What’s New in Orthopaedic Rehabilitation

Orthopaedic surgery and rehabilitation medicine continue to remain synergistic fields of medicine. This Guest Editorial reviews articles published from March 2022 through February 2023. We considered articles from the American Journal of Physical Medicine however, in an RCT, Rendek et al. revealed that loading of a nonoperatively treated Achilles tendon rupture at 2 weeks after the injury led to increased Achilles tendon thickness without an increase in the elastic modulus at 52 weeks after the injury15. There was no increase in adverse events associated with early loading and no difference in return to work or sport between the groups. High-volume injections have been used to treat midsubstance Achilles tendinopathy, with the theorized mechanism of action consisting of the disruption of neovascularization. In a double-blinded RCT, van Oosten et al. found no reduction in Doppler blood flow in 62 subjects with chronic midsubstance Achilles tendinopathy following a high-volume injection (50 mL) compared with a placebo (2-mL injection)16. The amount of post-injection hypervascularity did not correlate with clinical outcomes, suggesting that the disruption of neovessels may not be a mechanism of action of high-volume injection used to treat midsubstance Achilles tendinopathy. Spine In a prospective, longitudinal cohort study of adults with chronic low back pain, the feasibility of an evidence-based physical therapy program was adapted for telehealth using videoconferencing17. Up to 8 weekly sessions of telehealth physical therapy were used, and 126 participants enrolled. Acceptability, adoption, feasibility, and fidelity assessed using participant surveys and compliance with session attendance were included in implementation outcomes. Most participants reported general satisfaction with telehealth physical therapy (76.3%), but a smaller percentage of participants regarded the quality of telehealth physical therapy to be equal to in-person physical therapy (39.5%). At 10-week and 26-week follow-ups, participants reported significant improvement in low back pain-related disability, pain interference, physical function, pain intensity, and sleep disturbance from baseline, supporting the feasibility of telehealth physical therapy. Nested within the same study of patients, the authors used mixed-methods qualitative interviews and surveys of patient experience to characterize the working alliance, psychosocial risk, and patient-reported outcome measures to describe the experience of patients receiving telehealth physical therapy, including the concerns, advantages, and disadvantages that they may have encountered18. The advantages included convenience, time saving, and personalization; the disadvantages were lack of physical correction, difficulty making a personal connection with the therapist, and technology problems. This subset of participants endorsed a hybrid approach that might include both in-person and telehealth physical therapy. ESWT has emerged as a useful tool to treat a range of musculoskeletal conditions. Although the exact mechanism of ESWT is not completely understood, tissue regeneration and healing have been demonstrated after treatment. In a clinical trial, 34 patients with coccydynia were randomized to receive either ESWT or corticosteroid injection in the coccyx or sacrococcygeal junction19. Both groups had significantly decreased visual analog scale (VAS) pain with intervention; however, improvement at 6 months favored the group receiving ESWT. Arthroplasty A systematic review evaluated prehabilitation interventions for elective, unilateral total knee or hip arthroplasty in primary osteoarthritis20. Patient-reported health-care utilization and performance outcomes were assessed. Prehabilitation resulted in increased strength and reduced length of stay in 13 knee arthroplasty trials. Evidence for benefit with respect to pain, range of motion, and activities of daily living was low. The authors found no or insufficient evidence regarding all other outcomes. Also, 6 hip arthroplasty trials provided no or insufficient evidence regarding all evaluated outcomes. A large degree of heterogeneity among the programs limited strong conclusions. A multivariable, difference-in-difference model evaluated the effect of the U.S. Comprehensive Care for Joint Replacement (CJR) policy on post-acute care after total hip arthroplasty21. More than 350,000 Medicare beneficiaries before (2014 to 2015) and after (2017) CJR policy implementation were included. The results indicated that 47.6% of patients were discharged to the community and 52.4% of patients received institutional post-acute care. Patients in the CJR areas were 10% less likely to return to the community at 90 days after the policy. Despite high study power, no significant escalation of care was found after the CJR implementation. In a prospective RCT, Cheah et al. examined 125 patients after total shoulder arthroplasty and tested if multimodal care, including nonpharmacologic sleep hygiene interventions, zolpidem, and melatonin, would improve analgesia and sleep compared with the control group22. The intervention group consumed less morphine, had lower VAS pain scores on postoperative day 0, and objectively had improved sleep duration and quality. The length of hospital stay was unaffected. The results suggested that multimodal care with sleep hygiene interventions, zolpidem, and melatonin may benefit postoperative pain management and sleep. Pain Management In a double-blinded RCT of 99 patients undergoing arthroscopic rotator cuff repair, Alaia et al. compared the potential analgesic effects of buccally absorbed cannabidiol23. Three times a day for 14 days postoperatively, the experimental group received an oral, buccally absorbed tablet containing 25 mg of cannabidiol if the patient weight was 80 kg, and the placebo group received a placebo tablet. Opioid consumption, satisfaction with pain control, and VAS pain scores were recorded, as well as liver function tests to assess for safety. VAS pain and satisfaction were better in the intervention group, with the differences being significant in the first 1 to 2 days; otherwise, there was no significant difference in the outcome measures. The authors concluded that buccally absorbed cannabidiol showed promise in immediate pain reduction after rotator cuff repair and had an acceptable safety profile. Another double-blinded RCT evaluated the effect of single-dose, preoperative intravenous tranexamic acid on early postoperative pain scores after rotator cuff repair24. Tranexamic acid primarily functions as an antifibrinolytic agent to reduce bleeding and stabilize blood clots. Although its primary purpose is not pain management, some evidence has suggested that tranexamic acid may have a secondary analgesic effect in certain clinical scenarios. Mackenzie et al. randomized 89 patients to either 2 g of intravenous tranexamic acid or placebo at induction of anesthesia. Tranexamic acid did not improve postoperative pain scores, but patients in the intervention group had lower rates of adhesive capsulitis and demonstrated a greater range of motion at 6 months. In a single-center RCT of 67 patients undergoing total shoulder arthroplasty, Jolissaint et al. compared a completely opioid-free, multimodal pain plan with a traditional opioid-containing treatment25. Pain was measured postoperatively on a numerical rating scale at various time points up to 6 weeks. The opioid-free pain management pathway proved to be safe and effective in patients undergoing total shoulder arthroplasty, with superior pain relief through 2 weeks. 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