Friday, December 14, 2018 Large-Scale Study Finds Connection Between Early Physical Therapy and Lower Opioid Use The evidence of physical therapy's potential to make a difference in the nation's opioid crisis continues to mount—this time, by way of a study in JAMA Network Open, which concludes that for patients experiencing back, knee, neck, or shoulder pain, a visit to a physical therapist (PT) early on can reduce the chances that they'll take any opioids for the condition. And among those who do wind up taking opioids during the episode of care, researchers identified an association, albeit less strong, between early physical therapy and reduced number of pills taken for 3 of the 4 conditions. The study, one of the largest to date on the effects of early physical therapy, looked at data from 88,985 privately insured "opioid naïve" patients who had an index visit with a health care provider for back, knee, neck, or shoulder pain—the 4 most common musculoskeletal conditions. Researchers divided patients into 2 groups—those receiving treatment from a PT within 90 days of the index visit, and those who didn't—and tracked data for 1 year to note prescriptions and use, paying particular attention to use between 91 and 365 days after the index date. The patients, a national sample from multiple health networks, were 57.7% male with an average age of 46. Comorbidities and demographic factors were similar among both groups. Overall, 29.3% of the patients received early physical therapy. Here's what researchers found: Early physical therapy was associated with a reduced risk of any opioid use for all 4 conditions: a 16% drop for knee pain patients, a 15% reduction for those with shoulder pain, 8% for neck pain, and 7% for low back pain (LBP). Among patients who were prescribed (and used) opioids, early physical therapy seemed to have an association with fewer pills taken for 3 of the 4 conditions. Patients with knee pain recorded a 10.3% drop in oral morphine milligram equivalents taken compared with the control group; those with shoulder pain saw an average 9.7% reduction; and the LBP subgroup averaged a decline of 7%. The neck pain subgroup showed a slight 3.8% drop—not enough to be statistically significant, according to the study's authors. Early physical therapy for knee pain and LBP was associated with a significant reduction in the likelihood of chronic opioid use—by 66% for knee pain and 33% for LBP—compared with patients who didn't receive early physical therapy. Chronic opioid use among patients with neck and shoulder pain didn't differ between the study groups. As for when the early physical therapy group began sessions, that varied by condition, ranging from an average of 13 days after index visit for neck pain to 40 days for shoulder pain. The median number of physical therapy sessions ranged from 5 for knee pain and LBP to 8 for neck pain. Steven George, PT, PhD, FAPTA, one of the study's contributing researchers, told APTA that the study provides "encouragement and support" for guidelines such as those produced by the US Centers for Disease Control and Prevention (CDC) calling for nonopioid treatments, including physical therapy, to be considered a first-line approach to the management of chronic pain. "The guidelines emphasize nonpharmacological care being delivered early in the treatment episodes," George said. "In the study the nonpharmacological care was physical therapy, and there seemed to some benefit. The results provide early evidence that the new guidelines may help decrease long-term opioid use." George said that the finding related to early physical therapy's lack of impact on opioid use among patients with neck pain took researchers somewhat by surprise. In the study, authors characterize that finding as dissimilar to other research on the effects of early physical therapy, and they theorize that the variation "could be explained by the differences in patient populations, the resistance of many neck conditions such as whiplash to physical therapy, the underlying rate of opioid use, the timing and rate of patients receiving early physical therapy, or our decision to limit the analysis to patients with indicators of higher severity." The study makes a strong case for early physical therapy as it relates to opioid use, but it shouldn't be interpreted as a statement on overall results, according to George. "The biggest takeaway is that early physical therapy may be a viable option for several musculoskeletal conditions, especially if preventing long-term opioid use is a treatment goal," George said. "This study does not suggest those receiving early physical therapy had better clinical outcomes. That's an important thing to remember when interpreting these findings." In addition to George, APTA members Chad Cook, PT, PhD, MBA; and Adam Goode, PT, DPT, PhD, were among the coauthors of the study. APTA has taken a leadership role in the physical therapy profession's response to the opioid crisis. In addition to its flagship #ChoosePT opioid awareness campaign, APTA also hosted a Facebook Live panel discussion and satellite media tour to highlight the effectiveness of nonopioid approaches to pain management. In addition, APTA produced a white paper on reducing opioid use and contributed to the National Quality Partners Playbook on Opioid Stewardship. Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.