseldorf

First enrollment on 02.09.17

Actually patient No 9 is enrolled
 Possible Indications for Kinesio-Taping

Menalgia/Menstrual pain
Stomach ache/postprandial
Pleuritic pain with bronchitis/cold/asthma/cancer
Others

Your personal experience/set of ideas

 Questions for Prof. Klein
and associated research team members
1. When and how did you become aware of Kinesio Taping?

2. Did post-surgical uses come to mind immediately, or did you go through stages of
awareness?

3. What gave you the idea for this particular study?

4. Were there other topics that led up to this one?

5. Did anything surprise you about the results?

6. Are there further topics that you would like to study as a follow up?

7. What is your academic and medical background?

8. What else is important for people to know about you and about your research?