This meta-analysis explored the prognostic factors which can predict outcomes for patients with acute whiplash injuries.  As a disclaimer this study was meant to identify the factors only and not what scales or intensity would lead to prognostic factors.  The authors note that it is beyond the scope of their study to examine specific quantitative data regarding prognosis.  This concept will be discussed later in this summary.  I had two major takeaways from this piece: 50% of people who suffer from whiplash will have long term negative impacts, and that whiplash related pain and anxiety after a car accident are the most consistent prognostic factors for having long term negative impacts on their function.  Other factors that were prognostic included catastrophizing, compensation and legal factors, and early use of health care.  The authors did not identify what levels of pain or anxiety were more prognostic.  The authors did not identify the amount of compensation or specific measures of legal factors.  While a knee jerk reaction may be to say that people who have significant pain and anxiety who also get legal counsel quickly involved will have long term disability but that was not the focus of this paper and this assumption cannot be made based on the information provided.  Please read on to find out what factors were not associated with long term impact or required further research to establish the type of connection.

This meta-analysis was relatively sizeable in terms of the amount of studies analyzed and the number of patients which were included across all studies reviewed.  The authors analyzed 12 systematic reviews of moderate quality.  Each systematic review analyzed anywhere from 6 to 38 studies for a total of 200 studies which included over 99,000 patients.  The studies examined ranged from 1980-2012 and the meta-analysis was published in a 2017 journal.  Being able to look at over 20 years of research and explore nearly 100,000 patients is an achievement and does bring a little more merit to a relatively common population.

The study was funded by the Motor Accident Authority (MAA) of New South Wales, Australia.  However, the funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.  So why study acute whiplash injuries?

Whiplash is among the leading car crash related injuries in terms of burden on patients, to the healthcare system, and on insurance organizations.  Whiplash type injuries have been increasing over the past decade, and patterns of car accidents that causes whiplash have also changed and now include minor types of accidents.  The overall increase in whiplash may also be due to rise in traffic density and changes in societal and litigation factors but was not part of this paper’s exploration.  The authors examined potential prognostic factors and separated these factors into 4 categories: associated, non associated, lack of evidence, and controversial.  Associated factors were defined as those which found adequate evidence to conclude that a factor was associated with the outcome of acute whiplash injury.  Non associated was the opposite.  A lack of evidence was unable to identify adequate evidence regarding a prognostic factor.  Controversial factors were those which had conflicted evidence.

As mentioned earlier, the authors found the following as associated factors for predicting outcomes: post injury pain and disability, post-injury anxiety, catastrophizing, compensation and legal factors, early use of health care.  The most consistent finding was the association of post injury pain and disability with long term pain and disability.  The association of other factors was not as strong although the association of psychosocial factors with whiplash is notable.

Interestingly enough post injury MRI/X-ray findings, motor dysfunctions, or factors related to the collision were not associated with continuation of pain and disability in patient’s whiplash.  Factors related to the collision were more related to speed of collision or direction of impact.

However, evidence on demographics and 3 psychological factors and prior pain was conflicting and there is a shortage of evidence related to the significance of genetic factors.

Overall this meta review suggests an association between initial pain and anxiety and the outcome of acute whiplash injury, and less evidence for an association with physical factors.  To critically re-emphasize, this paper only sought to identify prognostic factors but not the scales or intensity of these factors.  This would be an opportunity for additional research.  There is a limited number of studies which examines prognosis of whiplash based on: occupation type, disc degeneration, pre-existing /new widespread body pain/fibromyalgia, or pre-injury fitness or exercise levels.  As humans we are incredibly complex individuals when you consider what makes us ‘us’ and to determine consistent patterns that can fit specific populations is difficult.  While the findings of this paper are unsurprising that having whiplash related pain is a factor for long term whiplash related pain, being able to identify factors which are not prognostic is also helpful.

1. Deltoid-rotator cuff force couple:

• Produces largest amount of force
• Rotator cuff muscles: supraspinatus, infraspinatus, teres minor, subscapularis
• When raising arm overhead, the deltoid causes an UPWARD and OUTWARD force on the humerus (upper arm bone) during the first part of the motion
• 3 of the rotator cuff muscles (infraspinatus, teres minor, subscapularis) collectively create a DOWNWARD and INWARD force on the humerus to maintain the proper positioning of the ball in its socket.
• The supraspinatus creates a compressive force to help keep the humerus in proper positioning. When rotator cuff muscles are not working properly, this can cause greater amount of UPWARD and OUTWARD movement at the shoulder potentially causing more pressure on the humeral head as well as potentially leading to injury of other shoulder structures

2. Upper trapezius and serratus anterior force couples

• To produce upward rotation of the scapula, or shoulder blade when raising our arms
• 4 major muscles: Serratus anterior, Lower trapezius, Upper Trapezius, Levator Scapula
• 4 important functions: Allows for rotation of the shoulder blade to keep the glenoid (socket of the shoulder) in proper positioning; Maintains proper length-tension relationship for the deltoids; Prevents impingement on the rotator cuff muscles; Provides stable scapular base for proper muscular recruitment
• Collectively, these 4 muscles act on the shoulder blade creating forces at different aspects of the shoulder blade in different directions where the end result becomes UPWARD ROTATION of the shoulder blade
• The serratus anterior and lower trapezius are the primary stabilizers of the shoulder blade when the arm is raised 90 degrees or more out to the side
• We need proper shoulder blade upward rotation to maintain shoulder stability when raising our arm to the side. It has been shown with shoulder impingement syndrome that there is decreased activity of serratus anterior, delay in activating lower trapezius, and overactivity of upper trap and levator scapula.

3. Anterior-posterior rotator cuff force couples

• Anterior (front) rotator cuff: subscapularis
• Posterior (back) rotator cuff: infraspinatus and teres minor
• Create a DOWNWARD stability within shoulder and contribute to compressive forces to maintain the humeral head within the socket when elevating arm
• Subscapularis (front) and infraspinatus (back) pull DOWNWARD and INWARD at about 45 deg angle; teres minor (back) pull DOWNWARD and INWARD at about 55 deg angle to keep shoulder centered in joint
• It is common that the shoulder internal rotator muscle groups, which includes the subscapularis are more developed compared to the teres minor and infraspinatus creating a potential force couple imbalance leading to potential lack of stability.

(picture on right demonstrates this)

Reference:

Ellenbecker T, Manske R, Kelley, M. Current Concepts of Orthopaedic Physical Therapy: The Shoulder: Physical Therapy Patient Management Using Current Evidence. 4th Edition. Orthopedic Section, APTA 2016

Introduction:

Sleep plays crucial roles in post-operative recovery, pain tolerance and healing process. Studies have shown that post-operative pain could significantly affect quality of sleep. Due to dangers of opioids, it is important to find alternative ways to manage pos-operative pain and encourage better sleep to decrease opioid use and enhance post-surgical recovery.

Zolpidem, a pharmacologic sleep aid, has presented to decrease use of opioid, reduce pain, and increase quality of life but it should not be used long term because it can lead to addiction.

CBT-I: Cognitive behavioral therapy for insomnia is a type of psychotherapy that is used to change thoughts and behaviors to encourage natural sleep. CBT treatments are available through apps and audio tracks, which patient could use on their smartphone devices when needed.

Methods:

11 studies were used to review in this article based on the selection criteria. Eight of the studies found were comparing zolpidem to a placebo or CBT to a placebo; three studies compared both CBT and zolpidem.

Summary of the Studies (Zolpidem):

• ACL reconstruction (a surgery at knee that allows the reconstruction of the anterior cruciate ligament) patients who take zolpidem took significantly less narcotics than those in the placebo group for one-week post-surgery
• Knee arthroscopy (a surgery at knee that do not require large cut) patients who are assigned in the zolpidem group took less hydrocodone/ibuprofen and reported improved post-surgical pain and fatigue
• Rotator cuff repair (a surgery at shoulder to repair the teared tendon) patients who were in the zolpidem group used fewer pain medications
• Total knee replacement (a surgery at knee to replace the knee joint with metal implants) patients in zolpidem group had better sleep quality, greater quality of life, better satisfaction, lower pain scores as well as took less opioid

Summary of the studies (CBT-I):

• A study compared the effects of CBT- I to zopiclone (a drug in the same class as zolpidem) and found that patients in the CBT-I group had improved efficiency in sleep and decreased in frequency of waking up during the night compared to zopiclone and the placebo group.
• In another study, CBT-I groups have demonstrated decreased sleep onset latency, increased sleep efficiency, the most normal compared with CBT-I + zolpidem group or zolpidem group, and those patients maintained their improved sleep at long-term follow-up.
• Researchers have also found that CBT is an effective intervention for patients with cancer, which has resulted in decreases in pain, fatigue, and sleep disturbances

Clinical application:

In Summary, zolpidem is a well-documented sleep aid that was shown to decrease the use of opioid, reduce pain, and increase quality of life when used for a short period of time. However, the type of sleep that zolpidem induces is different than natural sleep, and as a result does not offer the same health benefits. Excessive use of zolpidem and other sleeping pills can damage patient’s health and increases risks for life-threatening diseases.

CBT-I is a valid non-pharmacological alternative to zolpidem when considering how to improve sleep, and ultimately post-operative pain and recovery in patients.

Further studies looking at CBT-I, sleep, and how those two variables are related to post-surgical pain and opioid use could be beneficial to the field of orthopedic surgery. It would be beneficial to find out why zolpidem has better outcomes when the sleep they induce is not natural sleep.

Physical Therapy First Takeaways

If you are an individual who has planned surgery or are currently in pain after surgery, you could consider have a conversation with your provider regarding alternative interventions for pain reduction and improved quality of sleep.

Reference:

Petrie, K., & Matzkin, E. (2019). Can pharmacological and non-pharmacological sleep aids reduce post-operative pain and opioid usage? A review of the literature. Orthopedic Reviews, 11(4). https://doi.org/10.4081/or.2019.8306

The scapula, or shoulder blade is an integral part of the entire shoulder complex serving as the foundation for properly functioning shoulders. Often times, dysfunctions can occur with shoulder blade movement that can be related to shoulder pain that requires strengthening and stability training to help decrease shoulder pain. Physical therapists will often observe shoulder blade positioning in a resting position with arms by side, arms elevated, or with hands on hips. It is also beneficial to assess shoulder blade movement when raising arms up overhead in different planes of motion with and without holding weights. The following are shoulder blade anatomical structures that physical therapists look at to help determine shoulder blade dysfunctions:

Inferior Angle: If the lower angle of the shoulder blade is very prominent, this may be due to forward tipping of the shoulder blade. This is commonly seen in patients with rotator cuff impingement as this causes the acromion to be in a position to potentially get in the way of the elevating humeral head.

Medial Border: If the inner border of the shoulder blade becomes more displaced away from the body, this may be due to internal rotation of the shoulder blade. This is commonly seen in patients with shoulder joint instability. Due to the internal rotated position of the shoulder blade, this can cause an altered position of the glenoid (the socket of the shoulder) for the humeral head (the ball of the shoulder) to be centered in it and may lead to increased risk for shoulder instability or partial dislocations.

Superior Angle: This is when we look at the top of the shoulder blade and see if the shoulder blade moves upward early and excessively when elevating the arm overhead. This may be a sign of rotator cuff weakness and force couple imbalance between the muscles that move and stabilize the shoulder blade.

Physical therapists may also perform clinical tests for the shoulder blade to help them determine their treatment plan. The following are an explanation of some clinical tests for shoulder blade functioning:

Scapular Assistance Test: the clinician will provide manual assistance with one hand at the lower angle and the other hand at the top of the shoulder blade providing an upward rotation assistance to the shoulder blade while patient is actively raising their arm overhead. If patient elevates their arm with decreased pain or achieves greater range of motion, then it is a positive test and patients can benefit from exercises to improve their scapular muscle control.

Scapular Retraction Test: the clinician will manually retract the patient’s shoulder blade when they perform a pain provoking movement. This test has shown kinematic changes that places the glenohumeral joint (shoulder) in a more favorable position for functional movements. If a decrease in pain occurs, then this is a positive test and the patient will benefit from improving shoulder blade retraction exercises while moving their arms in different positions.

Flip Sign: when assessing shoulder external rotation strength, the clinician will observe the inner border of the shoulder blade. If the medial border becomes more prominent during the resisted external rotation movement, then this is a positive test that indicates a possible loss of scapular stability. It would be beneficial for the patient to improve their serratus anterior and trapezius force couple.

Using these clinical tests and assessing for shoulder blade functioning provides physical therapists with a better understanding of our patient’s shoulder conditions and helps us develop the proper treatment plan. Improving stability of the shoulder blades can be extremely helpful to decrease shoulder pain and improve functional abilities. If you have shoulder pain, give Physical Therapy First a call. We provide 1 on 1, hour long sessions to address your goals and get you moving in the right direction.

Reference:

Ellenbecker T, Manske R, Kelley, M. Current Concepts of Orthopaedic Physical Therapy: The Shoulder: Physical Therapy Patient Management Using Current Evidence. 4^th Edition. Orthopedic Section, APTA 2016