Purpose. Previous studies have demonstrated pronounced reduction of sleep quality following major surgery, which may affect postoperative pain and early recovery. This prospective, randomized, controlled trial was designed to evaluate the effect of zolpidem on sleep quality in fast-track total knee arthroplasty (TKA). Methods. 180 patients who underwent primary TKA were enrolled in this study and randomized 1:1 to receive either zolpidem (Group A) or placebo (Group B) for 6 days. VAS pain scores (rest, ambulation, flexion, and night), range of motion (ROM), opioid analgesics use, postoperative nausea and vomiting (PONV) and other complication, sleep efficacy and patients VAS satisfaction were recorded postoperatively and at 1, 3, 5 after surgery. Sleep quality was measured using the polysomnography (PSG) and Epworth Sleepiness Scale. Results. Sleep efficiency was decreased on all three postoperative nights but returned to pre-admission levels on the fifth postoperative night in Group A. Compared to Group B, Group A showed better sleep quality in early period. It was found that patients taking zolpidem showed greater improvement in quality of life, better patient VAS satisfaction, lower pain VAS score, and less opioid analgesics use. Conclusion. In conclusion, sleep quality is impaired after total knee arthroplasty and zolpidem could improve postoperative sleep or pain and be beneficial to patients' post-TKA early recovery

Purpose and Background. Back pain impinges upon all aspects of life, has a reported UK lifetime prevalence as high as 84% and considering approximately a third of our lives are spent asleep the paucity of research into the effect a mattress has on back pain and sleep is surprising. Mood changes, effecting an increase in pain perception, due to sleep loss may also lead to a downward spiral of increasing back pain and greater sleep loss. A controllable factor in this spiral, affecting both aspects, is the mattress but to the authors' knowledge none currently available on the market have any robust, published research to objectively support any claims made and at best being ‘endorsed’ by experts. This may lead to possible misinterpretation of efficacy and leave professionals at a loss with what to advise when questioned. Methods and Data collection. Method:. A three month, randomised, controlled, double blind crossover field study is proposed to take place in the participants own homes, ensuring the most natural sleep environment. Data collection:. Three 28 day phases. 1 - Baseline data, participants sleeping on their own mattress. 2 - Random allocation of mattresses, half allocated test and half control. 3 - Crossover of test and control mattress. Subjective measures of back pain and sleep quality will be collected utilising a daily sleep diary and visual analogue scales. Objective measures of sleep quality using activity monitors during sleep. Conclusion. Minimal evidence is available suggesting the optimal sleep surface for people with back pain. This research hopes to generate evidence to help this group with mattress selection. To confirm: this abstract has not previously been published in whole or part nor has it been presented previously at a national meeting. Conflicts of interest: All mattresses will be designed in conjunction with and provided by Innovative Health Organisation Caerphilly. Sources of funding: This work is part-funded by the European Social Fund (ESF) through the European Union's Convergence programme administered by the Welsh Government and is in conjunction with the Knowledge Economy Skills Scholarship (KESS) project

Aims. Patient-reported outcome measures have become an important part of routine care. The aim of this study was to determine if Patient-Reported Outcomes Measurement Information System (PROMIS) measures can be used to create patient subgroups for individuals seeking orthopaedic care. Methods. This was a cross-sectional study of patients from Duke University Department of Orthopaedic Surgery clinics (14 ambulatory and four hospital-based). There were two separate cohorts recruited by convenience sampling (i.e. patients were included in the analysis only if they completed PROMIS measures during a new patient visit). Cohort #1 (n = 12,141; December 2017 to December 2018,) included PROMIS short forms for eight domains (Physical Function, Pain Interference, Pain Intensity, Depression, Anxiety, Sleep Quality, Participation in Social Roles, and Fatigue) and Cohort #2 (n = 4,638; January 2019 to August 2019) included PROMIS Computer Adaptive Testing instruments for four domains (Physical Function, Pain Interference, Depression, and Sleep Quality). Cluster analysis (K-means method) empirically derived subgroups and subgroup differences in clinical and sociodemographic factors were identified with one-way analysis of variance. Results. Cluster analysis yielded four subgroups with similar clinical characteristics in Cohort #1 and #2. The subgroups were: 1) Normal Function: within normal limits in Physical Function, Pain Interference, Depression, and Sleep Quality; 2) Mild Impairment: mild deficits in Physical Function, Pain Interference, and Sleep Quality but with Depression within normal limits; 3) Impaired Function, Not Distressed: moderate deficits in Physical Function and Pain Interference, but within normal limits for Depression and Sleep Quality; and 4) Impaired Function, Distressed: moderate (Physical Function, Pain Interference, and Sleep Quality) and mild (Depression) deficits. Conclusion. These findings suggest orthopaedic patient subgroups differing in physical function, pain, and psychosocial distress can be created from as few as four different PROMIS measures. Longitudinal research is necessary to determine whether these subgroups have prognostic validity. Cite this article: Bone Jt Open 2021;2(7):493–502

Abstract. Introduction. There is a need to develop approaches to reduce chronic pain after total knee replacement. There is an established link between disturbed sleep and pain. We tested the feasibility of a trial evaluating the clinical and cost-effectiveness of a pre-operative sleep assessment and complex intervention package for improving long-term pain after TKR. Methodology. REST was a feasibility multi-centre randomised controlled trial with embedded qualitative study and health economics. Participants completed baseline measures and were randomised to usual care or the intervention, a tailored sleep assessment and behavioural intervention package delivered by an extended scope practitioner three months pre-operatively with a follow-up call up at four-weeks. Patient reported outcomes were assessed at baseline, one-week pre-surgery, and 3-months post-surgery. Results. 57 patients were randomised and 20 had surgery within the study timelines. All patients allocated the intervention attended an appointment and most engaged with treatment. The intervention group reported improvements in sleep (Sleep Conditions Indicator) and neuropathic pain (painDETECT) scores. Participants found the sleep treatments and study processes to be acceptable. The mean cost of the intervention was estimated at £134.45 per patient. Conclusion. The feasibility study has shown that patient recruitment is feasible, engagement with and adherence to the intervention is high, and the intervention is acceptable to patients and clinicians. Preliminary findings show that the intervention group had improved sleep quality and had reduced levels of pre-operative neuropathic pain. This study has demonstrated that a full RCT is feasible and identified areas for improvement to optimize the trial design

Background and purpose. Sleep disturbance is frequently reported by people with chronic low back pain (CLBP >12 weeks), but there is limited knowledge of their sleep quality compared to healthy people. While disturbed sleep influences patients' mood, quality of life and recovery, few studies have comprehensively investigated sleep in CLBP. This study investigated differences in sleep profiles of people with CLBP, compared to age- and gender matched controls over seven consecutive nights. Methods. Thirty-two consenting subjects (n=16 with CLBP, n=16 matched controls), aged 24-65 years (43.8% male) underwent an interview regarding sleep influencing variables (e.g. mattress firmness, caffeine consumption), completed the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Pittsburgh Sleep Diary, SF36-v2, Hospital Anxiety and Depression Scale, and CLBP measures (i.e. Oswestry Disability Index and Numerical Pain Scales), recorded seven consecutive nights of sleep in their home using actigraphy, and completed a Devices Utility Questionnaire. Results. Compared to controls, people with CLBP had significantly disturbed sleep on self-report measures (PSQI mean (SD) 10.9 (4.2); ISI mean 13.7 (7.6); Sleep Diary; p<0.001), but no significant differences on objective actigraphy (p>0.05). Actigraphy was found to be a user friendly sleep measure for use in the home environment (84.6%, n=11 CLBP; 73.3%, n=11 control). Conclusions. Self-rated sleep using a valid instrument should be routinely measured in LBP research and clinical practice. Further investigation of the relationship between patients' perception of their sleep quality and its objective measurement is warranted before actigraphy could be recommended as an objective outcome measure for the evaluation of sleep in this population

Background and purpose. Sleep disturbance is a prevalent symptom in people with chronic low back pain (CLBP >12 weeks), but there is currently no knowledge of the effectiveness of physiotherapy for this problem. This study evaluated the feasibility of a randomised controlled trial (RCT) exploring the effects of physiotherapy on sleep disturbance in CLBP [Current controlled trial ISRCTN 54009836]. Methods. A sample of 60 consenting patients with CLBP [23 M, 37 F; mean (SD) age = 44.93 (13.41) years] were recruited in Beaumont Hospital, Dublin and randomly allocated to one of three groups [supervised exercise class (SEC), walking programme (WP) and usual physiotherapy (UP)] in a concealed manner. The main outcomes were sleep quality, functional disability, pain, and quality of life at baseline, 3 and 6 months. Results. The majority of participants reported sleep disturbance (95%, n=57) and related it to their LBP (81%, n=46). At 3 months compared with the WP and SEC, participants in the UP group displayed greater reductions in average low back pain VAS (WP d=.97, SEC d=.86) and greater improvements in sleep disturbance (Pittsburgh Sleep Quality Index WP d=.59, SEC d=.29; Insomnia Severity Index WP d= .56, SEC d= .24). However, compared to UP there were greater improvements in functional disability (SF-36 PCS) in the WP (d= .32) and the SEC (d= .21). Conclusions. The results provide preliminary evidence of the effects of physiotherapy on sleep disturbance in CLBP, demonstrate the feasibility of undertaking a RCT in this field and inform refinement of the study protocol for a fully powered trial

Purpose: To measure quality and quantity of sleep in patients before and after hip arthroplasty. Methods: A prospective survey where 50 participants were sent a sleep diary, an acti-watch motion-logger, and a 32 item sleep questionnaire. These data were collected at least four weeks prior to and three months after surgery. Data analyses included descriptive statistics and within-subject pre and post surgery comparisons. For the subjective data, comparison was by the McNamar Test for the significance of changes. For the acti-graphy variables, comparison was by mixed model analysis of variance. Results: Preliminary results indicate that subjective measures of sleep quality improve significantly three months after hip arthroplasty, e.g. patients rated their sleep disturbance due to hip-pain on a scale from 1=never to 4=always. 75% of patients reported an improvement, and 25% reported no change in this variable, post surgery. Acti-graphy measures confirm the overall improvement in sleep quality (for sleep efficiency, (p(f)=0.05) and fragmentation index, (p(f)=0.05), and a reduction in mean activity during sleep (p(f)=0.04). Ongoing analyses are addressing the reliability of subjective measures compared to acti-graphy and why some patients show greater improvement in sleep than others, after hip arthroplasty. Conclusions: Findings suggest that sleep disturbance occurs as a result of painful osteoarthritis in the hip, and that this can be significantly ameliorated by hip arthroplasty surgery. The expected improvement in quality of life and level of day to day functioning that accompany improved sleep are perhaps an under-rated benefit of this procedure

Introduction:. Sleep disturbance is the one of major complaints associated with knee osteoarthritis, and sleep status is one factor that influences quality of life. The present study was designed to assess sleep status in patients undergoing total knee arthroplasty and to identify factors affecting sleep patterns. Methods:. We performed a prospective study of 112 patients undergoing total knee arthroplasty from June 2011 to February 2012. Data including demographic characteristics (age, gender, BMI, VAS pain scale score, SF 36, level of education, and psychologic comorbidities) and sleep profiles (Nottingham Health Profile – 0 to 100, with 0 indicating good sleep status; Sleep Satisfaction Scale – 0 to 10, with 10 indicating full satisfaction) was collected before and after (six days, two weeks, three months, and six months) total knee arthroplasty. Results:. There were 11 male and 101 female patients with an average age of 69.3 years (range: 49 to 85 years). The Nottingham Health Profile sleep scores were 30.3, 36.4, 21.0 and 16.7 before and two weeks, three months and six months after surgery, respectively. The corresponding sleep satisfaction scores were 6.6, 7.3, 7.3 and 7.7, respectively. A post-hoc analysis showed that the Nottingham Health Profile and sleep satisfaction scale scores had improved by three and six months after surgery, respectively. Patients with good sleep patterns six months after surgery did not differ from those with poor sleep patterns in terms of demographic characteristics, but a difference was detected in the preoperative sleep profiles between the two groups. Patients with good sleep patterns six months after surgery had better sleep profiles. Additionally, those undergoing unilateral TKA showed significantly better sleep patterns six months after surgery than those undergoing bilateral TKA. Conclusion:. These findings demonstrate that total knee arthroplasty improved sleep quality in patients with osteoarthritis. Sleep quality improvements were observed three months after surgery, and patients' sleep satisfaction increased six months after surgery. We also found that those with good sleep patterns preoperatively had better sleep patterns six months following surgery compared to those with poor preoperative sleep patterns. Patients undergoing unilateral TKA had a better sleep status than those undergoing bilateral TKA

Background. Opiate abuse is a rapidly growing epidemic in the US, and orthopaedic surgeons are among the highest prescribers. While surgeons have relied heavily on opiates after total hip replacement (THR), our goal was to determine whether a multimodal pain regimen could improve pain control and reduce or even obligate the need for opiates. Methods. In a cluster-randomised, crossover trial, we assigned 235 patients undergoing THR to receive either a multimodal pain regimen with a minimal opiate supply (Group A- 10 tablets only), a conventional multimodal regimen (Group B- 60 tablets), or a traditional opiate regimen without multimodal therapy (Group C- 60 tablets). Clusters were determined by surgeon, with each cluster alternating between regimens in 4-week intervals. The multimodal pain regimen comprised standing-dose acetaminophen, meloxicam, and gabapentin. Primary outcomes were VAS pain and daily opiate use for the first 30 days postoperatively. Secondary outcomes included daily assessments of satisfaction, sleep quality, and opiate-related symptoms, hip function at 1-month, and 90-day adverse events. Results. Daily pain was significantly lower in both multimodal groups, Group A (Coeff −0.81, p=0.003) and Group B (Coeff −0.61, p=0.021). While daily opiate utilization and duration of use was also lower for both Group A (Coeff −0.77, p=0.001) and Group B (Coeff −0.30, p=0.04) compared with Group C, Group A also had significantly lower daily opiate use than Group B (Coeff −0.46, p=0.002), and few prescription refills were required in any group. Opiate-related symptoms, in particular fatigue, were significantly lower in Group A compared to Group C (p=0.005), but Group B and C did not differ (p=0.13). Additionally, both multimodal regimens improved satisfaction and sleep, and there was no difference in hip function or adverse events. Conclusions. While a multimodal pain regimen after THR improved pain control and decreased opiate utilization, patients also receiving a minimal opiate supply had a much greater reduction in opiate use and, consequently, fewer opiate-related adverse effects. It's time to rethink traditional approaches to pain management after elective surgery

Background. Back pain has become a worldwide problem and excessive, repetitive rotation has been shown to cause tissue damage. A sleeping posture similar to that of the foetal position has been suggested to limit unnecessary rotation of the lumbar spine. The Rophi™ cushion, utilises this theory to provide spinal alignment and improved sleeping posture. This study aims to assess the subjective experience and biomechanical effects of the Rophi™ cushion in participants with simple mechanical lower back pain (LBP). Methods & Results. Fifteen participants (aged 44 ± 9.7 years) with simple mechanical LBP were recruited using the Red Flags screening form. The kinematics of the pelvis, lower limbs, lumbar and thoracic spine were analysed in six degrees of freedom whilst the participants lay in a semi-foetal position. Visual analogue scales were used to measure participant pain and discomfort levels during sleep pre and post a one week cushion intervention. Kinematic results show the main significant difference in joint angles occurred at the hip in all three planes, and between the lower lumbar region and the pelvis in the coronal plane. Subjective experience showed a reduction in the number of days with poor sleep quality and a significant reduction in frequency and intensity of lower back pain and stiffness when waking. Conclusions. Through repositioning of the hips and lower lumbar spine, overall it appears the individual is moved towards a more neutral position when using the Rophi™ cushion and a one week intervention shows a significant improvement in lower back pain on waking. Conflicts of Interest. None. Source of Funding. Funded by the NWDA Innovation voucher scheme. This abstract has not been previously published in whole or substantial part and has not been previously presented at a national meeting

Introduction. The Center for Medicare Services (CMS) recently proposed its phase 3 “Quality metrics” which include a section on patient engagement. CMS uses a fitness monitor as an example of an acceptable way for patients to contribute to the health record. Wearable technology allows measurement of activity, blood glucose, heart rate, sleep, and other health metrics, all of which can be useful in the management of patients in the orthopaedic practice. The purpose of this study is to thoroughly review existing fitness devices; and evaluate their potential uses in orthopaedic practice. Methods. Several fitness devices exist; we focused on the top 27 based on popularity mentioned in reputable tech review articles. Features of each device were reviewed including type, specifications, interfaces, measurable outcomes (HR, steps, distance, sleep, weight, calorie intake), cost to the patient, barriers to compliance and strengths. Ultimately all these factors were taken into consideration to look into potential uses for orthopaedic surgery. The orthopedic applications of these devices were reviewed. Nonsurgical management applications were: compliance with physiotherapy, distance walked and stairs completed, and compliance with activity restrictions. Preoperative optimization included detection of sleep apnea, blood glucose monitoring, preoperative weight, and preoperative activity level. Postoperative outcomes included postoperative activity level, stairs, and distance walked. Results. Twenty-seven devices were reviewed of which 26% were targeted for the beginner, 33% for runners and 41% were multipurpose fitness trackers. Most were designed as either a wrist band (26%) or watch (30%). Several used a smartphone as an interface (33%) while the majority (52%) synced automatically via Bluetooth to either the online, mobile device, smartphone or pc application. The majority (37%) had excellent battery life, over 7 days; all were either waterproof (26%) or water resistant (74%), and some (41%) had GPS tracking. A pedometer was included in 85% of devices, 63% monitored HR of which 26% required a separate chest strap or forearm strap, 7% measured respiratory rate and 7% devices measured temperature. Sleep was recorded in 63% of devices, mostly as length of sleep and quality of sleep based on wrist movement. One device was able to differentiate between sleep phases allowing the application of sleep apnea assessment for preoperative testing. Twenty devices monitored weight, twenty two monitored calorie intake, three could monitor glucose readings, seventeen measured distance walked, whereas five measured both stairs and distance walked. A few devices (15%) are already linked to electronic medical records (EMR), the majority allowed for sharing (67%) and 19% are linked to insurance companies which provide incentivized reimbursement rates. Conclusion. The fitness device technology has yet to be explored or implemented widely in orthopaedic surgery. We demonstrated how fitness devices can assist the orthopaedic surgeon in measurement of basic outcomes and can also assist with preoperative, perioperative and postoperative care. Further research is warranted as the use of these devices increases. Patient privacy issues may come into play as more practices employ these devices for their patients

The October 2014 Trauma Roundup³⁶⁰ looks at: proximal humeral fractures in children; quadrilateral surface plates in transverse acetabular fractures; sleep deprivation and poor outcomes in trauma; bipolar hemiarthroplasty; skeletal traction; forefoot fractures; telemedicine in trauma; ketamine infusion for orthopaedic injuries; and improved functional outcomes seen with trauma networks.

The April 2013 Shoulder & Elbow Roundup³⁶⁰ looks at: biceps, pressure and instability; chronic acromio-clavicular joint instability; depression and shoulder pain; shoulder replacement and transfusion; cuff integrity and function; iatropathic plexus injury; the accuracy of acromio-clavicular joint injection; and tennis as a risk factor for tennis elbow.