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

Chronic low back pain is extremely prevalent in the United States, especially in the adult population. It has been estimated that 80% of adults have experienced at least one occurrence of low back pain in their lifetime. One of the risk factors for low back pain is weakness of abdominal trunk muscles. In the article, “Abdominal Trunk Muscle Weakness and its Association with Chronic Low Back Pain and Risk of Falling in Older Women,” the authors investigated the association of trunk muscle strength with the presence of chronic low back pain in older women.

Trunk muscle strength was tested using an exercise device developed by the authors of the above study that was previously deemed reliable. The device measures general abdominal trunk strength of the diaphragm, abdominal rectus, internal oblique, external oblique, transverse abdominal, and levator ani muscles in combination. The article found that the women who were experiencing chronic low back pain had significantly weaker trunk muscles compared to those with no chronic low back pain. Chronic low back pain was defined as having low back pain of a defined pain intensity (equivalent to ~2/10 pain) for more than 3 months.

The same study then investigated whether women with lower trunk muscle strength were at a higher risk of falling. It was found that abdominal trunk muscle strength was significantly lower in the women who had experienced a fall in the past 12 months, regardless of if back pain was present.

For more information regarding this topic or the research presented, please see the article referenced below. If you’re experiencing low back pain or have experienced a recent fall, the physical therapists here at Physical Therapy First will examine you and develop an individualized rehabilitation plan to help improve your symptoms. Abdominal trunk strength can help to improve spinal stability and will likely be incorporated into your unique program. Give us a call or visit the website to schedule an appointment!

Reference:

Kato S, Murakami H, Demura S, Yoshioka K, Shinmura K, Yokogawa N, Igarashi T, Yonezawa N, Shimizu T, Tsuchiya H. Abdominal trunk muscle weakness and its association with chronic low back pain and risk of falling in older women. BMC Musculoskelet Disord. 2019 Jun 3;20(1):273. doi: 10.1186/s12891-019-2655-4. PMID: 31159812; PMCID: PMC6547466.

Following an injury or surgical procedure to the hip, knee, or ankle it is often painful and difficult to put weight through the affected leg. Often times, we avoid putting weight through the affected leg due to a large amount of pain and use an assistive device such as a walker or cane to help us offload our weight using our arms. Using an assistive device and limiting weight through the affected leg is beneficial early on, especially for those with weightbearing restrictions, to help promote proper healing. However, when ready and able to, it is good to start practicing putting more weight through the affected limb as early as possible to help your body get used to these stresses. When doing this, please consider your pain and swelling levels as both serve as a great guide to determine the amount one should perform. Also, please take into account your safety and consider practicing weight acceptance exercises with an assistive device or something sturdy nearby to hold onto.

Here is a progression of some common, simple exercises to help improve weight acceptance and standing tolerance for an affected lower extremity. These are great exercises one can perform at home as part of their home exercise program, however discuss proper technique and dosage with your physical therapist before performing independently.

In each picture, my RIGHT leg is the affected side and I am using a cane with my LEFT hand or holding on to a sturdy chair to help offload and balance.

Lateral Weight Shifts: Start standing with equal weight distribution and shift body weight onto affected leg.
Forward Weight Shifts: Start standing with most body weight on non-affected leg with affected leg in front, shift body weight onto affected leg.
Lateral Weight Shifts onto Single Leg Stance with Holding On: Shift body weight onto affected side with picking up foot of non-affected leg off the ground while holding on with hands for support.
Forward Weight Shifts onto Single Leg Stance with Holding On: Shift body weight onto affected side with picking up foot of non-affected leg off the ground while holding on with hands for support
Lateral Weight Shifts onto Single Leg Stance without Holding On: Shift body weight onto affected side with picking up foot of non-affected leg off the ground and do not hold on to accept 100% of body weight.
Forward Weight Shifts onto Single Leg Stance without Holding On: Shift body weight onto affected side with picking up foot of non-affected leg off the ground and do not hold on to accept 100% of body weight.
Single Leg Stance with Opposite Lower Extremity Movements: Great exercise to work on standing tolerance and hip stability. Feel free to perform with or without holding onto a sturdy object depending on the recommendation from your PT.   3 way hip – while standing on the affected limb, move your other leg out in front of you, out to the side, and behind you.     Circles – while standing on the affected limb, move your other leg in small circles in a clockwise and counterclockwise directions.

These exercises above are some of the more common ones I like to prescribe to patients, however there are multiple other variations to challenge our bodies in different ways. Weight acceptance exercises are only one part of a comprehensive physical therapy routine that may benefit you following injury or surgery to a lower extremity. The physical therapists at Physical Therapy First assess each patient on an individual level and determine PT interventions specific to each person’s needs. We spend 1 on 1 time with our patients for a full hour for every PT session.

INTRODUCTION

Trigger point dry needling (TDN) has become an increasingly common way to address the pain and dysfunction that comes from muscle pain. Myofascial trigger points are excessively irritable points in skeletal muscle that are associated with a painful knot in a taut band (2). Myofascial trigger points (MTrPs) are a common source of musculoskeletal pain in people. MTrPs can be found in a variety of conditions. MTrPs are associated with muscle spasms, increased sensitivity, stiffness, muscle weakness, decreased range of motion, fatigue, and autonomic dysfunction (2,3). Trigger points can be defined as being active or latent and either can produce local or referred pain, hyperalgesia, and allodynia (4). Hyperalgesia and allodynia are defined as a high sensitivity and pain to the touch.

METHODS

The aim of TDN on a MTrPs is to provoke a mechanical tissue stimulation in order to eliminate the MtrP and return the muscle to its normal function (4). Multiple studies have shown that trigger point dry needling immediately increases pain pressure threshold, range of motion, and decreases pain in patients with musculoskeletal disorders (6). The purpose of this systematic analysis (1) is to determine the short-term (0-72 hour), medium-term (1-12 week), and long-term (13-24 week) effectiveness of TDN on MTrPs. 42 studies were included in this meta-analysis after an original review of 102 potential studies that could have been included. The studies included all had to include measurements for pain. The studies were then broken down in to 3 subgroups: TDN versus placebo, TDN versus other therapies, and TDN plus other therapies versus other therapies.

RESULTS

16 of the 42 studies assessed were on neck pain and headaches, 5 on shoulder pain, 5 on knee pain, 3 on lumbar spine pain, 4 on ankle pain, 2 on hip pain, 1 on fibromyalgia, and all others on various musculoskeletal pains.

• Immediately post DN to 72 hours after treatment: low quality evidence, large effect
• 1 to 3 weeks post DN: moderate quality evidence, moderate effect
• 4 to 12 weeks post DN: low quality evidence, large effect
• 13 to 24 weeks post DN: low quality evidence, large effect

DISCUSSION & CONCLUSION

The results of this analysis show that trigger point dry needling produced better results than having no treatment, placebo treatment, sham dry needling, and produces better results than TENS, compression, conventional rehabilitation, massage, stretching, and friction massage. For the time period of immediate to 72 hours post treatment of the application of dry needling, there was a direct correlation between number of sessions of dry needling and trigger points affected creating an increased positive outcome. The best thought at this time as to why dry needling leads to a reduction in pain and improved function is due to an increase in blood flow to the area where the needling was performed, decreased presence of substance P-the bodies pain alerting peptide, and the overloading of the muscle that occurs when the needling creates a muscle twitch, which ultimately improves muscle activation and function similar to that of an intense workout (7,8). At this time the best recommendation for dry needling is 1 session per week to be effective (1).

For the time period of 4-12 weeks post needling, dry needling was again found to be more effective than most or all other therapies performed individually (1). And no specifics are provided for this time frame as to the appropriate number of sessions to be most beneficial, so further evidence is needed. For the time period of 13-24 weeks post TDN, the evidence at this time is extremely limited, so further research must be completed. It was however determined that the sooner a trigger point is treated upon its onset, the longer lasting the results (acute responds faster and longer than chronic) (1).

In summary, low to moderate quality evidence at this time shows a moderate to large effect of trigger point dry needling in reducing overall pain levels and improving muscle function. Further studies of higher quality are needed, but at this time trigger point dry needling is an effective treatment that comes at very little cost in regards to both time and money, and demonstrates nominal negative effects.

TDN is now legal in 36 states to be performed by PTs, the law is silent on PTs performing TDN in 8 states, and is prohibited in 6 states (9). The following infographic best displays the legality by state. TDN is legal to be performed by PTs in the State of Maryland, and Maryland requires the strictest dry needling education and competency requirements of any state in the US (10).

              Image courtesy of the American Physical Therapy Association (9)

Physical Therapy First

The clinical team at Physical Therapy First has more physical therapists certified in trigger point dry needling than anyone else in the Greater Baltimore region. Our team of board certified orthopedic clinical specialists provides you with a one-on-one appointment for one hour with a doctor of physical therapy, at any of our 4 greater Baltimore locations.

 References

This article is a summary from reference #1, cited below.

1. Sánchez-Infante J, Navarro-Santana MJ, Bravo-Sánchez A, Jiménez-Diaz F, Abián-Vicén F. Is Dry Needling Applied by Physical Therapists Effective for Pain in Musculoskeletal Conditions? A Systematic Review and Meta-Analysis. PTJ: Physical Therapy & Rehabilitation Journal | Physical Therapy, 2021;101:1–15.

2. Donnelly JM, Fernándezd el as Peñas C, Finnegan M, Freeman JL. Travell, Simons & Simons’ Myofascial Pain and Dysfunction: the Trigger Point Manual. 3rd ed. Philadelphia, PA, USA: Wolters Kluwer; 2018.

3. Kamanli A, Kaya A, Ardicoglu O, et al. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatol Int. 2005;25:604–611.

4. Hall ML, Mackie AC, Ribeiro DC. Effects of dry needling trigger point therapy in the shoulder region on patients with upper extremity pain and dysfunction: a systematic review with meta-analysis. Physiotherapy. 2018;104:167–177.

5. Dommerholt J,Mayoral del Moral O, Gröbli C. Trigger point dry needling. J Man Manip Ther. 2006;14:203–201.

6. Gattie E,Cleland JA, Snodgrass S. The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2017;47:133–149.

7. Pecos-Martín D,Montañez-Aguilera FJ,Gallego-Izquierdo T, et al. Effectiveness of dry needling on the lower trapezius in patients with mechanical neck pain: a randomized controlled trial. Arch Phys Med Rehabil. 2015;96:775–781.

8. Ibarra JM, Ge HY,Wang C, et al. Latent myofascial trigger points are associated with an increased antagonistic muscle activity during agonist muscle contraction. J Pain. 2011;12:1282–1288.

9. https://www.apta.org/patient-care/interventions/dry-needling/laws-by-state

10. https://health1.maryland.gov/bphte/Pages/dryneedling.aspx

Article Review:

The First 6 Weeks of Recovery After Primary Total Hip Arthroplasty With Fast Track; a diary study of 94 patients

Background:

Fast track protocols have been introduced to help speed up the recovery after total hip arthroplasties (THA), or hip replacements. A faster recovery means less time spent in the hospital and a quicker return to function for the individual. Fast track protocols have shown to reduce the length of stay in hospitals while still being safe as they did not show to cause any increase in complications, re-admission rates, or re-operations. Most studies have researched fast track within the hospital setting, however this study looked more into patient’s recovery for the first 6 weeks after discharge from the hospital in an outpatient or inpatient rehab setting.

Methods:

This study looked at 100 individuals who underwent a primary THA using an anterior supine intermuscular (ASI) approach (refer to article for complete inclusion and exclusion criteria). The fast track protocol was used for all patients. Here is a summary of what the fast track protocol entails:

Discharge criteria from hospital included: walk 30 meters with crutches/ rollator, climb stairs, dress independently, toilet independently, pain below 3/10 at rest, and proper healing of wound.

Outcome measures: Five questionnaires were used that each patient filled out themselves. The questionnaires were a measurement of function and pain.

Results:

94 patients were accepted for final analysis with 42 operated in outpatient and 52 operated in inpatient settings.

Pain and use of pain medications gradually decreased over first 6 weeks

Function and quality of life gradually improved based on questionnaires. 91% of all patients reported better functioning and less pain than pre-operatively.

Discussion:

Using the fast track protocol, patients had an overall decrease in hip pain and had greater functional capabilities within their first 6 weeks after hospital discharge. Most patients were pleased they were able to leave the hospital early and perform their rehab at home. Unfortunately, the demographics of patients between the inpatient rehab groups and outpatient rehab groups were different, therefore these groups are unable to be compared. Another major limitation of this study is that all outcome measures are based on patient reported questionnaires. There were no objective physical exam function measurements used.

Take Home Message:

From this study, it suggests a fast track protocol following hip replacement surgery is beneficial not only for the first couple days following surgery, but also safe and effective for the next 6 weeks. Despite some limitations of this study, the research still suggests less pain and improved functional outcomes when undergoing early mobility following a hip replacement. This is consistent with what I see clinically and I have worked with multiple patients have excellent results with even same day discharge following hip replacements. A common complaint patients have when undergoing hip replacement is hesitation and extra caution to get up and move around. This is totally understandable and I respect people feeling this way. Even though it is smart and necessary to be cautious, I hope this article can re-assure people how beneficial it is to get up and walk around early on and within each person’s tolerance levels. If you are planning on undergoing a hip replacement, the physical therapists here at Physical Therapy First can provide you complete 1 on 1 care to help get you back moving around safely and with confidence!

Article Reference:

Lisette C M Klapwijk, Nina M C Mathijssen, Jeroen C Van Egmond, Bianca M Verbeek & Stephan B W Vehmeijer (2017) The first 6 weeks of recovery after primary total hip arthroplasty with fast track, Acta Orthopaedica, 88:2, 140-144, DOI: 10.1080/17453674.2016.1274865