Ben Tollitt ACL Recovery Accelerated by PainPro™

Ben Tollitt – 30,11,1994 (22) – Right leg ACL

Ben Tollitt - ACL Injury

Normal ACL rehab stages are:

Stage 1, pre-operation:

  • Control swelling
  • Restore full mobility of the knee.
  • Maintain strength of the quadriceps and hamstring muscles. Using contraction device (such as painpro)
  • Regain normal walking patterns, no limping

Home treatment:

  • Apply the PRICE principles of rest, ice compression and elevation.
  • Wear a hinged knee brace to protect the knee from further injury.
  • Perform patella mobilizations.

Exercises:

  • Knee mobility exercises including heel slides, knee flexion and prone knee hangs.
  • Ankle mobility exercises.
  • Quadriceps and hamstring isometric exercises (static contractions with pain pro muscle building setting).
  • Hip strengthening exercises including bridging and adduction.

Stage 2, post op (week 0-4):

  • Control swelling.
  • Improve bending of the knee up to 90 degrees.
  • Improve straightening of the knee to full.
  • Continue quads and hamstrings contractions with pain pro on muscle building setting
  • Walk partial weight bearing in crutches. Get rid of crutches after 2 weeks

Home Treatment:

  • Apply principles of P.R.I.C.E.
  • Wear a Knee Brace to protect the knee from further injury – your surgeon will advise on how much movement the brace should allow.
  • Continue to perform patella mobilisations.

Exercises:

  • ¼ squats.
  • Bridging.
  • Step ups.
  • Static bike – high seat with NO resistance, in pain free range of movement.
  • Hamstring curls – only if patella tendon graft is used, not Hamstring graft.
  • Calf Raises.

General body weight exercises and movements with limited strain.

Stage 3, post op (week 5-12):

  • Control swelling.
  • Improve bending of the knee up to 120 degrees.
  • Maintain full straightening of the knee.
  • Improve quads and hamstrings strength.
  • Continue walking with a “normal” pattern, increase proprioception and balance.
  • Remove Brace at 6 weeks.

Home Treatment:

  • Continue to apply cold therapy post exercises.
  • Continue to perform patella mobilisations.

Exercises:

  • ½ squats.
  • Lunges.
  • Leg Press.
  • Step downs.
  • Static bike – high seat with NO resistance, in pain free range of movement.
  • Sit to stand.
  • Single leg balance exercises.

Build up the exercises during this stage from body weight to exercises with resistance and weight like normal gym work just not full on yet.

Stage 4, post op (week 13-20):

  • Continue to control swelling.
  • Regain full movement of the knee.
  • Continue to improve quads and hamstrings strength.
  • Continue to work on balance and proprioception.
  • Start jogging and progress speed straight line only.

Home Treatment:

  • Continue to apply cold therapy post exercises.
  • Continue to perform patella mobilisations.

Exercises:

Exercises that are typically introduced at this stage, in addition to the previous stage’s exercises are:

  • Hopping single leg.
  • Double leg jumps.
  • Static bike.
  • Jogging – start slowly and ensure there is no limp before going quicker.
  • Increase running speed slowly and progressively over a period of weeks but only in straight lines no twisting or turning.

Gym work should now be resisted weights work and from this point build up the amount of weight can be lifted

Stage 5, post op (week 21-24):

  • Introduce twisting, turning and cutting movements.
  • Introduce ball work (if required).
  • Continue to improve balance around the knee.
  • Achieve at least 90% strength in the quads and hamstrings in comparison to the other uninjured leg.
  • Improving confidence.

Home Treatment:

  • Continue to apply cold therapy post exercises.
  • Continue to perform patella mobilisations.

Exercises:

  • Box Jumps
  • Start to gradually introduce twisting and turning movements.
  • Start to introduce striking a ball (if required).
  • Start to perform functional sports specific drills.

Along side this continue gym work

Stage 6, post op (week 25+):

Return to sport

Improvements I made and stages I bettered during rehab:

Stage 1:

Was able to bike

Do weights in the gym

No pain

No swelling

Full quads muscle strength

Stage 2:

More than 90 degrees knee bend

Fully straight leg

Walking after 5 days

Better than normal quad strength

Doing single leg volleys standing on operated leg

Brace removed week 1 not week 6

Stage 3:

At week 6 (instead of week 13) was told I could jog)

Full knee bend not just 120 degrees

Full muscle strength back with good amount of hyperextension

Stage 4:

Twisting and turning week 16 not week 21

Full sprinting

Performing football ‘Hoff circuits’ week 16

Joining in with non contact pre season training week 17 not week 21

Stage 5:

Full training with the team not just returning and building it up

All through my rehab I was 5-6 weeks ahead of schedule.

Why the device helped

It helped me with many of the systems it had to offer. The muscle building setting helped massively as I was performing muscle contractions with the device rather than on my own so it gave me extra help in getting muscle strength back quicker and better than it was before. When I could then do gym weights I used this setting whilst performing workouts for extra help.

With the recovery cell repair settings they helped massively by placing the pads on affected areas like knee, quads, hamstring, etc it allowed me to recover quicker on back to back days of work and also on days off so that I healed quicker but was also able to perform in the gym during my rehab to a higher standard more often.

Operations director arrives at Ningbo Palletised Distribution

An award-winning warehouse and logistics company has appointed an operations director as it eyes further expansion.

Wrexham-based Ningbo Palletised Distribution has welcomed Tim Roper to its senior management team, a move described by managing director Chris Stockton as a ‘significant milestone’.

Ningbo has grown rapidly in the last few years, including opening a second warehouse, substantially increasing its postcode coverage with Palletline, diversifying into ADR to transport hazardous materials, and launching a dedicated next-day service to Ireland.

With plans to continue the growth including opening further UK depots, Chris sees Tim as a pivotal appointment to assist with the success.

He said: “The only thing that saddens me about the growth we have created, is having less day to day contact with all of our employees. I have a huge amount of respect for everyone here, and I’m extremely aware that the commitment of the whole team is what makes us so strong.

Tim Roper

Tim is very personable, and approachable, and his old team at Freightroute all thought a lot of him, with many drivers being with him more than 10 years. That is what I want to see at Ningbo. It is very, very important to me.

“Tim joining has opened up the scope of what we can do. The business was at risk of being held back by my own time limitations now that it is such a sizeable operation. His appointment is fundamental to the development plan to open strategic depots across the UK.

“But it wasn’t just about the role. It was finding the right person to support and lead us through future success and Tim is the ideal person.

“Tim’s old company Freightroute has a very structured management approach to enable it to effectively run and control multiple UK depots from Falkirk to Southampton.

“Tim has been part of its culture, which is very compliance and customer based. He has gained a wealth of experience with on-the-job training and external training and has got the skills we need to take a large part of my workload to concentrate on the business as a whole.”

Tim joined Freightroute as a driver in 2000 and progressed through the ranks to become depot general manager in 2008. During his time with the company he oversaw the relocation of the Shropshire depot to Staffordshire.

He said: “The first few weeks have gone very well. My new colleagues have been fantastic. It’s always a concern when a new person comes in and the worry is they will reinvent the wheel.

“There is no need for that at Ningbo. The business foundations are fantastic. It just needs support to enable it  to grow and develop to the next level. I’m here to try and enhance the work Chris and the team have put in place.

“It’s a very exciting time at Ningbo. There are lots of good challenges ahead including a planned new depot, expansion at Wrexham, and structured recruitment.

“My main duties include overseeing the managing of the depot, which already has 5 very capable managers, ensuring the company achieves compliance and adheres to health and safety, managing HR effectively, and making sure the business maintains high levels of customer service. In addition, I will be ensuring all departments are linked up and working together to maximise efforts and results.

“I’m keen to help take the business forward by supporting the team, and continuing the growth and following the good work that has already been done.”

Ningbo Palletised Distribution is part of the Ningbo Group. Sister business Ningbo Furniture, is a supplier of contract furniture.

For further information visit https://www.ningbo.co.uk/ or www.ningbodistribution.co.uk.

Cheltenham Banqueting Chair Silver

From: £27.95 ex VAT

Attractive banquet chair with range of colour options for both beech frame and seat pad. Can grace dining areas of special events. Stack 8 high

bulk pricing furniture

Email or Call: +448451214656


Online orders are usually shipped within 24 hours.

Telephone ordering is welcomed.

Next day delivery can be arranged on certain items, please call us.

Quantity discounts available:

1-49 50-149 150+
£29.95 £28.95 £27.95

Finance is available with WestWon Ltd, please call us for details.

Making room for the congregation – The church chairs that made a difference

Until fairly recently, sitting at a local church service was a very uncomfortable experience. With a seemingly ever growing congregation and the church chairs that were old, clunky and cumbersome, things were just too cramped, awkward and dare I say it, a little off-putting. It was very clear that something needed to be done, so the search began for chairs that would suit a new seating arrangement.

There were several things to take into consideration before deciding which chairs would work best.

Shape and size of the building

The building isn’t particularly large and it’s also quite a strange shape which isn’t very user-friendly. In addition, there is very little in the way of storage space, so that was another factor to take into consideration.

The frequent use of the building

It’s a busy church with meetings of various kinds happening almost every day. Meeting for adults and meetings for kids – where undoubtedly the kids need space to run around in. So, the ability to stack the chairs became ever more crucial, especially considering the lack of storage space. The previous chairs could only be stacked in two’s (one face down on the other), so took up huge amounts of space even when not in use.

Could the chairs be linked?

With lots of people in the building, it would be very easy for individual (non-linked) chairs to get moved around very easily and in the unfortunate event of a fire or other emergency, this could certainly prove a hazard. The old chairs could be linked, so it was important the new ones could link as well. When linked, rows of chairs can be created and linked together, so that there is very little movement when people are getting up and moving around the building.

Decision time

So, with all the factors on the table it was time to choose a chair that seemed most suitable. In the end a banquet chair style was chosen. The chosen chair also had the capacity to be linked together. Did the new chairs make a difference? Yes, they made a massive difference, a really big improvement in so many ways. First of all the amount of chairs that could fit safely into the building was significantly increased, allowing the congregation a little more breathing space.

The new stacking chairs were lighter and easier to move around when not in use. They can be stacked as many as 8 high and moved around really easily thanks to the handy chair trolley. There is now much more room for those kids meetings, with the chairs safely stacked out of the way. The chairs are easy to link together and just as easy to unlink when you want to move them.

It’s fair to say the church is still going from strength to strength and of course, much of that is down to the people themselves but without a radical overhaul of the seating system, many of the things happening simply wouldn’t have been possible.

How to Select A Single Phase UPS System

In a server room or data centre environment, single phase UPS systems can play a critical role keeping file servers and IT networks running during a power outage. Even when the mains power supply is present a single-phase UPS can provide protection from mains borne power problems.

Single Phase UPS System Checklist

To make sure you install the right single-phase UPS for your application use the following guide and let us know if you come across other aspects that you feel are important to consider.

UPS Topology

BS EN 62040-3 characterises three types of UPS topology including standby, line interactive and on-line UPS. For critical single-phase applications like server protection then the most appropriate formats are line interactive and on-line.

Line interactive UPS are classed in BS EN 62040-3 as Voltage Independent (VI). When mains power is present, a line interactive UPS will provide some protection from mains power problems e.g. brownouts, sags, surges, spikes and electrical noise using its built-in automatic voltage stabiliser. The inverter is powered up but does not support the server load until the input mains power supply fluctuates widely or there is a complete power outage. Then the inverter switches in to the line and provides power to the server loads using a battery set. Line interactive UPS can therefore provide a momentary break in electrical power when transferring to and from battery power, but this is generally well within the internal capacitance (energy reserve) of the switch mode power supply within the servers themselves.

On-line UPS are classed as Voltage and Frequency Independent (VFI). This is because the inverter is always connected to the load during normal running and provides a digitally generated sinewave output. When the mains power supply fails, the inverter simply relies on the DC supply from the battery set to power the inverter. On-line UPS also feature an additional safety feature compared to line interactive UPS in the form of a built-in automatic bypass. If the inverter output starts to collapse (during an overload or UPS internal fault) the load is automatically and safely transferred to the mains power supply (if present).

Overall on-line UPS provide superior and break-free power protection for server type loads and can have longer runtime battery packs installed. Line interactive topology UPS typically max out at 2kVA with on-line UPS capable of providing up to 20kVA single phase output available. Some on-line UPS can also be installed in a parallel redundant (N+X) configuration.

UPS Form Factor

The question of UPS form factor or format is important. If you are using 19inch rack mount server racks to house your servers, you may also want to use a similar format UPS system. Most UPS manufacturers offer tower, rack mount and dual format UPS units, with a Dual format capable of being installed as a tower or rack mount UPS.

If the tower format is chosen this will invariable take up a lot more U height within the server cabinet. The UPS will have to sit on the floor of the cabinet or a special shelf. If there are battery extension cabinets, to give extra runtime, then these will also have to be installed on the shelf or even outside or alongside the server cabinet.

A 19 inch rack mount UPS system, as the description implies, can be installed in a suitable server cabinet. The UPS may be installed on a shelf or if the weight is generally below 30Kg on slide out shelves. The advantage of this type of arrangement is that a rack mount UPS will more efficiently fill the space available as a horizontally mounted unit that will probably only take up from 1 to 4U in height. Any battery extension packs installed may also be rack mountable as may a UPS maintenance bypass switch if installed.

UPS Battery Technology

Traditionally the online choice for a UPS battery was Valve Regulated Lead Acid (VRLA) and the batteries were known as VRLA maintenance free lead acid batteries. Lead acid was the most appropriate battery technology for UPS systems as this type of battery is ideal for standby power and infrequent charge/discharge cycles. As lead acid batteries dominate the standby power world, the manufacturing volumes give rise to scale economies and the batteries are widely available.

Within recent years, Lithium-ion single phase UPS systems have become available, offering more advantages over those UPS fitted with lead acid batteries. The Lithium-ion (Li-ion) battery technology has emerged as a UPS battery contender thanks to the need for more cyclic batteries in the energy storage, electric vehicle and mobile phone industries.

There are several types of lithium-ion battery available and the areas where they stand out over lead acid batteries include:

  • Longer working life of up to 10-15 years compared to 3-7 for lead acid batteries. Lead acid batteries can be 5 or 10-year design life batteries with replacement expected around years 3-4 and 7-8 respectively.
  • Temperature performance in that lead acid batteries require a 20-25˚C ambient. For every 1degree rise above 30˚C battery design life halves. Lithium-ion batteries can work up to 40˚C without degradation as can the electronics on a UPS allowing server room and data centre operators to increase the ambient temperatures within their facilities and lower their cooling costs. For more information on data centre environments we recommend ASHRAE: https://www.ashrae.org/about/news/2016/data-center-standard-published-by-ashrae
    Smaller size and weight due to the increased power densities over lead acid batteries leading to more compact designs and easier installation.
  • Lower maintenance and improved Total Cost of Ownership (TCO) due to the longer operating life and even with a 30% premium for Li-ion technology over traditional lead acid UPS batteries.
  • Improved operational performance and more suited to multiple and faster charge/discharge cycles. Lead acid batteries typically have a design life of 300-400 complete charge/discharge cycles and can take up to 24 hours to recharge to 80% capacity. Any quicker than this can degrade the battery. Lithium-ion UPS batteries are far more suited to energy storage type applications with multiple power outages over a short time frame, requiring a fast ability to recover to full charge capacity.

Other aspects to consider for any server room or datacentre application include:

  • Electrical works
  • Maintenance bypass arrangements
  • Load and PDU connections
  • Network monitoring over TCP/IP and SNMP or Modbus
  • Maintenance and inspection arrangements

These are just some of the essential questions that must be answered to select the most appropriate single-phase UPS system for a serve room or datacentre application. For help and advice please contact our power consultants who can offer advice and support or visit your installation for a comprehensive UPS site survey.

Enhancing Post Operative Rehabilitation following Knee Arthroplasty – Physicool Study

Enhancing Post Operative Rehabilitation following Knee Arthroplasty Using a New Cryotherapy Product – a Prospective Study

Pavlou P. MBBS BSc(hons) FRCS (Tr&Orth) 1

Mumith A. MBBS BSc MRCS3

Barrett MD. MBBCh MRCS2

Thurston B. BMBCh1

Garrett SJW. BM MRCS FRCS(Tr&Orth) 1

  1. Department Of Trauma & Orthopaedics, Dorset County Hospital, Dorchester, UK.
  2. Department Of Trauma & Orthopaedics, Royal Hampshire County Hospital, Winchester, UK
  3. Department Of Trauma & Orthopaedics, St. Mary’s Hospital, Newport. IOW, UK

Neither the authors nor institution received industry support to conduct this study.

Correspondence: Mr Paul Pavlou  [email protected]

Aim: To compare a novel cooling product, PhysicoolTM, with a well-established cryotherapy system, CryocuffTM ; using pain scores, range of movement and cost as outcome measures in the early phase following total knee arthroplasty.

Method: We prospectively studied 90 consecutive patients undergoing unilateral total knee arthroplasty by a single surgeon. Following exclusions, 40 patients were recruited to each group. Visual analogue scale (VAS) for pain, and range of movement before and after application of cooling device was recorded at 24 and 48 hours after surgery.  The cost of treatment per patient was also calculated.

Results: Pain scores were significantly reduced in the PhysicoolTM group on day 1 post surgery (p=0.032) and day 2 (p= 0.0065) compared to the CryocuffTM group. A significant increase in range of movement was recorded in the PhysicoolTM group at 24 hours (p=0.00867) and at 48 hours (p= 0.00227) post surgery compared to the CryocuffTM group. The cost benefit of using PhysicoolTM over CrycocuffTM was approximately £25 per patient.

Conclusion: The PhysicoolTM system is a safe and effective cooling method for improving pain and range of movement in the early postoperative phase following total knee arthroplasty. Furthermore it offers substantial cost savings.

Key Words: Cryocuff, Cryotherapy, Pain, Physicool, Range of movement, Cost, TKA

INTRODUCTION

Total Knee Arthroplasty (TKA) is one of the most successful operations in terms of patient reported quality of life outcomes and as a result approximately 89,000 procedures were performed in England and Wales in 201216. However, despite significant long term benefits in mobility, pain, function and health related quality of life, the initial rehabilitation following surgery remains challenging7,19.

Enhanced recovery programs have been used successfully to improve early pain management, range of movement, blood loss and hospital stay3,4,11,12,13. Cooling devices used as part of enhanced recovery programs have been shown to reduce pain, hasten discharge and promote greater movement in the early post operative phase following total knee arthroplasty9,10.

Cooling devices deliver localised cryotherapy which works by reducing intra-articular temperature and thus slowing the neuronal conduction of both C- and A- Delta – pain fibres.1,14,15 Small decreases in temperature have also been shown to reduce enzyme activity in inflammation and as a result reduce the inflammatory response15. Due to these molecular and cellular level actions, cryotherapy reduces localised swelling and perceived pain. In addition, a decrease in the measured blood loss has been shown following application of cryotherapy, presumably due to vasoconstriction in response to the reduced temperature17

There are a number of commercially available cryotherapy systems used following TKA. The most recent Cochrane review supported their safety and efficacy.2 However, concerns have been raised due to the potential inconvenience to patients and the cost effectiveness of these devices.

The aim of this study is to compare a novel cooling product, PhysicoolTM, with a well-established cooling system, CryocuffTM. The outcome measures were post-operative pain, improvement in range of movement and cost savings.  Both devices are used in our institution as part of our knee arthroplasty Enhanced Recovery Programme (ERP).

BACKGROUND

The CryocuffTM device consists of four elements: A cooling reservoir that is filled with water and ice, a compression cuff that wraps around the knee and is secured by VelcroTM straps with an aperture anteriorly for the patella, a connecting tube that exchanges water between the cuff and the reservoir and an insulation disc which helps keep the water and ice cold. Once the cuff has been applied and connected to the filled reservoir, the air vent on the reservoir is opened and is raised to no more than 15 inches above the knee for thirty seconds to fill the cuff. The air vent is then closed and the reservoir can be disconnected from the cuff. In order to re-circulate the water, the reservoir is reattached, lowered and warmed fluid is free to pass into the cooler where it can mix with the ice to be cooled. After a minute or two the filling process can be repeated. It is recommended that an initial fluid change be performed after 15 minutes and then hourly for up to 6 hours, without refilling the reservoir.

The PhysicoolTM system safely employs the cooling effects of latent heat evaporation rather than traditional direct external cooling. It utilises a cotton bandage soaked in an ethanol based solution. A pre-soaked bandage, stored in resealable foil pouch is wrapped around the knee on top of a waterproof dressing and secured with the pre-attached self-grip strap. The cooling effect lasts for approximately 2 hours, by which time the bandage will have become dry.  It can either be recharged by spraying the cooling fluid directly to the bandage in situ or it can be re-rolled and placed in the re-sealable bag with additional cooling solution.

METHODS

Outline

We performed a prospective audit to evaluate PhysicoolTM , a novel cryotherapy device against CryocuffTM in patients undergoing primary total knee arthroplasty by a single surgeon (SG) using his default surgical technique. All patients were operated on in one hospital between March 2011 and February 2012.

During this period all patients were managed as part of a protocol driven Enhanced Recovery Program. Pre-operative information leaflets including expected length of stay were routinely used. Patients were pre-assessed prior to surgery and attended on the day of their operation to a dedicated admission unit. Patients received either spinal or general anaesthesia depending on their preference and clinical indications. Thigh tourniquets were in place for the entire procedure in all patients. The Triathlon Knee® (Stryker, ???location USA) system was used in all patients through a medial para-patellar approach. Local anaesthetic infiltration using standardised volume, concentration and technique was routinely used. A retransfusion drain was inserted prior to closure and removed on the first post-operative day.  An integrated care pathway was used to record a patient’s progress throughout the admission and post-operative rehabilitaion was standardised.

Power Calculation

Following a pilot study, a power calculation revealed that 40 patients in each group would be sufficient to show a significant difference in outcomes.

Patient Selection

Ninety consecutive patients were entered into the study. Consent was obtained from all patients and their rights were protected at all times. Exclusion criteria included any patients who had cryotherapy discontinued for any reason, any wound complications and any patients with incomplete data sets.

Ten patients were excluded in accordance with the exclusion criteria, leaving 80 patients; 40 patients in each group. The two groups were well matched. There was no significant difference in age or sex in either group (Table 1)

Outcome measures

Primary outcome measures were pain and range of movement (ROM). Pain was assessed using a visual analogue scale (VAS) and range of movement using a goniometer. Scores and ROM were recorded before and thirty minutes after application of the cooling device on the first and second post-operative day. The patients were often discharged home on the third post operative day.

Data Collection

Data collection was performed by physiotherapists. All data for each patient was recorded on a custom designed data collection form. The patient hospital number was recorded on the cover sheet with subsequent pages for recording pain and ROM for each post-operative day. Although all physiotherapists were appropriately trained and briefed on the methodologies of the study, these were also detailed within this tool. Data was kept in a secure location throughout the study period.

The devices were assigned on the first post-operative day.  Both devices were applied in the first instance by a physiotherapist. Following this, the patient was responsible for re-application of the device, unless they were unable to do so.

In the cryocuffTM group, ice and water changes were performed by physiotherapists or nursing staff. The physicoolTM group recharged the bandage themselves when they perceived the cooling benefit to have diminished,

Ethics

All methodology and data collection was approved and conformed to the Hospital Trust audit protocols.

RESULTS

Statistics

The data sets from the two independent groups were compared using Student’s t-test statistical analysis. Graphpad Prism® Version 5 (Graphpad Software, San Diego, California) was used to analyse the data. A p-value<0.05 was considered statistically significant.

Data

Range of movement: On day 1 the improvement in range of movement in the CryocuffTM group was 12 degrees compared to 20 degrees in the PhysicoolTM group. This was statistically significant (p = 0.00867) (Figure 1)

On day 2, the improvement in the CryocuffTM group was 9 degrees compared to 16 degrees in the PhysicoolTM group. This was statistically significant (p = 0.00227) (Figure 2)

Pain: On day 1 the improvement in pain score in the CryocuffTM group was 1.2 compared to 1.7 in the PhysicoolTM group. This was statistically significant (p = 0.03218) (Figure 3)

On day 2 the improvement in the CryocuffTM group was 0.8 compared to 1.7 in the PhysicoolTM group. This was statistically significant (p = 0.00065) (Figure 4)

Cost: The cost of a PhysicoolTM pre-soaked bandage and sufficient additional cooling fluid is £21. The cost of a CryocuffTM is £44, excluding the cost of water and ice production, which is difficult to quantify. The cooling reservoirs cost £80 each, and are replaced as required. Patients are not able to take them home with them due to the cost.

Cost savings of approximately £23 per patient were estimated accounting for the cost of disposables, replacement cooling reservoirs and ice. This equates to a potential saving of £8050 per year based on 350 Total Knee Arthroplasties performed annually.

DISCUSSION

A recent Cochrane meta-analysis concluded that potential benefits of cryotherapy on postoperative pain and range of motion may be too small to justify its use, when balanced against potential inconveniences and expense of using cryotherapy2. With increasing constraints on resources and pressure on hospital beds our department has successfully introduced enhanced recovery to reduce the length of inpatient stay without an increase in readmission rate.

The CryocuffTM system of cryotherapy, whilst used successfully in our department’s Enhanced Recovery Program, is not without its limitations. The bulkiness of the cuff limits full knee flexion. The lack of constant flow compared to more technologically advanced but expensive cooling devices may limit its effectiveness of cooling, and regular ice and water changes are labour intensive. The ice reservoirs are expensive and designed to be reusable, it is therefore impractical for patients to take them home.  Currently we do not have an option for patients to purchase the reservoirs.

In view of these factors we wanted to find a cooling product, which addressed the shortfalls of the CryocuffTM system, without increasing cost. The PhysicoolTM system is easy to apply and recharge.  Owing to its lack of bulk it does not limit knee flexion whilst in-situ on the limb. Furthermore it remains effective once taken home by the patient for continued use. No complications were associated with the use of PhysicoolTM either in our study or in the literature.

Our results show that the PhysicoolTM system was significantly better at providing pain relief and improving ROM compared to the Cryocuff TM system on both the first and second post operative days. We believe this difference continues following discharge from hospital. In addition, using the PhysicoolTM system provides a modest cost saving of £23 per patient, which multiplied by 350 knee replacements over the course of a year would save £8050 in an averaged size department.

Limitations

There are some limitations associated with our study design. We accept that this was not a randomised blinded study and therefore results are susceptible to bias. In view of the nature of the cryotherapy devices, patient blinding is not feasible. It may, however, have been possible to blind assessors, though due to resource and time limitations this was not included in our methodology.

Whilst there was no control group it was felt that sufficient evidence exists to support the efficacy of cryotherapy versus placebo for the outcome measures we examined. Previous work has shown CryocuffTM to be superior to compression bandages and external ice at reducing pain and improving early range of movement.6,20,21

Furthermore, we did not examine analgesic requirements between the two groups, although previous meta-analysis has shown a reduction in analgesia requirement with cryotherapy5.

Pain scores and range of movement data were only recorded for the first two post-operative days. The mean length of stay of TKA patients in our department is 4.2 days, with a significant number of patients being discharged on the 3rd post-operative day. As no provision for measurement following patient discharge was made we felt a shorter follow up was preferable to multiple incomplete data sets.

We used VAS as it provides a simple and validated scoring system18. Intra-observer variability was controlled by having the same physiotherapist recording pre and post cryotherapy measurements with a goniometer; however, no mechanisms were put in place to control inter-observer variability.

Some patients reported that the cooling fluid soaked bandage caused dampness on bed sheets and clothing, and some found the odour of the cooling fluid unpleasant.  Application of the device can be challenging for those with poor manual dexterity.

Implications

This study clearly demonstrates the superiority of the physicoolTM cryotherapy system over that of the CryoCuffTM method for patients undergoing total knee arthroplasty when considering pain scores, range of movement and cost in the early post-operative period.

In addition to the acute post-operative phase of knee arthroplasty, cryotherapy has been used successfully following several arthroscopic procedures, particularly cruciate ligament reconstruction22. It has been used to reduce both the recovery time from traumatic injuries and in the treatment of chronic sporting injuries. It would seem likely that the advantage of PhysicoolTM over CryocuffTM would be similar in these situations, so this study could prompt the exploration of the use of the PhysicoolTM system in a wide range of operative and non-operative scenarios.

Conclusion

This study shows that the PhysicoolTM system is a viable alternative to other available cooling methods.  It is relatively inexpensive and easy for the majority of patients to apply.

It allows patients to mobilise without removing the device and can be used following discharge.

This is the first study demonstrating that the PhysicoolTM system improves pain and range of movement in the acute post-operative phase following TKA. We have shown it to be more effective in reducing pain and in increasing range of movement of the knee and also more cost effective compared to the CryocuffTM system.

References

  1. D.I. Abramson, L.S. Chu, S. Tuck Jr. et al. Effect of tissue temperatures and blood flow on motor nerve conduction velocity JAMA, 198 (1966), p. 1082
  1. Adie S, Kwan A, Naylor JM, Harris IA, Mittal R. Cryotherapy following total knee replacement. Cochrane Database Syst Rev. 2012 Sep 12;9:CD007911..

3.Ayalon O, Liu S, Flics S, Cahill J, Juliano K, Cornell CN. A multimodal clinical pathway can reduce length of stay after total knee arthroplasty. HSS J. 2011 Feb;7(1):9-15.

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How to Cool Your Server Room and Reduce Your Energy Costs

Whether your organisation runs a small server closest or large server room or onsite datacentre, ambient and temperature control is critically important to prevent system downtime.

The electronics and microprocessors within a server or computer generate heat energy which must be managed in a confined space such as a server rack cabinet, server room and datacentre. Cooling fans are built-into the server or computer casing to draw air through the front of the unit and exhaust this through rear panel grills. If the internal fan(s) fail or the ambient air drawn through the front panel is too high, a build-up of heat will occur with the potential for component failure and fire. This potential disaster is always present and increases significantly where server cabinets or racks (into which more than one server is placed) are installed. In addition to this, whilst virtualisation technologies has reduced the number of physical servers required to perform computing tasks, the power drawn by typical servers and the energy generated as heat (measured in BTU/hr) has risen exponentially. A fully populated server rack can draw as much as 15kW or more. Server technologies have become more efficient in their design with lower heat outputs but at 15kW and say 95% operating efficiency this still leaves 2,564 BTU/hr of heat to deal with.

Most server rooms and datacentres should be run at around 20-25˚C to provide a sufficiently cool environment for the servers and any associated UPS systems and their batteries, whilst also maintaining a comfortable environment for the people within the IT team to work in. ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) also advocates increasing the temperature within the IT room to higher levels with changes to the operational infrastructure e.g. the movement of UPS valve-regulated lead acid batteries to a separate plant room. Most server, IT peripheral and UPS electronics will operate at higher temperatures above 30˚C without detriment to their long-term performance and this reduces the need for cooling and increases energy usage. For more information see the Data Centre ANSI/ASHRAE Standard 90.4-2016 (https://www.ashrae.org/about/news/2016/data-center-standard-published-by-ashrae).

Computer Room Cooling Efficiency Checklist

Datacentres are buildings dedicated to providing managed and controlled environments for server facilities. Most organisations will now operate some form of Cloud-based servers in addition to their on-site server rooms or server closets. This trend will increase through the adoption of Internet of Things (IoT) technologies and connectivity. The key is issue is to manage your on-site server room or closet as a controlled environment. It is in effect a mini-datacentre, without which your organisation may be incapable of operating.

The Server Room Environments team provide power, cooling and energy efficiency audits as a free of charge service. Here is our top-10 energy efficiency audit checklist for computer rooms, IT closets, server rooms and datacentres:

  1. Cooling Temperature Settings: cooling systems are single-control loops whose operation is controlled via thermostat settings. Measure the room ambient at several points within the server room and compare these to your thermostat/temperature control settings. The larger the differential the less efficient the cooling. Ideally there should only be a 1-2˚C difference.
  2. Air Conditioner Sizing: audit the load (server requirements) and size of air conditioning in the room and its positioning. Ideally the air conditioner system should be sufficiently sized to cool the ambient to 20-25˚C and leave a 20% safety margin.
  3. Cooling Airflow and Containment: cool air is normally drawn into the front of a server and expelled through the rear vents. The same format holds when servers are positioned inside a server cabinet. Multiple cabinets should be arranged into a hot-aisle/cold-aisle arrangement to optimise cooling efficiency. Hot air should be expelled from the rear of the cabinets into the ‘hot-aisle’ which is then collected and drawn into the cooling system air conditioner (computer room air conditioner – CRAC) unit. The front of the server racks should face the ‘cold-aisle’ and be supplied with conditioned/cooled air.
  4. Server Cabinet Efficiency: it is common to find temperature variations within a server cabinet. Heat will rise, and the highest temperatures can generally be found towards the top of the cabinet. Blanking panels should be used if there are unused spaces within the server rack to ensure that the cold air cannot ‘escape’ through the front of the unit and prevent hot air from being trapped. A typical server rack cabinet can see a 20% differential in temperature between the top and bottom of a rack.
  5. Ambient Temperature Monitoring: even in a small facility it is important to have some form of remote ambient and environmental monitoring and alarm system. This can take several forms. There are dedicated environmental monitoring systems as well as additional accessories that can be connected to power distribution units (PDUs) and access control systems. The important point is to ensure that they are IP-enabled so that measurements and alarms can be generated and sent via the IT-network. Sudden or alarm-triggering changes should be investigated immediately.
  6. Additional and Redundant Cooling: air conditioners require regular routine maintenance, and this can generally mean a complete IT power down. Where this is the case and there is no cooling redundancy built-into the cooling system, either the entire IT operation has to shutdown or additional cooling in the form of portable air conditioners must be installed. Temporary and portable cooling systems are available from Server Room Environments on hire contracts.
  7. Air Conditioner Maintenance: regular maintenance is required to ensure your cooling system is fully operational and energy efficient. There are consumable items including filters within an air conditioner that will require replacement. Other components have a defined working life e.g. cooling fans. During a preventative maintenance visit, an HVAC (heating, cooling and air conditioning) engineer should carry out visual inspections of the entire cooling system including checking vents, ducts and exhausts for blockages and dust, dirt and grime build-up.
  8. Secure IT Facility: server rooms and closets need to be well-planned with an efficient use of space. This will mean ‘empty’ floor space which to the untrained eye is there to be used for general storage. Avoid this at all costs and secure the room to prevent unauthorised access. Anything stored within the room can block air flow and if it is operational (electrical/electronics) add to the cooling demand.
  9. Energy Efficiency: it is important to consider the age and efficiency of all the components within the room and not just the servers. Lighting can generate heat and should only be operational when the room is accessed and/or upgraded to energy efficient LED lighting which has a far lower heat output than traditional halogen bulbs or neon strip lights. For a typical halogen light bulb, only 10% of the energy consumed converts to light; the other 90% is emitted as heat. Air conditioners and uninterruptible power supplies (UPS systems) should also be upgraded to the latest designs to guarantee the highest levels of operational efficiency.
  10. Growth Factor: plan for the unexpected. IT technology continues to evolve at a rapid rate and it is important to build growth into the server room cooling design. This can go both ways. Additional kit may be added including more powerful servers. IT equipment may also be removed using virtualisation technologies or services outsourced to a Cloud datacentre. The cooling system needs to be able to accommodate load changes to maintain energy efficiency.

It is often all-to-easy to overlook potential energy savings within a server room and the cooling system itself. Over the life of an air conditioning system, its operational load and demands will change and should be reviewed at least every 2-3 years with a view to a full system refresh around years 5-7. This reflects the pace at which air conditioning and cooling systems are evolving to keep pace with changes in IT server technologies.