ArticlePDF Available

Use of a Non-Pharmacological Pain Relief Kit to Reduce Opioid Use Following Orthopedic Surgery: A Prospective Randomized Study

Authors:
  • Nicholas Institute of Sports Medicine and Athletic Trauma Lenox Hill Hospital
Article

Use of a Non-Pharmacological Pain Relief Kit to Reduce Opioid Use Following Orthopedic Surgery: A Prospective Randomized Study

Abstract and Figures

Introduction Opioid prescription to treat pain among orthopedic surgery patients remains common practice in the United States but overprescribing opioids can lead to abuse. The purpose of this study was to determine the effect of a multimodal non-pharmacological ‘pain relief kit’ on pain, function, and opioid consumption in individuals recovering from orthopedic surgery. Hypothesis Patients provided with the pain relief kit would consume less opioid medication, report lower pain levels, and have better functional outcome scores than the control group. Level of Evidence 2b Methods Fifty-three subjects (18 women, 35 men) having orthopedic surgery were randomly assigned to either receive the Pain Relief Kit (treatment) or control group. At the first postoperative physical therapy visit (within 1 week of surgery) the treatment group was provided elastic resistance bands, kinesiology tape, Biofreeze, and a hot/cold pack as part of the Pain Relief Kit. Patients completed the SF-36 and either the DASH or LEFS questionnaires consistent with their surgery at baseline and four weeks post-op. Both groups reported daily pain (Visual Analogue Scale), opioid use, and over the counter medication use. The treatment group also recorded daily kit modality use. Results There was no significant difference in total opioid use between the treatment (108±252 milligram morphine equivalents) and control groups (132±158 MME; p=0.696). Opioid use and pain declined from week one to four with no difference between groups (p<0.001). Outcome scores and SF-36 scores improved from week one to four with no difference between groups (p<0.001). Conclusion A non-pharmacological pain relief kit did not have an effect on opioid use in this patient population nor did it improve pain relief or function compared to controls.
Content may be subject to copyright.
(H?=?D7B+;I;7H9>
Use of a Non-Pharmacological Pain Relief Kit to Reduce Opioid Use
Following Orthopedic Surgery: A Prospective Randomized Study
Denis J O'Hara
1 a , Timothy F Tyler , Malachy P McHugh
1 , Susan Y Kwiecien
1 , Tyler Bergeron
1 NISMAT - Lenox Hill Hospital Northwell Health
Keywords: opioids, opioid abuse, orthopedic surgery, postoperative pain, pain managemen
https://doi.org/10.26603/001c.36625
"DJ;HD7J?ED7B#EKHD7BE<,FEHJI)>OI?97B->;H7FO
/EB"IIK;
Introduction
(F?E?:FH;I9H?FJ?EDJEJH;7JF7?D7CED=EHJ>EF;:?9IKH=;HOF7J?;DJIH;C7?DI9ECCED
FH79J?9;?DJ>;.D?J;:,J7J;I8KJEL;HFH;I9H?8?D=EF?E?:I97DB;7:JE78KI;->;FKHFEI;
E<J>?IIJK:OM7IJE:;J;HC?D;J>;;<<;9JE<7CKBJ?CE:7BDEDF>7HC79EBE=?97BUF7?DH;B?;<
A?JVEDF7?D<KD9J?ED7D:EF?E?:9EDIKCFJ?ED?D?D:?L?:K7BIH;9EL;H?D=<HECEHJ>EF;:?9
IKH=;HO
Hypothesis
)7J?;DJIFHEL?:;:M?J>J>;F7?DH;B?;<A?JMEKB:9EDIKC;B;IIEF?E?:C;:?97J?EDH;FEHJ
BEM;HF7?DB;L;BI7D:>7L;8;JJ;H<KD9J?ED7BEKJ9EC;I9EH;IJ>7DJ>;9EDJHEB=HEKF
Level of Evidence
8
Methods
?<JOJ>H;;IK8@;9JIMEC;DC;D>7L?D=EHJ>EF;:?9IKH=;HOM;H;H7D:ECBO
7II?=D;:JE;?J>;HH;9;?L;J>;)7?D+;B?;<$?JJH;7JC;DJEH9EDJHEB=HEKFJJ>;YHIJ
FEIJEF;H7J?L;F>OI?97BJ>;H7FOL?I?JM?J>?DM;;AE<IKH=;HOJ>;JH;7JC;DJ=HEKFM7I
FHEL?:;:;B7IJ?9H;I?IJ7D9;87D:IA?D;I?EBE=OJ7F;?E<H;;P;7D:7>EJ9EB:F79A7IF7HJ
E<J>;)7?D+;B?;<$?J)7J?;DJI9ECFB;J;:J>;,7D:;?J>;HJ>;,!EH%,
GK;IJ?EDD7?H;I9EDI?IJ;DJM?J>J>;?HIKH=;HO7J87I;B?D;7D:<EKHM;;AIFEIJEFEJ>
=HEKFIH;FEHJ;::7?BOF7?D/?IK7BD7BE=K;,97B;EF?E?:KI;7D:EL;HJ>;9EKDJ;H
C;:?97J?EDKI;->;JH;7JC;DJ=HEKF7BIEH;9EH:;::7?BOA?JCE:7B?JOKI;
Results
->;H;M7IDEI?=D?Y97DJ:?<<;H;D9;?DJEJ7BEF?E?:KI;8;JM;;DJ>;JH;7JC;DJR
C?BB?=H7CCEHF>?D;;GK?L7B;DJI7D:9EDJHEB=HEKFIR&&F(F?E?:KI;
7D:F7?D:;9B?D;:<HECM;;AED;JE<EKHM?J>DE:?<<;H;D9;8;JM;;D=HEKFIF
(KJ9EC;I9EH;I7D:,I9EH;I?CFHEL;:<HECM;;AED;JE<EKHM?J>DE:?<<;H;D9;
8;JM;;D=HEKFIF
Conclusion
DEDF>7HC79EBE=?97BF7?DH;B?;<A?J:?:DEJ>7L;7D;<<;9JEDEF?E?:KI;?DJ>?IF7J?;DJ
FEFKB7J?EDDEH:?:?J?CFHEL;F7?DH;B?;<EH<KD9J?ED9ECF7H;:JE9EDJHEBI
Corresponding author:
Denis O’Hara
Nicholas Institute of Sports Medicine and Athletic Trauma
Lenox Hill Hospital
210 East 64 Street
New York, New York 10065
dohara@nismat.org
a
O’Hara DJ, Tyler TF, McHugh MP, Kwiecien SY, Bergeron T. Use of a Non-
Pharmacological Pain Relief Kit to Reduce Opioid Use Following Orthopedic Surgery: A
Prospective Randomized Study. IJSPT. 2022;17(5):915-923.
"'-+(.-"('
(HJ>EF;:?9 IKH=;EDI 7H; J>; J>?H: >?=>;IJ EF?E?: FH;
I9H?8;HI7CED=7BBF>OI?9?7DI(F?E?:I7H;HEKJ?D;BOFH;
I9H?8;: <EH F7?D H;B?;< :KH?D= J>; FEIJEF;H7J?L; H;9EL;HO
FHE9;II7<J;HEHJ>EF;:?9IKH=;HO"DH;9;DJO;7HIH;=KB7JEHO
7=;D9?;I ?D9BK:?D= IJ7J; =EL;HDC;DJI >7L; ;D79J;: ?D?
J?7J?L;IJE :;9H;7I;J>;KI; E<EF?E?:I?D J>;F;H?EF;H7J?L;
I;JJ?D= ->;I; ?D9BK:; B;=?IB7J?L; H;<EHCI ?DIJ?JKJ?ED7B
H;<EHCI IK9> 7I ;:K97J?ED7B FHE=H7CI 7D: FH;I9H?8?D=
=K?:;B?D;I 7D: F>OI?9?7DB;: FH79J?9;87I;: H;<EHCI
+;9;DJ;L?:;D9; IK==;IJIJ>7JIJ7J;B;L;BB;=?IB7J?ED ?I ;<
<;9J?L;?D:;9H;7I?D=EF?E?:KI;?DJ>;FEIJEF;H7J?L;F;H?E:
<EH F7J?;DJI KD:;H=E?D= EHJ>EF;:?9 FHE9;:KH;IT (HJ>E
F;:?9F7J?;DJI JH7:?J?ED7BBO >7L;J>;CEIJ?DF;HIED U<79;
J?C;VM?J>J>;?H9B?D?9?7DI ->;H;<EH;EHJ>EF;:?9IKH=;EDI
97D>7L;7:?H;9JHEB;?DDEJEDBOF7J?;DJ;:K97J?ED8KJ7BIE
?D ?CFHEL?D= F7?D C7D7=;C;DJ IJH7J;=?;I 7D: :;9H;7I?D=
J>;EF?E?:8KH:;DEDIE9?;JO
->; KI; E< EF?E?:I <EH F7?D C7D7=;C;DJ 7<J;H C7@EH
IKH=;HO>7I8;;DB?DA;:JEIK8I;GK;DJFHEBED=;:EF?E?::;
F;D:;D9;I 7 H;IKBJJ>;=HEM?D= 9ED9;HD<EHEF?E?:
C?IKI;7D:78KI;>7I?D9H;7I;:?DJ>;=;D;H7BFK8B?9->KI
H;:K9?D=FEIJEF;H7J?L;F7?D8OEJ>;HC;7DI9EKB::;9H;7I;
EF?E:9EDIKCFJ?EDF7HJ<HEC9EKDI;BB?D=F7J?;DJI7D:
;IJ78B?I>?D= H;7IED78B; ;NF;9J7J?EDI <EH F7?D 9EDJHEB 7I
F7HJE<J>;JH;7JC;DJFB7DI;L;H7BDEDEF?E?:7BJ;HD7J?L;
IJH7J;=?;I;N?IJ<EHF7?DC7D7=;C;DJ)>OI?97BJ>;H7FOC7O
8;KI;:JE?D9H;7I;;NFEIKH;JEDEDF>7HC79EBE=?97BJH;7J
C;DJI<EHF;EFB;M?J>CKI9KBEIA;B;J7BF7?D9ED:?J?EDI"D
H;9;DJFH79J?9;=K?:;B?D;IDEDF>7HC79EBE=?97BJH;7JC;DJI
>7L;8;;D;CF>7I?P;:<EH?D?J?7BF7?DC7D7=;C;DJE<CKI
9KBEIA;B;J7BF7?D7D:F>OI?97BJ>;H7F?IJI7H;FHEL?:;HIM>E
HEKJ?D;BO :;B?L;H DEDF>7HC79EBE=?97B JH;7JC;DJI IK9> 7I
?9; >;7J J7F; 7D: J>;H7F;KJ?9 ;N;H9?I; ::?J?ED7BBO
I7C; :7O F>OI?97B J>;H7FO <EBBEM?D= EHJ>EF;:?9 IKH=;HO
B;7:IJE:;9H;7I;:?DF7J?;DJEF?E?:9EDIKCFJ?ED->;H;
<EH; ?J C7O 8; FEII?8B; J>7J ?< ?CFB;C;DJ;: ?D 7::?J?ED
JEH;=KB7HBOI9>;:KB;:F>OI?97BJ>;H7FOJ>;I;DEDF>7HC7
9EBE=?9 ?DJ;HL;DJ?EDI 97D FHEL?:; IK<Y9?;DJ FEIJEF;H7J?L;
F7?DH;B?;<JEH;:K9;EF?E?:KI;
HOEJ>;H7FO79ECCEDH;9EL;HOCE:7B?JO;7I?BOKI;:7J
>EC;>7I9EDI?IJ;DJBO8;;D I>EMDJE7BB;L?7J;F7?DT
HOEJ>;H7FOMEHAIJEH;:K9;F7?D8OH;:K9?D=IA?DIKH<79;
J;CF;H7JKH;M>?9>97DFHECEJ;7H;:K9J?ED?DD;HL;9ED
:K9J?ED L;BE9?JO  FEFKB7H 7D: IEC;J?C;I CEH; KI;H
<H?;D:BOIK8IJ?JKJ;JE9HOEJ>;H7FO?I?E<H;;P;?E<H;;P;
?I 7 C;DJ>EB87I;: IKF;HY9?7B 9EEB?D= FHE:K9J M>?9> >7I
FH;L?EKIBO8;;DI>EMDJE;<<;9J?L;BOH;:K9;F7?D?D7L7H?;JO
E<CKI9KBEIA;B;J7B9ED:?J?EDIBJ>EK=>J>;79J?L;?D
=H;:?;DJ?D ?E<H;;P;C;DJ>EB:E;IDEJBEM;HJ?IIK;J;C
F;H7JKH;?JIJ?CKB7J;I9EB:J>;HCEH;9;FJEHITJ>HEK=>7
9>;C?97BH;79J?EDH;IKBJ?D=?DF7?DH;B?;<
J>HEK=>79EKD
J;H?HH?J7DJ;<<;9J!;7J F79AI 7H;7BIE9ECCEDBOKJ?B?P;:
7J>EC;M>;D?D:?L?:K7BII;;A9EC<EHJ7D:F7?DH;B?;<T
.BJ?C7J;BO 8EJ> 9EB: 7D: >EJ CE:7B?J?;I FHEL?:; 7D 7D7B
=;I?9 ;<<;9JI 7D: IK99;II<KBBO 7B8;?J J;CFEH7H?BO H;:K9;
F7?D
(J>;H 7BJ;HD7J?L; H;9EL;HO CE:7B?J?;I 97F78B; E< ?D:?
H;9JBOH;:K9?D=F7?D?D9BK:;;B7IJ?97:>;I?L;J7F;7D:;B7I
J?9 H;I?IJ7D9; ;N;H9?I;I B7IJ?9 7:>;I?L; J7F; 9ECCEDBO
ADEMD 7I A?D;I?EBE=O J7F; ?I IKF;H?EH JE C?D?C7B ?DJ;H
L;DJ?ED <EH F7?D H;B?;< 8KJ J>?I ;<<;9J :E;I DEJ >EB: JHK;
M>;D9ECF7H;:JEEJ>;HJH;7JC;DJ7FFHE79>;I?D?D:?L?:K
7BIM?J>9>HED?9CKI9KBEIA;B;J7BF7?DEDL;HI;BO;B7IJ?9
H;I?IJ7D9;;N;H9?I;I?DLEBL;J>;F7HJ?9?F7J?EDE<J>;F7J?;DJ
7D: 7H; 9ECCEDBO KI;: JE 8K?B: IJH;D=J> ?D9H;7I; H7D=;
E<CEJ?ED7D:H;:K9;F7?D?DJ>;F>OI?97BJ>;H7FOI;JJ?D=
BJ>EK=>FEJ;DJ?7BBO9EKDJ;H?DJK?J?L;JE?D:?L?:K7BI;NF;H?
;D9?D=IOCFJECIE<F7?D;B7IJ?987D:;N;H9?I;I97D8;BEM
?CF79J 7D: M>;D :EI;: 7FFHEFH?7J;BO M?BB DEJ ;N79;H87J;
F7?DB7IJ?9H;I?IJ7D9;;N;H9?I;I>7L;8;;DI>EMDJEH;:K9;
F7?D7D:?CFHEL;H7D=;E<CEJ?ED?DAD;;7HJ>HEFB7IJOF7
J?;DJI"D=;D;H7B;N;H9?I;FHE=H7CI J>7J ?CFHEL; ED;VI
IJH;D=J>DEJEDBOB;II;DF7?D8KJ7BIE?CFHEL; <KD9J?ED7B
78?B?JO
'EDF>7HC79EBE=?9J>;H7F?;IC?=>J8;E<=H;7J;H?DJ;H;IJ
JEJ>;F7J?;DJ9ED9;HD;:M?J> EHEFFEI;:JEJ7A?D=EF?E?:
C;:?97J?ED 7D: 9EKB: FEJ;DJ?7BBO FHEL?:; 7 9ECF7H78B;
7D7B=;I?9 ;<<;9J F7HJ?9KB7HBO ?< KI;: ?D 7 CKBJ?CE:7B F7?D
C7D7=;C;DJIJH7J;=O->;H;<EH;J>;FKHFEI;E<J>?IIJK:O
M7IJE:;J;HC?D; J>;;<<;9JE< 7CKBJ?CE:7BDEDF>7HC7
9EBE=?97BUF7?DH;B?;<A?JVEDF7?D<KD9J?ED7D:EF?E?:C;:
?97J?ED9EDIKCFJ?ED?D?D:?L?:K7BIH;9EL;H?D=<HECEHJ>E
F;:?9IKH=;HO"JM7I>OFEJ>;I?P;:J>7JF7J?;DJIM>EM;H;
FHEL?:;:M?J>J>;F7?DH;B?;<A?JMEKB:9EDIKC;B;IIEF?E?:
C;:?97J?EDH;FEHJBEM;HF7?DB;L;BI7D:>7L;8;JJ;H<KD9
J?ED7BEKJ9EC;I9EH;IJ>7DJ>;9EDJHEB=HEKF
&-!(,
)7J?;DJIM;H;?D9BK:;:?DJ>;IJK:O?<J>;OKD:;HM;DJ7DEH
J>EF;:?9IKH=;HOJ>7J ?D9BK:;:8ED;:H?BB?D=7IF7HJ E<J>;
FHE9;:KH;N9BKI?ED9H?J;H?7<EHJ>?IIJK:O?D9BK:;:7DOF7
J?;DJM>EM7I9KHH;DJBO7BH;7:OJ7A?D=EF?E?:IEH>7:7>?I
JEHOE<7B9E>EBEHIK8IJ7D9;78KI;7I;:EDJ>;L7H?78?B?JO
8;JM;;D F7J?;DJI ?D EF?E?: KI; 7<J;H JEJ7B AD;; 7HJ>HE
FB7IJO 7D: % H;9EDIJHK9J?ED ?J M7I ;IJ?C7J;: J>7J
M?J>F7J?;DJIF;H=HEKFJ>;H;MEKB:8;FEM;HJE:;
J;9J7BEM;HKI;E<EF?E?:I?DJ>;F7?DH;B?;<A?J=HEKF7J
F
)7J?;DJIM;H;H7D:EC?P;:JEH;9;?L;;?J>;HIJ7D:7H:97H;
M?J>EKJ9EDJHEBEH M?J>J>;7::?J?EDE<J>;F7?DH;B?;<A?J
JH;7JC;DJ->;JH;7JC;DJ:KH7J?EDM7I<EKHM;;AI8;=?D
D?D=EDJ>;YHIJFEIJEF;H7J?L;F>OI?97BJ>;H7FOL?I?JM>?9>
JEEAFB79;M?J>?DED;M;;AFEIJEF)7J?;DJI?DJ>;9EDJHEB
=HEKFH;9;?L;:KIK7B 97H; ?D J>;9B?D?98KJ:?:DEJ H;9;?L;
7DO9ECFED;DJIE<J>;F7?DH;B?;<A?J7IF7HJE<J>;?H>EC;
FHE=H7C->;JH;7JC;DJ=HEKFH;9;?L;:IJ7D:7H:97H;?D7:
:?J?EDJEJ>;F7?DH;B?;<A?J-H;7JC;DJ=HEKFF7J?;DJIM;H;
I>EMD>EMJEFHEF;HBOKI;;79>?J;C?DJ>;A?J7JJ>;YHIJ
F>OI?97BJ>;H7FOL?I?JBBF7J?;DJIM;H;FH;I9H?8;:F>OI?97B
J>;H7FOJMEJEJ>H;;:7OIF;HM;;A)7J?;DJIA;FJ7:7?BOBE=
E<J>;LEBKC;7D:H7J;E<EF?E?:7D:DEDEF?E?:F7?DC;:
?97J?ED9EDIKCFJ?ED /,F7?DI9EH;7D:7 BE=E<9ECFB?
7D9;M?J> ;79>E<J>; ?J;CI?DJ>;F7?D H;B?;<A?J?< ?DJ>;
JH;7JC;DJ=HEKFBBF7J?;DJI9ECFB;J;:J>;,>EHJEHC
!;7BJ>,KHL;O*K;IJ?EDD7?H;,GK;IJ?EDD7?H;?D7::?
J?EDJE,!?I78?B?J?;IE< J>; HC,>EKB:;H7D:!7D:
I9EH;I<EH KFF;H;NJH;C?JOFHE9;:KH;IEHJ>;%, %EM;H
NJH;C?JOKD9J?ED7B,97B;I9EH;I<EHBEM;H;NJH;C?JOFHE
.I;E<7'ED)>7HC79EBE=?97B)7?D+;B?;<$?JJE+;:K9;(F?E?:.I;EBBEM?D=(HJ>EF;:?9,KH=;HO)HEIF;9J?L;+7D:EC?P;:
International Journal of Sports Physical Therapy
9;:KH;I7J87I;B?D;EHJ>;YHIJFEIJEFF>OI?97BJ>;H7FOL?I?J
7D:7J<EKHM;;AIFEIJEF
'('()"(""'-+/'-"(')"'+%"$"-
79>?J;C?DJ>;F7?DH;B?;<A?JM7IH;9ECC;D:;:JE8;KJ?
B?P;:KF JEJ>H;;J?C;I:7?BOEH ;L;HO >EKHI#E?DJIF;
9?Y9;N;H9?I;IM;H;?D?J?7BBOF;H<EHC;: 7=7?DIJ=H7L?JO7D:
FHE=H;II;:JE;B7IJ?9H;I?IJ7D9;KI?D= O;BBEM7D:J>;DH;:
->;H77D:I->;H787D:AHED(!.,
?EH;;P; +EBB(D  C;DJ>EB ?EH;;P; 07HH;DL?BB;
"%.,M7IH;9ECC;D:;:JE8;7FFB?;::KH?D=J>;CEHD
?D=>O=?;D;HEKJ?D;EHKFJEJ?C;IJ>HEK=>EKJJ>;:7O?D
H;IFEDI;JEF7?D::?J?ED7BBO?J M7I H;9ECC;D:;:JE8;
7FFB?;:YL;C?DKJ;IFH?EH JE7D: <EBBEM?D=;N;H9?I;EH7DO
EJ>;HCE:;H7J;?DJ;DI?JO79J?L?JO$?D;I?EBE=OJ7F;M7IH;9
ECC;D:;:JE8;7FFB?;:JEJ>;7<<;9J;:7H;77J;BED=7
J?ED7D:H;7FFB?;:;L;HOJ>H;;:7OIEH7ID;;:;:M>;DJ7F;
<7?B;:JE7:>;H; .FF;H;NJH;C?JOF7J?;DJI M;H;?DIJHK9J;:
JE 7FFBO J>; J7F; 79HEII J>; JH7F;P?KI ?D 799EH:7D9;M?J>
J?=>JD;II EH F7?D 7D: BEM;H ;NJH;C?JO F7J?;DJI ?DIJHK9J;:
JE 7FFBO J>; J7F; 7BED= J>; GK7:H?9;FI ->;HC7B ->;H7FO
4M7HCEH9EEBM7I :;B?L;H;:KI?D=J>;->;H7);7HB 7KI9>
%EC8"D9';M2EHA.,5M7IH;9ECC;D:;:JE8;7F
FB?;: :KH?D= J>; CEHD?D= >O=?;D; HEKJ?D; 7D: 7I D;;:;:
J>HEK=>EKJJ>;:7O?DH;IFEDI;JEF7?DFFB?97J?EDE<>;7J
M7IH;9ECC;D:;:<EHC?DKJ;IFH?EHJE;D=7=?D=?D;N;H
9?I;7D:7FFB?97J?EDE<9EB:M7IH;9ECC;D:;:<EH C?D
KJ;I<EBBEM?D=;N;H9?I;
"%2&"-"('%(
&EIJ F7J?;DJI M;H; FH;I9H?8;: ENO9E:ED;79;J7C?DEF>;D
C=C=JE8;J7A;D;L;HOI?N>EKHI7ID;;:;:,?N
F7J?;DJIM;H; DEJFH;I9H?8;:ENO9E:ED;?DIJ;7: <EKHM;H;
FH;I9H?8;: >O:HE9E:ED;79;J7C?DEF>;D 7D: JME -H7
C7:EB)7J?;DJI M;H;7IA;:JEA;;F7:7?BOBE=E<FH;I9H?F
J?ED 7D: DEDFH;I9H?FJ?ED 7D7B=;I?9I J7A;D (F?E?: KI; ?I
H;FEHJ;:?DJ>?IH;I;7H9>7I&?BB?=H7C&EHF>?D;GK?L7B;DJ
&&EHJ>;7CEKDJE<CEHF>?D;?DC?BB?=H7CI;GK?L7B;DJ
JEJ>;IJH;D=J>E<J>;EF?E?::EI;FH;I9H?8;:
"%2)"'%( /",.%'%( ,%/,
);H9;?L;:F7?DM7IH;9EH:;::7?BOKI?D=7 9C/,M?J>
7D9>EHIJ7J;C;DJIEDJ>;B;<JDEF7?D7D:EDJ>;H?=>J;N
JH;C;F7?D->;/,?IM?:;BO799;FJ;:7I7H;B?78B;IJ7D
:7H: <EH I;B<H;FEHJ?D=E< F7?D FEIJ EF;H7J?L;BO <EH 7 M?:;
H7D=; E< IKH=?97B 7D: EHJ>EF;:?9 FHE9;:KH;I ?D 7 9B?D?97B
I;JJ?D=T->;F7J?;DJM7I7IA;:JE C7HA J>;?H 7L;H7=;
F7?DEL;HJ>;FH;L?EKI>EKHIEDJ>;B?D;7JJ>;I7C;J?C;
;79>:7O
(.-(&,(+,
%(0+1-+&"-2.'-"('%,%%,
%EM;H;NJH;C?JO EKJ9EC;IM;H; ;L7BK7J;:KI?D=J>; %,
->;%,?I7I;B<H;FEHJGK;IJ?EDD7?H;J>7J7IAIF7J?;DJIJE
7DIM;HJ>;GK;IJ?EDW-E:7O:EOEKEHMEKB:OEK>7L;7DO
:?<Y9KBJO7J7BBM?J>X?DH;=7H:JEJM;DJO:?<<;H;DJ;L;HO:7O
79J?L?J?;I->;%,>7I I>EMD IK<Y9?;DJ H;B?78?B?JOJE7:
C?D?IJ;H7D:?I7FFB?978B;<EHH;I;7H9>FKHFEI;I7D:9B?D?97B
:;9?I?EDC7A?D=<EH?D:?L?:K7BF7J?;DJI
","%"-",(-!+&,!(.%+'!'
,!
.FF;H;NJH;C?JOEKJ9EC;IM;H;;L7BK7J;:KI?D=J>;,!
->;,!EKJ9EC;C;7IKH;?I7?J;CI;B<H;FEHJGK;I
J?EDD7?H;:;I?=D;:JE7II;IIJ>;F7J?;DJVI>;7BJ>IJ7JKI->;
,!GK;IJ?EDD7?H;?IKI;:7I7D?D:?97JEHE<J>;?CF79JE<
7D?CF7?HC;DJEDJ>;B;L;B7D:JOF;E<:?I78?B?JO"J7II;II;I
J>; M>EB; F;HIEDVI 78?B?JO JE <KD9J?ED ;L;D?< J>; F;HIED
?I 9ECF;DI7J?D= M?J> J>; EJ>;H B?C8 ;7JED ;J 7B >7I
I>EMD IJHED= L7B?:?JO J;IJH;J;IJ H;B?78?B?JO 7D: H;IFED
I?L;D;II E< J>; ,!GK;IJ?EDD7?H; ?D 8EJ> FHEN?C7B 7D:
:?IJ7B:?IEH:;HIE<J>;KFF;H;NJH;C?JO9EDYHC?D=?JIKI;
<KBD;II<EH7II;II?D=:?I78?B?JO?DJ>;KFF;H;NJH;C?JO
,!(+-(+&!%-!,.+/2*.,-"(''"+
,
)7J?;DJIV =BE87B H7J?D= E< >;7BJ> IJ7JKI 7D: GK7B?JO E< B?<;
M7I7II;II;: KI?D=J>;, ->;,?I7I;B<H;FEHJ;:
GK;IJ?EDD7?H;;L7BK7J?D=;?=>J7IF;9JIE<J>;F7J?;DJVIF;H
9;FJ?ED E< >;7BJ> F>OI?97B <KD9J?ED?D= 8E:?BO F7?D HEB;
B?C?J7J?EDI :K; JE F>OI?97B >;7BJ> FHE8B;CI HEB; B?C?J7
J?EDI :K; JE F;HIED7B EH ;CEJ?ED7B FHE8B;CI ;CEJ?ED7B
M;BB8;?D=IE9?7B <KD9J?ED?D=;D;H=O<7J?=K;7D: =;D;H7B
>;7BJ> F;H9;FJ?EDI ->; , >7I 8;;D M?:;BO L7B?:7J;:
7D:>7I 8;;DI>EMDJE >7L;>?=> H;B?78?B?JO<EHC;7IKH?D=
>;7BJ>F;H9;FJ?ED?D7=;D;H7BFEFKB7J?ED
,--",-"%'%2,",
->; ;<<;9JI E< J>; F7?D H;B?;< A?J ED EF?E?: KI; EL;H J>;
9EKDJ;HF7?D C;:?97J?ED /,F7?DI9EH;I<KD9J?ED7B EKJ
9EC;I9EH;I7D:,I9EH;IM;H; 7II;II;: KI?D= C?N;:
CE:;B7D7BOI?IE<L7H?7D9;M?J>H;F;7J;:C;7IKH;I<EHJ?C;
M;;AI  7D: JH;7JC;DJ 7I 7 8;JM;;DIK8@;9JI <79JEH
F7?DH;B?;<A?JL;HIKI9EDJHEB0?J>?DJ>;JH;7JC;DJ=HEKF
J>;H;B7J?EDI>?F8;JM;;DKI;E<J>;F7?DH;B?;<A?J7D: EF?
E?:7D: DEDEF?E?:C;:?97J?ED KI;M7I 7II;II;:KI?D= J>;
);7HIED9EHH;B7J?ED9E;<Y9?;DJ?<<;H;D9;?DEF?E?:KI;8;
JM;;DF7J?;DJI>7L?D=7HJ>HEFB7IJOL;HIKIEJ>;HFHE9;:KH;I
M7IJ;IJ;:KI?D=7D?D:;F;D:;DJJJ;IJ
+,.%-,
->;H; M;H;  F7J?;DJI ?D J>; F7?DH;B?;< A?J =HEKF 
MEC;D  C;D 7D:  ?D J>; 9EDJHEB =HEKF  MEC;D
 C;D -M;BL; F7J?;DJI >7: JEJ7B @E?DJ 7HJ>HEFB7IJO 
F7?DH;B?;< A?J  9EDJHEB 7D: J>; H;C7?D?D=  F7J?;DJI
 F7?DH;B?;< A?J  9EDJHEB >7: L7H?EKI FHE9;:KH;I H;
GK?H?D=8ED;:H?BB?D=%H;9EDIJHK9J?EDI I>EKB:;H
7HJ>HEI9EF?;IJMEEJ>;HAD;;FHE9;:KH;IJ>H;;;B8EMFHE
9;:KH;I7D:ED;7DAB;FHE9;:KH;)HE9;:KH;IF;H<EHC;:ED
J>; F7J?;DJI ?D J>; F7?D H;B?;< A?J =HEKF ?D9BK:;:  %
H;9EDIJHK9J?EDI<EKH7HJ>HEFB7IJ?;II;L;DI>EKB:;H7HJ>HE
.I;E<7'ED)>7HC79EBE=?97B)7?D+;B?;<$?JJE+;:K9;(F?E?:.I;EBBEM?D=(HJ>EF;:?9,KH=;HO)HEIF;9J?L;+7D:EC?P;:
International Journal of Sports Physical Therapy
I9EF?;I7D:JMEEJ>;H FHE9;:KH;I D ->; F7J?;DJI?D
J>;9EDJHEB=HEKF?D9BK:;:;?=>J%H;9EDIJHK9J?EDI;?=>J
7HJ>HEFB7IJ?;I YL; I>EKB:;H 7HJ>HEI9EF?;I 7D: <EKHEJ>;H
FHE9;:KH;ID->;H;M;H;J>H;;:HEFEKJI?DJ>;9EDJHEB
=HEKF 7D: DED; ?D J>; F7?D H;B?;< A?J =HEKF 7J7 7H; H;
FEHJ;:<EHJ>;H;C7?D?D=F7J?;DJIJH;7JC;DJ9ED
JHEB ->; JH;7JC;DJ =HEKF M7I OEKD=;H J>7D J>; 9EDJHEB
=HEKFROHI LIROHIF HEKFIM;H;DEJ
I?=D?Y97DJBO :?<<;H;DJ ?D 8E:O C7II R A= LI
RA=FEH>;?=>JRCLIR
CF
ECFB?7D9;M?J>J>;F7?DH;B?;<A?JL7H?;:8;JM;;DJ>;
:?<<;H;DJ9ECFED;DJIM?J>J>; ;B7IJ?9H;I?IJ7D9;;N;H9?I;I
>7L?D=>?=>;IJ9ECFB?7D9;R:7OIF;HM;;A<EBBEM;:8O
J>;JEF?97B>;7JJH;7JC;DJ R :7OI F;H M;;A?EH;;P;
R:7OI F;H M;;A 7D: J>; ;B7IJ?9 J7F; JH;7JC;DJ R
:7OI F;H M;;A .I; E< F7?DH;B?;< A?J M7I DEJ 9EHH;B7J;:
M?J> EF?E?: H F EH DEDFH;I9H?FJ?ED F7?D
C;:?97J?ED KI; H F EH J>; 9EC8?D7J?ED E<
EF?E?:7D: DEDFH;I9H?FJ?EDF7?DC;:?97J?EDKI;H
F
->;H;M7IDEIJ7J?IJ?97BBO I?=D?Y97DJ :?<<;H;D9;?DJEJ7B
EF?E?: KI; 8;JM;;D J>; JH;7JC;DJ =HEKF R &&
7D: 9EDJHEB =HEKF R && F EL;H J>; <EKH
M;;AIE<J>; IJK:O(F?E?:KI; :;9B?D;: <HECM;;AED;JE
M;;A<EKH-?C;;<<;9JFM?J>DE:?<<;H;D9;8;JM;;D
=HEKFI-H;7JC;DJ8O-?C;F'EDEF?E?:F7?DC;:
?97J?EDF7D:JEJ7BC;:?97J?EDFM;H;DEJIJ7
J?IJ?97BBOI?=D?Y97DJBO:?<<;H;DJ8;JM;;D=HEKFI->?HJ;;DE<
F7J?;DJI?DJ>;F7?DH;B?;<A?J=HEKF7D:D?D;E<
F7J?;DJI?D J>;9EDJHEB=HEKF:?:DEJKI; 7DOEF?E?:
C;:?97J?ED
(F?E?:KI;M7ICK9>>?=>;H?DJ>;F7J?;DJI M>E>7:
JEJ7B @E?DJ 7HJ>HEFB7IJO R && L;HIKI J>EI; M?J>
EJ>;HFHE9;:KH;IR&&F->; I7CFB;I?P;
M7IJEE IC7BBJEIJ7J?IJ?97BBO 7D7BOP;J>;;<<;9JE<J>;
F7?DH;B?;<A?JJH;7JC;DJ?DJ>;F7J?;DJIM>E>7:JEJ7B@E?DJ
7HJ>HEFB7IJO(F?E?:KI;<EHJ>;H;C7?D?D=F7J?;DJIM7I
7D7BOP;:I;F7H7J;BO?=KH;EHJ>;I;F7J?;DJIEF?E?:
KI; :;9B?D;: EL;H J>; <EKH M;;AI E< J>; ?DJ;HL;DJ?ED
F M?J> DE IJ7J?IJ?97BBO I?=D?Y97DJ :?<<;H;D9; 8;
JM;;D J>; F7?D H;B?;< A?J =HEKF 7D: 9EDJHEB =HEKF -H;7J
C;DJ;<<;9JF-H;7JC;DJ8O-?C;F
)7?D :;9B?D;: IJ;7:?BO <HEC M;;A ED; JE M;;A <EKH
F?=KH;M?J>DE I?=D?Y97DJ :?<<;H;D9;8;JM;;D
J>; F7?DH;B?;< A?J =HEKF 7D: 9EDJHEBI -H;7JC;DJ ;<<;9J
F-H;7JC;DJ8O-?C;F
(KJ9EC; I9EH;I 7BIE ?CFHEL;:<HEC M;;A ED; JE M;;A
<EKH F M?J> DE :?<<;H;D9; 8;JM;;D J>; F7?DH;B?;<
A?J =HEKF 7D: 9EDJHEBI -H;7JC;DJ ;<<;9J F -H;7J
C;DJ8O-?C; F,I9EH;I?CFHEL;:<HECM;;A
ED;JEM;;A<EKHFM?J>DE:?<<;H;D9;8;JM;;DJ>;
F7?DH;B?;<A?J=HEKF 7D:J>;9EDJHEB =HEKF-H;7JC;DJ;<
<;9JF-H;7JC;DJ8O-?C;F
",.,,"('
->?IIJK:O?DL;IJ?=7J;:J>;;<<;9JE<7 CKBJ?CE:7BF7?D H;
B?;<A?JEDF7?DF7J?;DJH;FEHJ;:EKJ9EC;I7D:EF?E?:9ED
IKCFJ?ED?D J>;<EKHM;;AF;H?E:<EBBEM?D=L7H?EKIEHJ>E
F;:?9 IKH=?97B FHE9;:KH;I EDJH7HO JE J>; >OFEJ>;I?I
EF?E?: KI; M7I DEJ :?<<;H;DJ 8;JM;;D J>; F7?D H;B?;< A?J
=HEKF7D:J>;9EDJHEBF7J?;DJIKHJ>;HCEH;J>;H;M7IDE
:?<<;H;D9; ?D J>; /, F7?D I9EH;I , 7D: EKJ9EC;
I9EH;I8;JM;;DJ>; F7?DH;B?;<A?J7D:9EDJHEB=HEKFIEJ>
=HEKFI>7:I?C?B7H:;9B?D;I?DF7?D7D:?CFHEL;:EKJ9EC;I
EL;HJ>;<EKHM;;AI7<J;HIKH=;HO
->;78?B?JOJE :;J;9J 7H;:K9J?ED?DEF?E?: KI; M?J>J>;
F7?D H;B?;< A?J C7O >7L; 8;;D 7<<;9J;: 8O BEM;H J>7D ;N
F;9J;:EF?E?:KI;?DJ>;I;IK8@;9JIMO;H;J7BH;FEHJ;:
EF?E?:KI;E<R&&EL;HJMEM;;AI7<J;HJEJ7BAD;;
7HJ>HEFB7IJO-EJ7BEF?E?:KI;?DJ>; FH;I;DJ IJK:O <EH J>;
F7J?;DJIM>E>7:@E?DJ 7HJ>HEFB7IJOM7IR &&
,?C?B7HBOEHB;DP7 ;J7BH;FEHJ;: EF?E?:KI;E< R
&&EL;H:7OI7<J;H%H;9EDIJHK9J?ED"DJ>;FH;I;DJ
IJK:OEF?E?:KI;<EHF7J?;DJIJ>7J>7:FHE9;:KH;IEJ>;HJ>7D
7HJ>HEFB7IJOM7IR&&->;9EC8?D7J?EDE<7BEM;H
J>7D;NF;9J;:EF?E?:KI; 7D: 7>?=>;HJ>7D;IJ?C7J;:?D
J;HIK8@;9J L7H?78?B?JO ?D EF?E?: KI; B?A;BO ?D:?97J;I J>7J
J>;H;M7I?DIK<Y9?;DJFEM;HJE:;J;9J7D;<<;9JE<J>;?DJ;H
L;DJ?ED->;>?=>L7H?78?B?JO?DEF?E?:KI;M7I:K;JE7IK8
IJ7DJ?7BFHEFEHJ?EDE<F7J?;DJIDEJJ7A?D=7DOEF?E?:I
:KH?D=J>;<EKHM;;AIE<J>?IIJK:O,?D9;J>?IM7I7F>OI?
97BJ>;H7FO:H?L;D?DJ;HL;DJ?EDJ>;F7?DH;B?;<A?JM7I?DJHE
:K9;:ED J>; F7J?;DJVIYHIJ L?I?J <EHF>OI?97BJ>;H7FO->?I
E99KHH;: ED 7L;H7=; R :7OI 7<J;H IKH=;HO:KH?D= M>?9>
J?C; EF?E?: KI; MEKB: >7L; 8;;D >?=>;IJ !EM;L;H J?C;
<HEC IKH=;HO JE ;DHEBBC;DJ ?D J>; IJK:O 7J YHIJ F>OI?97B
J>;H7FOL?I?J M7I DEJ9EHH;B7J;:M?J> EF?E?:KI;H
F->?I?D:?97J;I J>7J F7J?;DJH;B7J;:<79JEHI:HEL;
EF?E?: KI; ?D J>?I IJK:O H7J>;H J>7D J>; :;B7O 8;JM;;D
IKH=;HO 7D: IJK:O ;DHEBBC;DJ ->; <79J J>7J IE C7DO F7
J?;DJI:?:DEJJ7A;EF?E?:I?D:?97J;IJ>7JJ>;FK8B?97M7H;
D;IIE<J>;H?IAI7IIE9?7J;:M?J>EF?E?:KI;C7O>7L;8;;D
7<79JEH
 I;9ED: ?IIK; JE 9EDI?:;H ?D 7II;II?D= J>; B79A E< ;<
<;9J?L;D;IIE<J>;F7?DH;B?;<A?J?IJ>;9ECFB?7D9;M?J>J>;
CKBJ?CE:7B 7FFHE79> ->; <EKHFHED=;: ?DJ;HL;DJ?ED M7I
?D7::?J?EDJE7BBJ>7JM7I;NF;9J;:?DF>OI?97BJ>;H7FO->;
?DF;HIEDF>OI?97BJ>;H7FOL?I?JI7BED;JMEJEJ>H;;J?C;I
F;HM;;AC7O>7L;H;:K9;:F7?DJE7D;NJ;DJJ>7JJ>;7::?
J?EDE<<EKHF7?DH;B?;<IJH7J;=?;IKI;:ED7L;H7=;EDJMEJE
<EKH:7OI?DJ>;M;;A:?:DEJFHEL?:;<KHJ>;HF7?DH;B?;<I
MEKB:8;;NF;9J;:J>;H;M7I7H;:K9J?ED?DF7?D<HEC
M;;AED;JEM;;A<EKH<EH8EJ>=HEKFI
)EIJEF;H7J?L;F7?D 9EDJHEB M?J> 7 DEDEF?E?: F7?D H;=
?C;D 9EDI?IJ?D= E< ?8KFHE<;D 79;J7C?DEF>;D 7D: EJ>;H
9ECCED 7DJ??DZ7CC7JEHO 7=;DJI >7I 8;;D IK99;II<KBBO
79>?;L;:?DF7J?;DJI KD:;H=E?D= 9ECCEDBO F;H<EHC;: EH
J>EF;:?9 7HJ>HEI9EF?9 FHE9;:KH;I ?C8;B ;J 7B
:;CEDIJH7J;:J>7JF7J?;DJI FH;I9H?8;:EDBO7 DEDIJ;HE?:7B
7DJ??DZ7CC7JEHO:HK=;NF;H?;D9;:=H;7J;HF7?DH;B?;<7D:
<;M;H7:L;HI;;L;DJIJ>7DJ>EI;FH;I9H?8;:EF?E?:7D7B=;I?7
7<J;H 7C8KB7JEHO EHJ>EF;:?9 IKH=;HO ,?C?B7HBO 7D?;BI ;J
7B 9ED9BK:;: J>7J  E< F7J?;DJI M>E KD:;H=E 7HJ>HE
I9EF?9 F7HJ?7B C;D?I9;9JECO 7D:EH 9>ED:HEFB7IJO 97D
79>?;L; I7J?I<79JEHO F7?D 9EDJHEB M?J> DEDEF?E?: F7?D
C7D7=;C;DJ  C7@EH?JO E< F7J?;DJI KD:;H=E?D= 7HJ>HE
I9EF?9 FHE9;:KH;I C?=>J 8; IK99;II<KBBO C7D7=;: M?J> 7
DEDEF?E?:F7?DC;:?97J?ED?D9BK:?D=?8KFHE<;D7D:EJ>;H
9ECCED7DJ??DZ7CC7JEHO7=;DJI"JH;C7?DIJE8;:;J;H
C?D;:?<7F7?DH;B?;<A?JIK9>7IJ>7J;CFBEO;:?DJ>?IIJK:O
.I;E<7'ED)>7HC79EBE=?97B)7?D+;B?;<$?JJE+;:K9;(F?E?:.I;EBBEM?D=(HJ>EF;:?9,KH=;HO)HEIF;9J?L;+7D:EC?P;:
International Journal of Sports Physical Therapy
Figure 1. Opioid use in morphine equivalents for patients using pain-relief kit versus controls over the four
weeks of the intervention (data for 38 patients who did not have total joint arthroplasty are shown). Time effect
p<0.001, Treatment effect p=0.352, Treatment by Time p=0.653.
Figure 2. Visual analog scale pain scores for the pain-relief kit group and the control group over the four-week
study period. Time effect p<0.001, Treatment effect p=0.205, Treatment by Time p=0.942.
9EKB:>;BFH;:K9;KI;E<DEDEF?E?:F7?DC;:?97J?EDM>;H;
EF?E?:I7H;DEJ8;?D=FH;I9H?8;:
->;H; ?I ;L?:;D9; JE IKFFEHJ J>; KI; E< 9HOEJ>;H7FOJE
H;:K9;F7?D<EBBEM?D=EHJ>EF;:?9IKH=;HOT"9;EH9EB:
M7J;H H;9?H9KB7J?ED ?I 7 C7?DIJ7O E< EKJF7J?;DJ 97H; 7<J;H
AD;; 7HJ>HEI9EF?9 IKH=;HO 7D: 97D ;<<;9J?L;BO H;:K9; H;
FEHJ;: F7?D M?J>EKJ ?D9H;7I;: H?IA E< 7:L;HI; ;L;DJI
.I;E<7'ED)>7HC79EBE=?97B)7?D+;B?;<$?JJE+;:K9;(F?E?:.I;EBBEM?D=(HJ>EF;:?9,KH=;HO)HEIF;9J?L;+7D:EC?P;:
International Journal of Sports Physical Therapy
!EM;L;HD;?J>;HM;H;I>EMD JE 8;;<<;9J?L;7<J;H ;B;9J?L;
JEJ7BAD;;7HJ>HEFB7IJO
EDL;HI;BOJ>;H;?I7 F7K9?JOE<;L?:;D9;EDJ>;KI; E<
>;7JF79AIEDF7?D9EDJHEB EH EF?E?: 9EDIKCFJ?ED<EBBEM
?D=EHJ>EF;:?9FHE9;:KH;I';L;HJ>;B;IIJ>;F7HJ?9?F7DJI?D
J>;JH;7JC;DJ =HEKFE<J>; FH;I;DJIJK:OKJ?B?P;:J>;>;7J
F79A7J7 =H;7J;H H7J;F;HM;;A9ECF7H;: M?J>J>;JEF?97B
7D7B=;I?9RLIR:7OIF;HM;;A->;H;IJ?BBM7I
DE:?<<;H;D9;?DJ>;F7?DC7D7=;C;DJM>;J>;HJ>;OKI;:
>;7JEH9EB:
->; ;B7IJ?9 87D:I M;H; J>; CEIJ <H;GK;DJBO KI;: JEEB
?DJ>;F7?DA?JR:7OIM;;AB7IJ?9H;I?IJ7D9;;N;H
9?I;I7H; L;HO9ECCEDBO?DJ;=H7J;:?DJEJ>;F>OI?97BJ>;H
7FO HEKJ?D; <EBBEM?D= 8EJ> 7HJ>HEI9EF?9 7D: 7HJ>HEFB7IJO
FHE9;:KH;I ->; IJK:O F7HJ?9?F7DJI H;9;?L;: ;NFEIKH; JE
J>?I ?DJ;HL;DJ?ED :KH?D= J>;?H F>OI?97B J>;H7FO 7D: J>KI
J>;O <;BJ CEIJ 9EC<EHJ78B;KI?D= ?J ,JH;D=J> JH7?D?D= ;N
;H9?I;I ?CFB;C;DJ;: I>EHJBO <EBBEM?D= 7HJ>HEFB7IJO >7L;
FHEL;D JE 8; <;7I?8B; M?J>EKJ ;N79;H87J?D= FEIJEF;H7J?L;
IOCFJECIIK9>7IF7?D7D:J>;;B7IJ?987D:I7H;7KI;H
<H?;D:BO M7O <EH F7J?;DJI JE F;H<EHC J>;?H H;I?IJ7D9; ;N
;H9?I;I 7J >EC; !EM;L;H J>; ;NJ;DJ JE M>?9> J>; KI; E<
;B7IJ?987D:I<EBBEM?D=EHJ>EF;:?9FHE9;:KH;IC?=>JH;:K9;
EF?E?:KI;>7IDEJ8;;D;N7C?D;:
.BJ?C7J;BOF>OI?97BJ>;H7FO?JI;B<>7I8;;DI>EMDJE:;
9H;7I;?DF7J?;DJEF?E?:9EDIKCFJ?ED<EBBEM?D= EHJ>EF;:?9
IKH=;HOIJ>;H;M7IDE:?<<;H;D9;?DJEJ7BEF?E?:KI;8;
JM;;DJ>;JH;7JC;DJ=HEKF7D:9EDJHEB=HEKFE<J>;FH;I;DJ
IJK:OEL;HJ>;<EKHM;;A<EBBEMKFF;H?E:?J?IFEII?8B;J>7J
J>;F7J?;DJII?CFBO 8;D;YJJ;: <HEC J>;?HF>OI?97BJ>;H7FO
I;II?EDI 7D: J>;H; M7I DE 7::;: 8;D;YJ E< J>; F7?D A?J
!EM;L;HJ>?I7D7BOI?I M7I8;OED:J>;I9EF;E<J>?IIJK:O
KHJ>;H ?J I;;CI J>7J J>; J?C?D= E< F>OI?97B J>;H7FO <EB
BEM?D=IKH=;HOC7JJ;HICEIJ "D 7 H;9;DJH;L?;MHEMD
-7OBEH;J7B9ED9BK:;:J>7J7BJ>EK=>;7HBOF>OI?97BJ>;H7FO
H;:K9;:IK8I;GK;DJ EF?E?:KI;J>;H; ?IB?C?J;:7D: ?D9ED
9BKI?L;;L?:;D9;JE;IJ78B?I>M>;J>;HJ>;9EDJ;DJ7D:EHBE
97J?EDE< J>;F>OI?97B J>;H7FO?DJ;HL;DJ?EDI?CFHEL;IEKJ
9EC;I8;97KI;E<>;J;HE=;D;?JO8;JM;;DIJK:?;I
->?IIJK:O?I DEJ M?J>EKJB?C?J7J?EDI->;L7H?78?B?JO ?D
EF?E?:KI;8;JM;;DF7J?;DJIM7ICK9>B7H=;HJ>7D;NF;9J;:
7D: I?=D?Y97DJBO B?C?J;: J>; FEM;H JE :;J;9J 7 :?<<;H;D9;
8;JM;;D J>; JH;7JC;DJ =HEKFI EH J>; F7J?;DJI M>E >7:
FHE9;:KH;I EJ>;H J>7D JEJ7B @E?DJ 7HJ>HEFB7IJO J>; EL;H7BB
EF?E?:KI;M7ICK9>BEM;HJ>7D;NF;9J;:->;H;M;H;L7H
?EKIB;L;BIE< KI7=;E<J>;?D:?L?:K7BCE:7B?J?;IM?J>?DJ>;
A?J79HEIIJ>;F7J?;DJFEFKB7J?EDM?J>DEED;CE:7B?JO8;
?D=FH;<;HH;:8O7BBF7J?;DJI"J?IFEII?8B;J>7JJ>;EKJ9EC;
MEKB:>7L;8;;D CEH;8;D;Y9?7BJEM7H:I J>; F7?DA?J>7:
J>;H;I;7H9>;HI9EDJHEBB;:<EH<H;GK;D9OE<KI;E<7BBCE:7B
?J?;IJEC7A;J>;?HKI;;L;D79HEII7BBF7HJ?9?F7DJI!EM;L;H
J>;7FFHE79>J7A;D?DJ>?IIJK:OM7I?DJ;D:;:JEE8I;HL;
>EMF7J?;DJI9>EEI;JEC7D7=;J>;?HEMDF7?DKI?D=H;9EL
;HOCE:7B?J?;I
?D7BBO J>; JH;7JC;DJ =HEKF M7I I?=D?Y97DJBO OEKD=;H
J>7D J>; 9EDJHEB =HEKF )H;L?EKI H;I;7H9> IK==;IJI J>7J
OEKD=;H F7J?;DJI ?D J>; 7=; H7D=; E<  O;7HI >7: 7
I?=D?Y97DJBO>?=>;HH;FEHJ;:C;7DEF?E?:9EDIKCFJ?ED<EH
@E?DJ FHE9;:KH;I 9ECF7H;: M?J> EB:;H F7J?;DJI 
O;7HIM>?B;J>;OEKD=;IJ7:KBJF7J?;DJIO;7HIM>E
H;9;?L;:JH;7JC;DJ<EH<H79JKH;YN7J?EDH;FEHJ;:J>;>?=>;IJ
C;7D 9EDIKCFJ?ED ?L;D J>; B?C?J7J?EDI E< J>; FH;I;DJ
IJK:O<KHJ>;HH;I;7H9>?ID;9;II7HOJE?DL;IJ?=7J;>EMEJ>;H
7BJ;HD7J?L; F7?DH;B?;L?D= CE:7B?J?;I 9EKB: 8; 7FFB?;: ?D
9B?D?97B FH79J?9; JE H;:K9; EF?E?: KI; 7D: FEII?8BO H;:K9;
KI;E<DEDEF?E?:C;:?97J?EDI
('%.,"('
->;H;IKBJIE<J>?IIJK:O?D:?97J;J>7JJ>;H;?IDE:?<<;H;D9;
?DFEIJEF;H7J?L;EF?E?: 9EDIKCFJ?ED?D7 =HEKF M>E KJ?
B?P;: 7 CKBJ?CE:7B F7?D A?J 7I 9ECF7H;: JE J>; 9EDJHEB
=HEKF->?IDEDF>7HC79EBE=?97BF7?DH;B?;<A?J:?:DEJI?=
D?Y97DJBOH;:K9;EF?E?:KI;?DJ>?IF7J?;DJFEFKB7J?ED"D
=;D;H7B EF?E?: 9EDIKCFJ?ED M7I L;HO BEM EL;H J>; <EKH
M;;AI<EBBEM?D=IKH=;HO7D:8EJ>=HEKFI:?IFB7O;:C7HA;:
IOCFJECH;B?;<EL;HJ>;<EKHM;;AIE<J>;IJK:O0>?B;J>;
FK8B?9VI7M7H;D;IIE<J>;EF?E?:;F?:;C?9M?BB>;BF<KHJ>;H
H;:K9;EF?E?:KI;EL;HJ?C;?J ?I?CFEHJ7DJ JE9EDJ?DK;JE
I;7H9><EH7BJ;HD7J?L;F7?D9EDJHEBC;J>E:I<EHF7J?;DJI
('%"-,("'-+,-
BB7KJ>EHI:;9B7H;J>7JJ>;O>7L;DE9EDZ?9JIE<?DJ;H;IJ
,K8C?JJ;:K=KIJ-99;FJ;:&7H9>
-
This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License
(CCBY-NC-4.0). View this license’s legal deed at https://creativecommons.org/licenses/by-nc/4.0 and legal code at https://cre-
ativecommons.org/licenses/by-nc/4.0/legalcode for more information.
.I;E<7'ED)>7HC79EBE=?97B)7?D+;B?;<$?JJE+;:K9;(F?E?:.I;EBBEM?D=(HJ>EF;:?9,KH=;HO)HEIF;9J?L;+7D:EC?P;:
International Journal of Sports Physical Therapy
++',
&EHH?I#&?H!+->;EF?E?:;F?:;C?9"CF79JED
EHJ>EF7;:?9IKH=;HOJ Am Acad Orthop Surg
:E?@77EI:
';M2EHA,J7J;;F7HJC;DJE<!;7BJ>'7H9EJ?9
D<EH9;C;DJ%7MI7D:+;=KB7J?EDI>JJFIMMM>;7
BJ>DO=ELFHE<;II?ED7BID7H9EJ?9B7MI67D:6H;=KB7J?E
DI
';M2EHA,J7J;;F7HJC;DJE<!;7BJ>'7H9EJ?9
D<EH9;C;DJ&7D:7JEHO)H;I9H?8;H
:K97J?ED>JJFIMMM>;7BJ>DO=ELFHE<;II?ED7BI
D7H9EJ?9C7D:7JEHO6FH;I9H?8;H6;:K97J?ED
>;D2;J7D9EKHJ%%?%-HK9AI&7H97DJED?E
-EHD;JJ7)",J7D:7H:?P;:F7J?;DJIF;9?Y9
FEIJEF;H7J?L;EF?E?:FH;I9H?8?D=7<J;H?DF7J?;DJ
EHJ>EF7;:?9IKH=;HOJ Am Acad Orthop Surg
;;:E?@77EI:
7D?;BI, 7HL;O$EBB?DI#&7JPA?D 
)7J?;DJI7J?I<79J?EDM?J>DEDEF?E?:F7?DC7D7=;C;DJ
<EBBEM?D=7HJ>HEI9EF?9F7HJ?7BC;D?I9;9JECO7D:EH
9>ED:HEFB7IJOArthrosc - J Arthrosc Relat Surg
:E?@7HJ>HE

;DY;B:)E;$$)HEJPKA(->79A;H%+
EBB7:7O #<<;9JE<IJ7J;B;=?IB7J?EDED:?I9>7H=;
EF?E?:FH;I9H?FJ?EDI7<J;HJEJ7B>?F7D:AD;;
7HJ>HEFB7IJ?;IArthroplasty Today
:E?@7HJ:
0>7B;,!;DD?D=I;D#!K<<,,9>D;?:;H
!?@@?2HE;>B;0<<;9JIE<J>;(>?EEF?E?:
FH;I9H?8?D==K?:;B?D;IEDJEJ7B@E?DJ7HJ>HEFB7IJO
FEIJIKH=?97BFH;I9H?8?D=7D:H;YBB?D=8;>7L?EHE<
IKH=;EDI7D:F7J?;DJIJ Arthroplasty
:E?@7HJ>
+;?:)7J;B,,>7>$';J7B(F?E?:B?C?J?D=
B;=?IB7J?ED7IIE9?7J;:M?J>:;9H;7I;::7OEF?E?:
KJ?B?P7J?ED<EBBEM?D=7DJ;H?EH9;HL?97B:;9ECFH;II?ED
7D:<KI?EDSpine J:E?@IF
?D;;
%EJJ!KJPB;H%!EI9E#%7@7C&(F?E?:
)H;I9H?8?D=)7JJ;HDI?D(HJ>EF7;:?9,KH=;HO)7J?;DJI
->;<<;9JE<';M2EHA,J7J;+;=KB7J?EDI7D:
"DIJ?JKJ?ED7B"D?J?7J?L;IJ Am Acad Orthop Surg
:E?@77EI:

-H7IEB?D?'&9$D?=>J&EHH%->;EF?E?:
9H?I?I7D:J>;EHJ>EF;:?9IKH=;EDJ Arthroplasty
;:E?@7HJ>

&EKJPEKHEI/#?B:;>-+$>7B?B%,;J7B
CKBJ?CE:7BFHEJE9EBJE:?C?D?I>F7?D<EBBEM?D=
9ECCEDEHJ>EF;:?9IFEHJIFHE9;:KH;I7DM;
;B?C?D7J;FEIJEF;H7J?L;EF?E?:IArthrosc - J Arthrosc
Relat Surg:E?@7HJ>H
E
B7HA;!,ED;@?'$E-2KD%0?@;OIKD:;H7
'+7J;I7D:H?IA<79JEHI<EHFHEBED=;:EF?E?:KI;
7<J;HC7@EHIKH=;HO)EFKB7J?ED87I;:9E>EHJIJK:O
BMJ:E?8C@=
,ED;@?'B7HA;!$E-0?@;OIKD:;H7'
+?IAIE<:;L;BEF?D=F;HI?IJ;DJEF?E?:KI;7<J;HC7@EH
IKH=;HOJAMA Surg:E?
@7C7IKH=
%7)EHJ;+7>B&O;D?(+&;D=;-#
)EIJEF;H7J?L;F7?DC7D7=;C;DJIJH7J;=?;I?D>?F
7HJ>HEI9EFOCurr Rev Musculoskelet Med
:E?IN
 ;EH=;,3 EE:;))>OI?97BJ>;H7FO7D:EF?E?:
KI;<EHCKI9KBEIA;B;J7BF7?DC7D7=;C;DJ
ECF;J?JEHIEH9ECF7D?EDIPain Rep
;:E?FH
,7HFED='(%7AH7#;DD?D=IEEF;H!#,>7>
+) ;BB;H#,7C;:7OF>OI?97BJ>;H7FO<EBBEM?D=
JEJ7BAD;;7HJ>HEFB7IJOB;7:IJE?CFHEL;:?DF7J?;DJ
F>OI?97BJ>;H7FOF;H<EHC7D9;7D::;9H;7I;:
?DF7J?;DJEF?E?:9EDIKCFJ?EDJ Arthro

B;7AB;O&7L?IED 0HOEJ>;H7FO7D:
?DZ7CC7J?EDL?:;D9;8;OED:J>;97H:?D7BI?=DI
Phys Ther Rev:E?
NO
BE9A#EB:7D:9ECFH;II?ED?DJ>;C7D7=;C;DJ
E<CKI9KBEIA;B;J7B?D@KH?;I7D:EHJ>EF;:?9EF;H7J?L;
FHE9;:KH;ID7HH7J?L;H;L?;MOpen Access J Sport
Med:E?E7@ICI
&;HH?9A&$D?=>J$%"D=;HIEBB)EJJ;?=;H#
->;;<<;9JIE<?9;7D:9ECFH;II?EDMH7FIED
?DJH7CKI9KB7HJ;CF;H7JKH;I7JL7H?EKI:;FJ>IJ Athl
Train
&;HH?9A&#KJJ;%,,C?J>&EB:CE:7B?J?;I
M?J>:?<<;H;DJJ>;HCE:OD7C?9FHEF;HJ?;IFHE:K9;
:?<<;H;DJIKH<79;7D:?DJH7CKI9KB7HJ;CF;H7JKH;IJ
Athl Train
.I;E<7'ED)>7HC79EBE=?97B)7?D+;B?;<$?JJE+;:K9;(F?E?:.I;EBBEM?D=(HJ>EF;:?9,KH=;HO)HEIF;9J?L;+7D:EC?P;:
International Journal of Sports Physical Therapy
B=7ZO ;EH=;$)!;HH?D=JED%->;;<<;9JE<
9HOEJ>;H7FOEDD;HL;9ED:K9J?EDL;BE9?JOF7?D
J>H;I>EB:7D:F7?DJEB;H7D9;Br J Sports Med
:E?8@IC
7KJ?IJ7&,?;C;DI# B7P;H#&;J7B->;
C;DJ>EBH;9;FJEH-+)&?IJ>;FH?D9?F7B:;J;9JEHE<
;DL?HEDC;DJ7B9EB:Nature
:E?D7JKH;
?I>EF H;;DIJ;?D#-EFF+<<;9JIE<
?E<H;;P;LI?9;ED79KJ;DED9ECFB?97J;:D;9A
F7?DClin Chiropr:E?
@9B9>
)7=;)B;N7D:;H%->;9B?D?97B;<<;9J?L;D;IIE<
?E<H;;P;QJEF?97B7D7B=;I?9EDCKI9KBEIA;B;J7B
F7?DIOIJ;C7J?9H;L?;MJ Perform Health Res
:E?@F>HF7=;
 H;;D ,9>E;D$%->;HC7B7D:DE9?9;FJ?L;
I;DI7J?EDI<HECC;DJ>EB7D:J>;?HIKFFH;II?ED8O
:OD7C?99EDJ79JBehav Brain Res
:E?@88H
!7J;C,JJ7B'0?BB;H#EK>7II?H7
)IO9>EF>OI?97BIJK:OE<J>;;<<;9JIE<JEF?97B
7FFB?97J?EDE<C;DJ>EB?D>;7BJ>OLEBKDJ;;HIPain
:E?@F7?D

07ID;H -EF?97BC;DJ>EB7>KC7DCE:;B<EH
9EB:F7?D8O79J?L7J?ED7D:I;DI?J?P7J?EDE<
DE9?9;FJEHIBrain:E?
8H7?D7M>
07ID;H '7B;I9>?DIA??D:;H
,9>7JJI9>D;?:;H#&9B79>B7D&7HED+->;;<<;9J
E<C;DJ>EBED9EB:7BBE:OD?7?DF7J?;DJIM?J>
D;KHEF7J>?9F7?DPain Med:E?
@N
!7;I;B;H &7K; HEIIAH;KJP#;J7B/EBJ7=;
:;F;D:;DJ8BE9AE<D;KHED7B9>7DD;BI8OJ>OCEB7D:
C;DJ>EBEur J anaesthrsiol:E?
I
!7;I;B;H  K:;>KI,KZ;H#;D=B;H+
%;KM;H&!?=>7<YD?JO8BE9A7:;E<LEBJ7=;EF;H7J;:
IA;B;J7BCKI9B;IE:?KC9>7DD;BI8O
:?C;J>OB9>BEHEF>;DEBEur J Anaesthesiol
:E?I
'7:B;H,0;?D=7D:$$HKI;+#->;F>OI?EBE=?9
87I?I7D:9B?D?97B7FFB?97J?EDIE<9HOEJ>;H7FO7D:
J>;HCEJ>;H7FO<EHJ>;F7?DFH79J?J?ED;HPain Phys
:E?FF@
'7:B;H,,J;?D;H#H7I7B7 '!;D=;>EB:
8;BD,0;?D=7D:$0EDJ?DKEKIBEMB;L;B
>;7JMH7FJ>;H7FO<EHJH;7J?D=79KJ;DEDIF;9?Y9BEM
879AF7?DArch Phys Med Rehabil
:E?7FCH
&7O;H#&+7BF>%%EEA&;J7B-H;7J?D=79KJ;
BEM879AF7?DM?J>9EDJ?DKEKIBEMB;L;B>;7JMH7F
J>;H7FO7D:EH;N;H9?I;H7D:EC?P;:9EDJHEBB;:
JH?7BSpine J:E?@IF?D;
;
?I9>;H,EBECED,Therapeutic Heat and Cold
D:;:%?9>J,;:07L;HBO)H;II
%?C0-7O& 1$?D;I?EJ7F?D=?D
CKI9KBEIA;B;J7BF7?D7D::?I78?B?JOJ>7JB7IJI<EH
CEH;J>7DM;;AI"I?JJ?C;JEF;;BE<<J>;J7F;7D:
J>HEM?JEKJM?J>J>;IM;7JIOIJ;C7J?9H;L?;MM?J>
C;J77D7BOI?I<E9KI;:EDF7?D7D:7BIEC;J>E:IE<
J7F;7FFB?97J?EDBr J Sports Med
:E?8@IFEHJI

2;E'&>;D#22;M>?7,%%E''2;E,#
)HEIF;9J?L;H7D:EC?I;:JH?7B9ECF7H?D=KDB?DA;:
CE:KB7H8?9ECF7HJC;DJ7BAD;;7HJ>HEFB7IJO7D:JEJ7B
AD;;7HJ>HEFB7IJOYL;O;7HI<EBBEMKFKnee
:E?@AD;;
JJ?D=;H0!H7D:EC?P;:JH?7B9ECF7H?D=
7;HE8?9;N;H9?I;7D:H;I?IJ7D9;;N;H9?I;M?J>7>;7BJ>
;:K97J?EDFHE=H7C?DEB:;H7:KBJIM?J>AD;;
EIJ;E7HJ>H?J?IJAMA:E?@7
C7
/7D77H&II;D:;B<J0##;AA;H#
(EIJ;D:EHF+?@BIC7#0#<<;9J?L;D;IIE<
;N;H9?I;J>;H7FO?DF7J?;DJIM?J>EIJ;E7HJ>H?J?IE<J>;
>?FEHAD;;IOIJ;C7J?9H;L?;ME<H7D:EC?P;:
9B?D?97BJH?7BIArthritis Rheum
:E?"
'+(
MO;H&$-KCFEMIAO&!?BJP'%%;;#
!;7BO0%;:7?H!,>7H79J;H?P7J?EDE<FEIJ
EF;H7J?L;EF?E?:KI;<EBBEM?D=JEJ7B@E?DJ
7HJ>HEFB7IJOJ Arthroplasty:E?
@7HJ>
EHB;DP7&%7LE?; 7=D;(%K2;J7B
)H;EF;H7J?L;EF?E?:KI;FH;:?9JIFHEBED=;:
FEIJEF;H7J?L;EF?E?:KI;7D:?D<;H?EHF7J?;DJ
EKJ9EC;I<EBBEM?D=7DJ;H?EH9HK9?7J;B?=7C;DJ
H;9EDIJHK9J?EDArthrosc - J Arthrosc Relat Surg
;:E?@7HJ>HE

H;?L?A!EH9>=H;L?DA)BB;D,&;J7B
II;IIC;DJE<F7?DBr J Anaes:E
?8@77;D
.I;E<7'ED)>7HC79EBE=?97B)7?D+;B?;<$?JJE+;:K9;(F?E?:.I;EBBEM?D=(HJ>EF;:?9,KH=;HO)HEIF;9J?L;+7D:EC?P;:
International Journal of Sports Physical Therapy
7DEI#EI9>7D;BB7I&7IIEBI(HJ;=7
?=EHH7#99;FJ78?B?JOE<L?IK7B7D7BE=K;I97B;I?D
J>;9B?D?97BI;JJ?D=9ECF7H?IEDM?J>L;H87BH7J?D=
I97B;I?DFEIJEF;H7J?L;F7?DMethods Find Exp Clin
Pharmacol
E;9AIJODI&!79A;H&+;B?78?B?JO7D:
L7B?:?JOE<J>;;L7BK7J?EDE<F7?D?DF7J?;DJIM?J>
JEJ7BAD;;H;FB79;C;DJPain:E?

!@;HCIJ7:&#7O;HI)&!7K=;D;J7B
,JK:?;I9ECF7H?D=DKC;H?97BH7J?D=I97B;IL;H87B
H7J?D=I97B;I7D:L?IK7B7D7BE=K;I97B;I<EH
7II;IIC;DJE<F7?D?DJ;DI?JO?D7:KBJIIOIJ;C7J?9
B?J;H7JKH;H;L?;MJ Pain Symptom Manage
:E?@@F7?DIOCC7D

->ED=",$#;DI;D&)&?HS#-7D ->;L7B?:?JO
E<F7?D?DJ;DI?JOC;7IKH;I0>7J:EJ>;'+,/,
/+,7D:),+C;7IKH;Scand J Pain
:E?I@F7?D
?DAB;O#&,JH7J<EH:)0%EJJ,+?::B;%->;
BEM;H;NJH;C?JO<KD9J?ED7BI97B;%,,97B;
:;L;BEFC;DJC;7IKH;C;DJFHEF;HJ?;I7D:9B?D?97B
7FFB?97J?EDPhysical Therapy:E
?FJ@
;7JED$7JP#'EII;B!0H?=>J# -7H7IKA
/EC87H:?;H&;7IKH?D=J>;M>EB;EHJ>;F7HJI
/7B?:?JOH;B?78?B?JO7D:H;IFEDI?L;D;IIE<J>;
:?I78?B?J?;IE<J>;7HCI>EKB:;H7D:>7D:EKJ9EC;
C;7IKH;?D:?<<;H;DJH;=?EDIE<J>;KFF;H;NJH;C?JOJ
Hand Ther:E?I

&9!EHD;O07H;##H+79>;B%K#
,>;H8EKHD;->;&(,?J;CI>EHJ<EHC>;7BJ>
IKHL;O,"""-;IJIE<:7J7GK7B?JOI97B?D=
7IIKCFJ?EDI7D:H;B?78?B?JO79HEII:?L;HI;F7J?;DJ
=HEKFIMed Care:E?

 ;H8;HI>7=;D!#:K9A7J>?B,L7D0?@9A#&
);;B;D%&$7BAC7D#&;?IID;H0)7?D?DJ;DI?JO
EDJ>;YHIJ:7O7<J;HIKH=;HOAnesthesiology
:E?7BD8;
8
 ?C8;B#,HK==;H3>7E0/;H8KH=$& ;?I
,<Y979O7D:JEB;H78?B?JOE<9;B;9EN?8L;HIKI
>O:HE9E:ED;79;J7C?DEF>;D?DJ>;JH;7JC;DJE<F7?D
7<J;H7C8KB7JEHOEHJ>EF;:?9IKH=;HO?D7:KBJIClin
Ther:E?I

07J;HC7D07BA;H##,M7?CI;J7B->;
;<Y979OE<9EC8?D;:9HOEJ>;H7FO7D:9ECFH;II?ED
9ECF7H;:M?J>9HOEJ>;H7FO7BED;<EBBEM?D=7DJ;H?EH
9HK9?7J;B?=7C;DJH;9EDIJHK9J?EDJ Knee Surg
:E?I
7D=%!KD=!0K,%7D=,!,JE9A;H#->;
;<<;9JIE<9HOEJ>;H7FO?DH;B?;L?D=FEIJ7HJ>HEI9EFO
F7?DJ Clin Nurs:E?
@N
,9>;<Z;H'&,>;?J;B)%%?FJED&'.I;E<HOE
K<<-&<EHJ>;9EDJHEBE<FEIJEF;H7J?L;F7?D7D:
;:;C7J Foot Surg>JJFI;KHEF
;FC9EH=7HJ?9B;C;:
E>D-H7;=;H+"#79AIED0->;;<<;9JIE<
9EB:J>;H7FO?DJ>;FEIJEF;H7J?L;C7D7=;C;DJE<
F7?D?DF7J?;DJIKD:;H=E?D=7DJ;H?EH9HK9?7J;
B?=7C;DJH;9EDIJHK9J?EDAm J Sports Med
:E?

0>?J;B7M );&KJ>$;CEI!,9>;FI?I
#79GK;I->;KI;E<J>;HOEK<<L;HIKI?9;7D:
;B7IJ?9MH7F?DJ>;FEIJEF;H7J?L;97H;E<AD;;
7HJ>HEI9EFOF7J?;DJIAm J Knee Surg

&7HJ?C8?7D9E% EC;I:7,?BL7':;
7HL7B>E)/,?BL7/-EHBED?&+);99?D&,
<<;9J?L;D;II7D:I7<;JOE<9HOEJ>;H7FO7<J;H
7HJ>HEI9EF?97DJ;H?EH9HK9?7J;B?=7C;DJ
H;9EDIJHK9J?EDIOIJ;C7J?9H;L?;ME<J>;B?J;H7JKH;
Phys Ther Sport:E?@FJ
IF
:?;,$M7D'7OBEH#&!7HH?I"&?JJ7B+
HOEJ>;H7FO<EBBEM?D=JEJ7BAD;;H;FB79;C;DJ
Cochrane Database Syst Rev:E?
9:FK8
->?;DFEDJE;I7:L7D9;:9HOEJ>;H7FOH;:K9;
F7?D7D:D7H9EJ?99EDIKCFJ?ED7<J;HAD;;
7HJ>HEFB7IJOClin Orthop Relat Res
:E?I

#7AE8I;D-%$;>B;J!!KIJ;:!);J;HI;D#
7D:>EBC-7HBOFHE=H;II?L;IJH;D=J>JH7?D?D=JE
;D>7D9;H;9EL;HO7<J;H<7IJJH79AJEJ7BAD;;
7HJ>HEFB7IJOH7D:EC?P;:9EDJHEBB;:JH?7BArthritis
Care Res:E?79H

HEMD-7OBEH%;9AD;H,97<<$;J7B
+;B7J?EDI>?FI8;JM;;DF>OI?97BJ>;H7FO?DJ;HL;DJ?ED
7D:EF?E?:KI;I9EF?D=H;L?;MPM & R18:E?
FCH@
.I;E<7'ED)>7HC79EBE=?97B)7?D+;B?;<$?JJE+;:K9;(F?E?:.I;EBBEM?D=(HJ>EF;:?9,KH=;HO)HEIF;9J?L;+7D:EC?P;:
International Journal of Sports Physical Therapy
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Background: Recent literature suggests that state-level legislation is effective in reducing postoperative opioid prescribing after total joint arthroplasty but has not addressed the effect on opioid antagonist coprescribing. This study aims to describe the change in postoperative opioid and opioid antagonist prescribing patterns after total joint arthroplasty following passage of state-level opioid-limiting legislation and to determine the comorbidities associated with increased opioid prescribing in this population. Methods: Billing data were used to identify all patients who underwent primary total hip or knee arthroplasty admitted between March 2016 and March 2018 at our institution. The data were divided into 2 cohorts comprising the year before (671 subjects) and after (713 subjects) the legislation. Discharge prescriptions were reviewed, and the median morphine milligram equivalents (MME) per day and naloxone prescriptions were recorded. International Classification of Diseases codes were used to identify comorbid conditions of interest present during previous inpatient or outpatient encounters. Results: There was a significant reduction in both the minimum and maximum median MME per day after introduction of state legislation and a substantial increase in opioid antagonist coprescription. Total knee arthroplasty, younger age, male sex, chronic pain disorders, post-traumatic stress disorder, and prior opioid abuse were correlated with increased opioid prescribing. Conclusion: Our findings suggest that state-level legislation is effective in decreasing the MME per day prescribed and increasing opioid antagonist coprescription in the postoperative period for patients undergoing total hip and knee arthroplasties at our institution. These changes may lead to a decrease in opioid-related morbidity and mortality in the patient population undergoing total hip and knee arthroplasties.
Article
Full-text available
Musculoskeletal (MSK) pain conditions are highly prevalent and a leading cause of disability globally. When people with MSK pain seek health care, they often receive treatment not aligned with best practices, including initial management options such as opioids. In recent practice guidelines, nonpharmacological treatments have been emphasized for initial pain management, and physical therapists are providers who routinely deliver nonpharmacological treatments. The purpose of this review is to describe the current and future state for how physical therapy may be used to increase exposure to nonpharmacological treatments for MSK pain conditions. For the current state, we review existing observational evidence investigating early exposure to physical therapy and its influence on subsequent opioid use. For the future state, we propose clinical research questions that could define the role of physical therapy on interdisciplinary teams working towards improving effectiveness of nonpharmacological treatments through more rigorous study designs. These clinical questions are intended to guide health services research and clinical trials when building an evidence base of nonpharmacological care options for MSK pain conditions.
Article
Full-text available
Purpose To determine if postsurgical pain, measured by visual analogue scale (VAS), following common orthopedic sports procedures could be managed effectively with a nonopioid multimodal analgesic protocol. Methods This prospective study evaluated a custom multimodal non-opioid pain protocol in patients undergoing common orthopedic sports procedures by a single fellowship trained Orthopaedic Sports surgeon from May 2018 to December 2018. Procedures included anterior cruciate ligament reconstruction, rotator cuff repair, arthroscopic partial meniscectomy, and labrum repair. The non-opioid pain protocol consisted of preoperative analgesics, intraoperative local infiltration analgesia, and a postoperative pain regimen. Patient pain was immediately reported after surgery and 1 week postoperatively using the VAS, while rescue opioids (oxycodone 5 mg) used were recorded using a prescription opioid journal. Statistical analysis of patient VAS scores, demographic correlations, and comparison between opioid rescue users vs. nonusers was performed. Results A total of 141 patients were included. One week following surgery patients reported a mean VAS level of 3.2±2.3 and required on average 2.6±3.6 breakthrough oxycodone pills (8.6±12.0 morphine equivalents). Forty-five percent of patients did not require any breakthrough prescription opioids and reported satisfaction with pain management. Patients who required opioids were more likely to have a history of anxiety/depression (44.2% vs. 23.8%,P=.012) and reported higher pain scores as compared to non-users (3.94±2.5 vs. 2.41±1.75,P=.016). The most common side effect of the pain protocol was feeling drowsy (23.5%). All patients were satisfied with their pain management postoperatively. Conclusions A multimodal, non-opioid pain protocol was found to be effective in managing postoperative pain following common orthopedic sports procedures. Patients were found to have low levels of pain, require minimal rescue opioids and had no severe side effects related to the protocol. These results suggest a non-opioid alternative to pain management following common orthopedic sports procedures.
Article
Full-text available
Purpose of Review Hip arthroscopy is a rapidly growing field due to its significant diagnostic and therapeutic value in the management of numerous hip disorders. Adequate control of postoperative pain in patients undergoing hip arthroscopy continues to be a challenging and evolving area in orthopedics. In the absence of standardized protocols for pain management in these patients, a variety of different approaches have been utilized in an effort to find a regimen that is effective at reducing postoperative pain, narcotic consumption, and cost to the patient and healthcare system. The purpose of this article, therefore, is to provide a comprehensive review of current literature regarding postoperative pain management techniques in patients undergoing hip arthroscopy. Recent Findings Recent literature demonstrates the importance of a multimodal approach to treat postoperative pain in patients undergoing hip arthroscopy. When a peripheral nerve block or intraoperative anesthetic is used in combination with a pre- and postoperative analgesic medication regimen, patients report less pain and postoperative narcotic consumption. Patient-reported pain scores and postoperative opioid use were similar between the different modalities, however, postoperative complications appear to be less in groups receiving intra-articular (IA) injection or local anesthetic infiltration (LAI) compared to peripheral nerve blocks. Summary In summary, we present evidence that intraoperative techniques, such as IA injection or LAI, in conjunction with pre- and postoperative pain medications, offers an effective multimodal strategy for treating postoperative pain following hip arthroscopy. This topic is of increasing importance due to the need for cost-effective strategies of managing pain and decreasing opioid consumption following hip arthroscopy.
Article
Objective Synthesize available evidence that have examined the relationship between physical therapy (PT) and opioid-use. Literature Survey Data sources including Google scholar, Embase, PubMed, Cochrane Library, and CINAHL were searched for English articles up to 10-24-2019 using terms (“physical therapy”[Title/Abstract] OR physiotherapy[Title/Abstract] OR rehabilitation[Title/Abstract]) AND (opiate*[Title/Abstract] OR opioid*[Title/Abstract]). Methodology Included studies evaluated a PT intervention and reported an opioid-use outcome. Data were extracted to describe the PT intervention, patient sample, opioid-use measurement, and results of any time or group comparisons. Study quality was evaluated with Joanna Briggs checklists based on study design. Synthesis Thirty studies were included that evaluated PT in at least one of these seven categories: interdisciplinary program (n = 8), modalities (n = 3), treatment (n = 3), utilization (n = 2), content (n = 3), timing (n = 13), and location (n = 2). Mixed results were reported for reduced opioid-use after interdisciplinary care and after PT modalities. Utilizing PT was associated with lower odds (ranging from 0.2-0.8) to use opioid medication for persons with low back pain (LBP) and injured workers; however, guideline-adherent care did not further reduce opioid-use for persons with LBP. Early PT utilization after index visit for spine or joint pain and after orthopaedic surgery was also associated with lower odds to use opioid medications (ranging from 0.27-0.93). Emergency department PT care was not associated with fewer opioid prescriptions than standard emergency department care. PT in a rehabilitation center after total knee replacement was not associated with lower opioid use than inpatient PT. Conclusions The relationship between timing of PT and opioid use was evaluated in 13 of 30 studies for a variety of patient populations. Eight of these 13 studies reported a relationship between early PT and reduced subsequent opioid use, making the largest sample of studies in this scoping review with supporting evidence. There is limited and inconclusive evidence to establish whether the content and/or location of PT interventions improves outcomes due to heterogeneity between studies. This article is protected by copyright. All rights reserved.
Article
Purpose (1) To determine patient factors associated with prolonged opioid use following Anterior Cruciate Ligament Reconstruction (ACLR) and (2) to evaluate the influence of preoperative opioid use on patient reported outcomes. Methods Patients who underwent ACLR and used opioids prior to the perioperative period, which was defined as the window 30 days prior to 15 days following the index surgery, were designated as pre-operative opioid users (OU). Patients who used opioids only in the perioperative period or post-operative period were designated as opioid-naïve (N-OU).. Predictors of opioid use at 6 and 12 months post-operatively and associations between preoperative opioid use and patient outcomes were assessed. Results After IRB approval, we identified 253 patients (225 N-OU and 28 OU) who underwent ACLR from 2014 to 2018 at a single institution and had one year follow up (median: 11.6 months; IQR: (8.9-14.3)). Patients with a history of preoperative opioid use (OR: 3.63, P=0.034), higher preoperative VAS pain scores (OR: 1.32, 95% CI 1.04-1.67; P=0.003) and higher BMI (OR: 1.09, P=0.018) were significantly more likely to be taking opioids at 6 months postoperatively. Patients with a perioperative opioid intake of greater than 513 oral morphine equivalents were significantly more likely to continue taking opioids at the 6 month (OR: 3.17, P=0.024) and the 1 year (OR: 3.34, P=0.048) postoperative time points. Patients with preoperative opioid use were significantly less likely to achieve the patient acceptable symptomatic state (PASS) on the IKDC, KOOS Sport, KOOS JR, KOOS Pain, KOOS Symptoms, KOOS QoL and KOOS ADL. Conclusion Preoperative opioid use, BMI >30 and higher VAS pain scores were predictors of continued opioid use at 6 months postoperatively. Preoperative opioid users were more likely to continue taking opioids, demonstrate significantly worse patient reported outcomes at baseline and 1-year postoperatively, and were less likely to achieve PASS.
Article
Background The opioid epidemic has been declared a public health crisis, with thousands of Americans dying from overdoses each year. In 2017, Ohio passed the Opioid Prescribing Guidelines (OPG) limiting narcotic prescriptions for acute pain. The present study sought to evaluate the effects of OPG on the prescribing behavior of orthopedists following total knee arthroplasty (TKA) and total hip arthroplasty (THA). Methods An institutional database was queried to compare morphine equivalent dose (MED) prescribed at discharge, acute follow-up (<90 days), and chronic follow-up (>90 days) pre- and post-OPG. Cases were identified over a 2-year period starting 1 year prior to OPG implementation. Results Nine orthopaedic surgeons performed 1160 TKAs (692 pre-OPG, 468 post-OPG) and 834 THAs (530 pre-OPG, 304 post-OPG). Total MED for TKA and THA dropped post-OPG (1602.6±54.3 vs. 1145.8±66.1, P<0.01; 1302.3±47.0 vs. 878.3±62.2, P<0.01). Much of the total MED decrease was accounted for by the decrease in discharge MED, which was the largest in magnitude (904.8±16.4 vs. 606.2±20.0, P<0.01; 948.4±19.6 vs. 630.6±25.9, P<0.01). Seven of the nine surgeons statistically reduced mean MED prescribed at discharge following OPG. The percentage of patients receiving new narcotic scripts at acute follow-up increased post-OPG for both TKA (41.5% vs 47.2%, P=0.05) and THA (18.3% vs. 25.7%, P=0.01). Conclusions Orthopedists reduced total MED prescribed after TKA and THA following the onset of OPG. The majority of this decrease is explained by decreased MED at discharge. Conversely, the post-OPG period saw slightly more new narcotics scripts written during acute follow-up.
Article
Background: The opioid epidemic in the United States is a public health crisis. As a result, regulatory agencies, including state governments, have enacted initiatives to decrease the use of opioids in the perioperative setting. The purpose of this study was to compare opioid utilization in orthopaedic surgery patients at discrete points after implementation of State regulatory and institution/physician-led initiatives to decrease opioid utilization in the perioperative period. Methods: We reviewed the electronic medication orders for all patients who underwent orthopaedic surgery procedures between September 2015 and June 2018 at our urban academic medical center. The outcome measures were the number of patients who were prescribed opioid medications, duration of prescription (days), and average milligram morphine equivalents prescribed. Patients were divided into three time cohorts to assess the effect of the NY State (NYS) policy and institutional initiatives to decrease opioid utilization. Results: A total of 20,483 patients met the inclusion criteria over all three time cohorts. After the initiation of the NYS 7-day supply legislation, there was a decrease in the average supply of opioids prescribed from 10.1 to 7.6 days and the average daily milligram morphine equivalent decreased from 67.9 to 56.7 mg (P < 0.0001). However, with the combination of physician education and surgeon-led institutional initiatives, the percentage of patients who were prescribed opioids decreased by over 10% (96% to 84%), with continued decrease in duration of prescription by 1.0 to 6.4 days (P < 0.0001). Conclusions: The addition of institution-led initiatives and education programs to previously established government-led prescription limits produced a substantial reduction in the amount of opioids prescribed to orthopaedic surgery patients in the perioperative period. Although mandatory limits set by the state government resulted in a decreased amount of opioid medications being prescribed per patient, it was only after the introduction of educational programs and institution- and physician-led programs that perioperative patient exposure to opioids decreased. Level of evidence: Level III.
Article
Background context: Since 2016, 35 of 50 US states have passed opioid-limiting laws. The impact on postoperative opioid prescribing and secondary outcomes following anterior cervical discectomy and fusion (ACDF) remains unknown. Purpose: To evaluate the effect of opioid-limiting regulations on postoperative opioid prescriptions, emergency department (ED) visits, unplanned readmissions, and reoperations following elective ACDF. Study design/setting: Retrospective review of prospectively-collected data. Patient sample: Two hundred and eleven patients (101 pre-law, 110 post-law) undergoing primary elective 1-3 level ACDF during specified pre-law (December 1st, 2015-June 30th, 2016) and post-law (June 1st, 2017-December 31st, 2017) study periods were evaluated. Methods: Demographic, medical, surgical, clinical, and pharmacological data was collected from all patients. Total morphine milligram equivalents (MMEs) filled was compared at 30-day postoperative intervals, before and after stratification by preoperative opioid-tolerance. Thirty- and 90-day ED visit, readmission, and reoperation rates were calculated. Independent predictors of increased 30-day and chronic (>90 day) opioid utilization were evaluated. Results: Demographic, medical, and surgical factors were similar pre-law versus post-law (all p>.05). Post-law, ACDF patients received fewer opioids in their first postoperative prescription (26.65 vs. 62.08 pills, p<.001; 202.23 vs. 549.18 MMEs, p<.001) and in their first 30 postoperative days (cumulative 30-day MMEs 444.14 vs. 877.87, p<.001). Furthermore, post-law reductions in cumulative 30-day MMEs were seen among both opioid-naïve (363.54 vs. 632.20 MMEs, p<.001) and opioid-tolerant (730.08 vs. 1,122.90 MMEs, p=.022) patient populations. Increased 30-day opioid utilization was associated with surgery in the pre-law period, preoperative opioid exposure, preoperative benzodiazepine exposure, and number of levels fused (all p<.05). Chronic (>90 day) opioid requirements were associated with preoperative opioid exposure (odds ratio 4.42, p<.001) but not with pre/post-law status (p>.05). Pre- and post-law patients were similar in terms of 30- or 90-day ED visits, unplanned readmissions, and reoperations (all p>.05). Conclusions: Implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization following ACDF without a rebound increase in prescription refills, ED visits, unplanned hospital readmissions, or reoperations for pain.
Article
Background: Opioid-related mortality has increased over the past 2 decades, leading to the recognition of a nationwide opioid epidemic and prompting physicians to reexamine their opioid prescribing practices. At our institutions, we had no protocol for prescribing opioids upon discharge after inpatient orthopaedic surgery, resulting in inconsistent and potentially excessive prescribing. Here, we report the results of the implementation of a patient-specific protocol using an opioid taper calculator to standardize opioid prescribing at discharge after inpatient orthopaedic surgery. Methods: The opioid taper calculator is a tool that creates a patient-specific opioid taper based on each patient's 24-hour predischarge opioid utilization. We implemented this taper for patients discharged after inpatient orthopaedic surgery at our two institutions (Boston Medical Center and Lahey Hospital and Medical Center-Burlington Campus). We compared discharge opioid quantities between orthopaedic patients postimplementation and quantities prescribed preimplementation. We also compared discharge opioid quantities between orthopaedic and nonorthopaedic surgical services over the same time period. Results: Nine-months postimplementation, a patient-specific taper was used in 74% of eligible discharges, resulting in a 24% reduction in opioids prescribed at discharge, along with a 35% reduction in variance. Over the same time frame, a smaller reduction (9%) was seen in the opioids prescribed at discharge by nonorthopaedic services. The most notable reductions were seen after total joint arthroplasty and spinal fusions. Despite this reduction, most patients (65%) reported receiving sufficient opioids, and no substantial change was observed in 30-day postdischarge opioid prescription refills after versus before protocol implementation (1.58 versus 1.71 fills per discharge). Discussion: Using the opioid taper calculator, a patient-specific taper can be successfully used to standardize opioid prescribing at discharge after inpatient orthopaedic surgery without a substantial risk of underprescription. Level of evidence: Level II.