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CASE STUDY
D.H. is a 72-year-old man with a primary diagnosis of lumbar strain that was the result of lifting a large generator during an electricity outage due to a recent tropical hurricane. The patient was initially seen in an urgent care facility. He followed up with an orthopedic physician who recommended spinal imaging, which was negative for any bony abnormalities. The orthopedic physician recommended physical therapy for evaluation and treatment as indicated. On initial examination, the physical therapist noted that the patient demonstrated a forward flexed posture with limited trunk range of motion in all planes with pain at end ranges. Upon palpation, D.H. had tenderness in the low back paraspinal musculature. The patient had significant pain with bed mobility, sit-to-stand transfers, and stair negotiation. D.H. was also unable to assist with the post-hurricane cleanup of his home and property. D.H. stated that he felt useless because he had to rely on others to take care of these issues. This made him very anxious and unable to sleep at night. He stated he has been taking diazepam (10 mg) occasionally at night to help him sleep and have a restful night. The urgent care physician prescribed this benzodiazepine for his back spasms, but D.H. found that it helped him sleep.
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The prevalence of the use of sedative-hypnotics is high in patients undergoing rehabilitation. With the exception of diazepam that is prescribed as a skeletal muscle relaxant, sedative-hypnotics are not typically used to directly influence musculoskeletal disorders. Since this class of drugs is frequently used to decrease anxiety and insomnia, many patients involved in rehabilitation programs will be taking these agents. In all practice settings, patients may experience increased levels of anxiety related to their physical state of health and well-being. In hospitalized patients or those in long-term care facilities, sedative-hypnotics may also be used for sleep disorders.
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Use of these drugs as antianxiety agents can be beneficial during therapy sessions if they result in the patient being able to remain calm and relaxed. However, if their use produces significant central nervous system (CNS) depressant effects, therapy sessions requiring active participation and coordination such as gait training or motor control training may be unproductive and potentially hazardous. As a class, sedative-hypnotic drugs are associated with significant adverse outcomes such as motor vehicle accidents, falls, and fractures resulting in hospitalization. To emphasize this concern, most of the drugs within the sedative-hypnotics class are listed in Beers Criteria as potentially inappropriate medications for older adults.
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Assignment of a drug to the sedative-hypnotic class indicates that it is able to cause sedation (with concomitant relief of anxiety) or encourage sleep (hypnosis). Because there is considerable chemical variation within the class, this drug classification is based on clinical uses rather than on similarities in chemical structure. Anxiety states and sleep disorders are ...