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  • Study: More 'Collaboration and Consistency' Needed Between PTs and Surgeons in TKA, THA Measures

    As health care moves toward value-based approaches, it's going to become increasingly important for physical therapists (PTs) and orthopedic surgeons (OSs) to pursue more "collaboration and consistency" when it comes to outcome measures used in total knee and hip arthroplasty cases, say authors of a new study. That study, based on a survey of PTs in New England, found that many PTs relied on a range of performance-based outcome measures (PBOMs) and were less likely to use certain patient-reported outcome measures (PROMs) preferred by OSs—though that could be changing.

    The study, which appears in Arthroplasty Today, is based on a survey of 122 PTs in Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, and Connecticut. Researchers were trying to uncover differences between outcome measures commonly used by PTs, and those recommended for use in the American Joint Replacement Registry (AJRR), which authors of the study believe reflects measures most commonly used by OSs.

    To qualify for inclusion in the survey, a PT must have treated patients undergoing total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) in the past 5 years. PTs were asked to rate their current use of various outcome measures on a 4-point scale, from "not familiar" to "considerable experience." The respondents further were asked to estimate their future use of the outcome measures, also based on a 4-point scale: "unable to rate," "unlikely to use," "likely to use," and "will use and recommend."

    As for the outcome measures being evaluated, authors selected the Lower Extremity Function scale (LEFS), the numeric pain rating scale, Oxford Knee Score (OKS), Oxford Hip Score (OHS), EQ-5D quality of life measure, Knee Injury and Arthritis Outcome Score (KOOS), Hip Injury and Arthritis Outcome Score (HOOS), and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) as the PROMs. For PBOMs, they asked PTs to rate walking speed, the 6-minute walk test, timed up-and-go (TUG), timed stair climb, Tinetti Mobility Test, Single-Leg Balance Test, and functional reach test.

    Here's what they found:

    Respondents. The PTs included in the survey were mostly from mixed urban-rural areas (62.3%). Over half (53.5%) reported practicing in a private practice clinic; nearly 1 in 5 (18%) practiced in an outpatient clinical associated with an academic hospital or medical center. About a third of respondents (32.8%) reported 25 years' experience or more; 17.2% reported between 10 and 14 years of experience, and 13.9% listed experience at between 15 and 19 years. Just over 42% of PTs surveyed said they'd treated 25 or fewer TKA/THA patients in the past year; nearly that many (38.9%) reported treating between 26 and 49 such patients during the past year.

    Use of PROMs. The Numeric Pain Rating Scale and the LEFS were the measures most often cited by the respondents in terms of both current and future use of patient-reported data. Nearly all (99.2%) of the PTs reported current considerable experience with the pain rating scale, with 97.5% saying that they'd use and recommend the scale in the future. LEFS was also popular among the PTs, with 76.2% reporting considerable current experience and 77% supporting future use and recommendation.

    Use of PBOMs. In the performance-based category, the PTs cited the Single-Leg Balance Test and the TUG as the most relied-upon measures. For the Single-Let Balance Test, 90.2% of respondents reported current use, with 87.7% saying they would use and recommend that test in the future. The TUG was even more popular, with 93.4% of the PTs reporting current use, and 85.2% reporting future use and recommendation.

    The problem, according to the study's authors, is that the PTs' choices for PROMs don't line up with the AJRR recommendations, which lean more toward general quality of life measures and specific joint measures such as the HOOS, KOOS, and Oxford knee and hip measures. "It is difficult to explain why [the surveyed PTs] prefer the LEFS," authors write. "LEFS is easy to implement and broadly applicable to all lower extremity sites in various stages of disability, but is not specific to hip and knee osteoarthritis. The HOOS and KOOS are joint specific, including the [WOMAC] score, and have been shown to be more sensitive and responsive than the LEFS in total joint replacement. However, they take longer to administer." [Editor's note: APTA encourages the use of HOOS and KOOS for PTs participating in the Comprehensive Care for Joint Replacement bundled care model.]

    And while authors point out that PROMs are probably more reflective of the direction health care is heading, they acknowledge that PBOMs such as TUG have their place, too.

    "PROMs may overestimate patient mobility, especially in the immediate postoperative phase after both TKA and THA," authors write. "Because [PTs] evaluate TJA [total joint arthroplasty] patients multiple times in the early postoperative period, they may utilize PBOM more frequently to avoid overestimation of function during the early phase of rehabilitation." It's an approach that the researchers say echoes recommendations from the Osteoarthritis Research Society International, which supports use of the sit-to-stand test, walking speed test, timed stair climb, 6-minute walk test, and TUG.

    "PROMs and PBOMs also assess different time periods of recovery," authors write. "PROMs generally assess a period of weeks of overall symptoms and function while PBOMs objectively measure function at a particular point in time. Both types of information are valuable in assessing patient recovery."

    Still, they argue, the evolution toward patient-centered care means that patient-reported outcomes are likely to become more important in the future. And while the PTs surveyed may not yet be fully in sync with this trend in THA and TKA measures, there are some signs of positive movement.

    "This study showed that of the 16 outcome measures queried for clinical decision making, [PTs] indicated that they were less likely to use 4 of them in the future, all them PBOMs, and more likely to use 2 in the future, both PROMs," authors write. "As surgeons and [PTs] work more closely, developing better understanding and consensus in the use of PROM and PBOM between surgeons and physical therapists will allow for improved assessment of TJA patient outcomes."

    Authors acknowledge several limitations of their study, including a low response rate and the lack of data indicating when the various measures were used in the course of treatment. Another potential limitation: a large proportion of PTs (42.6%) reported seeing fewer than 25 patients with THA or TKA annually.

    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.

    Study: Adding Dry Needling to Exercise for Shoulder Pain Could Reduce Broader Costs

    Adding trigger point dry needling to an exercise program for patients with chronic shoulder pain may be more cost-effective than exercise alone, according to a recent clinical trial. The combined intervention led to “improved quality of life and lower…costs than exercise alone,” write authors in Pain Medicine (abstract-only available for free).

    The study is an expansion of earlier published results of the trial, which indicated that including trigger point dry needling was just as effective as exercise alone at reducing shoulder pain intensity, and better at improving pain-related disability. That open-access article appears in The Journal of Pain.

    Researchers recruited 50 participants with unilateral shoulder pain lasting more than 3 months from a hospital in Madrid, Spain. All patients had been diagnosed with subacromial pain syndrome and had no history of shoulder or neck injury, cervical radiculopathy, fibromyalgia, shoulder or neck surgery, shoulder steroid injections, or any type of shoulder or neck intervention.

    Patients were randomly assigned to 1 of 2 groups; both groups received treatment once per week for 5 weeks. Both groups received a supervised, clinical practice guideline-based exercise program of 3 exercises targeting the supraspinatus, infraspinatus, and scapular stabilizer musculature. The second also received trigger point dry needling on the second and fourth sessions.

    Authors analyzed societal costs and measured health-related quality of life during the 12-month follow-up period. Here’s what they found:

    Direct health care costs. Patients in the exercise-only group made more visits to their physicians. They also received more supplemental treatments, such as cold packs and extra physical therapy sessions, compared with the exercise plus trigger point dry needling group.

    Indirect costs of lost productivity. Work absenteeism and average cost of absenteeism were significantly higher for patients in the exercise-only group.

    Quality of life. Patients who also received trigger point dry needling “reported significantly better quality of life” compared with those who only received exercise.

    Cost-effectiveness. Exercise plus trigger point dry needling was “more likely to be cost-effective” than exercise alone. The greatest cost savings, say researchers, came from lower work absenteeism in the trigger point dry needling group.

    While authors acknowledge that the study results do not necessarily apply to other countries, they suggest “these differences would not alter the direction of current results.”

    Authors of the study include APTA members Joshua Cleland, PT, DPT; and Shane Koppenhaver, PT, PhD. Both Cleland and Koppenhaver are board-certified orthopaedic clinical specialists and fellows of the American Academy of Manual Physical Therapy.

    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.

    APTA's New Mission Statement: A Healthier Society Through a Strong Community

    APTA has a new mission, and it's all about bringing people together.

    "Building a community that advances the profession of physical therapy to improve the health of society" is now the official mission statement for APTA. Developed by the APTA Board of Directors after the 2017 House of Delegates entrusted the Board to update and maintain the association's mission, the statement is strongly integrated with APTA's vision statement for the profession of physical therapy: "Transforming society by optimizing movement to improve the human experience."

    "The vision statement APTA adopted in 2013 positions the association as an outward-facing organization committed to positive change," said APTA President Sharon L. Dunn, PT, PhD. "Our new mission statement articulates the association's role in that change—by being a place of engagement, where multiple perspectives can be brought together in support of advancing physical therapist practice to create pathways toward a healthier society."

    According to Dunn, as the APTA Board of Directors explored the creation of a new mission statement, members realized that in many ways the association already is living out its mission.

    "Our emphasis on being better together, our recommitment to diversity and inclusiveness, and our energized and connected members pointed the way toward this new mission statement," Dunn said. "We believe it's a forward-looking mission, but it's also a mission firmly rooted in our profession's values and its history of compassion, concern for society, and willingness to make bold moves.

    Move Forward Radio: Avoiding Muscle Atrophy When Injured

    It's not unusual for people who work out or participate in sports on a regular basis to experience an injury. It's also not unusual for the physically active-but-injured to be hesitant to take a break from or alter their activity while they seek care from a physical therapist (PT). They may fear losing muscle mass, gaining weight, or simply surrendering that regular sense of well-being. But under the right care, it doesn't have to be that way.

    Now available from APTA's Move Forward Radio: a conversation with Ryan Balmes, PT, DPT, who addresses many common questions and concerns about what happens when the body is recovering from injury and the role of the PT in that process. “If you’re injured, it’s not the end of the day,” he says, “but there’s a process” to avoid further injury.

    Balmes describes for listeners how he helps injured athletes safely stay in shape while still treating their injuries, how age affects injury recovery and prevention, and how patients and clients can work collaboratively with a PT to meet their unique needs and treatment goals. Balmes is a board-certified clinical specialist in both sports physical therapy and orthopaedic physical therapy.

    Move Forward Radio is archived at MoveForwardPT.com, APTA's official consumer information website, and can be streamed online or downloaded as a podcast via iTunes.

    Other recent Move Forward Radio episodes include:

    Beyond Opioids: Transforming Pain Management to Improve Health
    On February 5, 2018, APTA convened a panel of 7 experts to discuss how pain management in America can move beyond opioids and improve the health of society. The panel was broadcast live on Facebook and included the debut of APTA’s latest public service announc
    ement for the #ChoosePT opioid awareness campaign.

    Optimal Breathing and the Role of Physical Therapy
    Rohini K. Chandrashekar, PT, describes the mechanics of respiration, the causes and effects of breathing dysfunction, how breathing can affect movement and pain perception, and how PTs can help people breathe easier.

    Girl Power: Keeping Female Adolescent Athletes Healthy and Prepared for Sports
    Kate Hamilton, PT, DPT, discusses the safe, supportive, and fun environment she has created for adolescent girls only. The spectrum of services they provide range from individual and group strength and conditioning to performance enhancement, injury prevention, and physical therapy.

    Surfing and the Role of Physical Therapy
    Mark Kozuki, PT, DPT, explains the physical demands and challenges of surfing, how it’s different for recreational versus professional surfers, and what things surfers of any ability level should keep in mind to minimize injury risk and maximize performance.

    The Good Stuff: Members and the Profession in the Media, March 2018

    "The Good Stuff," is an occasional series that highlights recent media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    James Lewis, PT, MS, outlines the do's and don'ts of fitness apps. (Dallas News)

    Widener University PT student Jackie Krempasky, SPT, received a unique opportunity to put her clinical skills to use. (Delaware County, Pennsylvania, Daily Times)

    Ashley Hubregtse, PT, DPT, ATC, discusses the careful approach necessary in helping injured student athletes return to play. (KSFY News, Sioux Falls, South Dakota)

    "I, like many Olympians, have learned the value of a physical therapist. After surgery, to avoid it, or to help strengthen an area of the body and relieve pain, they are worth their weight in gold. The process is painful at first, but yields valuable gains from the pain. The healing process reveals strength, helps to mend, lessens soreness, and gives patients the ability to meet their goals – whatever they may be." –Opinion piece by Beth Willis Tedio (Tallahassee, Florida, Democrat)

    Jessie Fisher, PT, MPT, explains the differences between acupuncture and dry needling. (Reno, Nevada, Gazette Journal)

    Want stronger ankles? Robert Gillanders, PT, DPT, shares tips. (Spartan)

    “We really push physical therapy prior to surgery, as well as strengthening prior to chemotherapy. We want to optimize physical function, so we’ll do exercises that focus on endurance, gait, balance and strengthening. Physical therapy is quite important.” --Ekta Gupta, MD, assistant professor of palliative, rehabilitation and integrative medicine in the Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, on the role of physical therapy in cancer treatment. ("Let's Get Physical," curetoday.com)

    A. Lynn Millar PT, PhD, suggests questions patients should ask their physical therapists. (Outside)

    Luke O'Brien, PT, offers advice on exercises to help avoid knee pain. (Men's Health)

    Andwele Jolly, PT, DPT, MBA, MHA, has received a prestigious Eisenhower Fellowship. (Eisenhower Fellowship newsletter)

    "… it's such a vexing issue for anyone who treats chronic pain. Some of the treatments that have been proven more effective, and safer, and have better outcomes, such as physical therapy, may have a $20 to $40 copay for each visit, versus an opioid, which might have a $5 copay for an entire month's supply. So it's a huge problem that insurance companies…need to contend with across the country. There are all sorts of hidden additional costs with prescribing an opioid, and in the long run, it may be that using these nonopioid approaches, like physical therapy, and other medications, really provides the best improvement in chronic pain but also lowers costs. -Ajay Wasan, MD, professor and vice chair for pain medicine at the University of Pittsburgh Medical Center ("Questions and Answers About Opioids and Chronic Pain," National Public Radio)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    Study: Optimal Exercise Dose for Knee Disorders Still Unclear

    While much research has shown positive effects of therapeutic exercise for common knee disorders, “optimal dosing is still unclear,” say experts, largely a result of the way authors report their results. Identifying the best dosage is important, they write, because overdosing can have adverse effects, while underdosing can lead to no improvement for the patient.

    In a systematic review published in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free), authors examined 45 “fair-quality” studies on the use of therapeutic exercise to treat knee osteoarthritis (OA), patellar tendinopathy, or patellofemoral pain (PFP). Researchers analyzed duration of a single session, frequency of sessions, total number of sessions, duration of treatment, and effect size. Here's what they found:

    • Effect sizes in the included studies varied widely because so many different outcome measures were used, even for the same conditions.
    • For all 3 conditions, some studies did not report or were unclear about the length of each therapy session, frequency of sessions, and whether or not the exercise was supervised.
    • While nearly all studies clearly reported total number of sessions, the number ranged from 3 to 108 for knee OA, from 36 to 180 for patellar tendinopathy, and from 12 to 146 for PFP.
    • Researchers were able to identify only 3 trends from their analysis—all for knee OA. Both 24 total number of sessions and 8-week and 12-week durations were most often related to large effect sizes.
    • Once-per-week session frequency had no effect for knee OA.

    The review’s findings illustrate the challenge of appropriate dosing.

    “Exercise dosing is complex,” note authors, speculating that “an identical bolus of 315 minutes of exercise per week could be disseminated in a variety of ways.” More frequent sessions could be more effective, they write, but that would likely be affected by the duration and intensity of each session.

    Authors acknowledge the balancing act between tailoring exercise prescription to each patient while establishing general dosage parameters that help “standardize effective care, inform clinical practice guidelines, and decrease dosage variance in clinical trials.” It is critical, they say, to improve the quality of dosage reporting in clinical trials, because “these data can better allow researchers to fine tune exercise dosage in subsequent trials, and improve our understanding of exercise parameters that work better than others.”

    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.

    APTA Contributes to New 'Playbook' on Pain Management and Opioid Stewardship

    Understanding the link between overreliance on opioids for pain management and the broader opioid crisis in the US isn't difficult: identifying realistic steps to break that link is another matter. A high-profile national partnership that includes APTA is hoping to change that with the release of an opioid "playbook" focused on realistic, patient-focused, and scalable actions to transform health care's approach to pain.

    The National Quality Partners Playbook: Opioid Stewardship , released on March 12, aims to provide "a blueprint to help address the nation's devastating opioid epidemic," according to Shantanu Agrawai, ME, MPhil, president and CEO of National Quality Forum (NQF), which sponsored the creation of the resource. The guide is the product of an NQF "action team" composed of representatives from more than 40 health care and provider organizations including the US Centers for Disease Control and Prevention, BlueCross BlueShield Association, the American Nurses Association, the American Society of Health Systems Pharmacists, Magellan Health, and the Veterans Health Administration. APTA was represented on the action team by Alice Bell, PT, DPT, senior payment specialist for the association.

    The playbook is built around 7 "fundamental actions" that authors believe could help shift health care patterns away from the overuse of opioids for noncancer pain. Those actions are rooted in the concept of opioid "stewardship"—the idea that health care systems, clinicians, and patients must take a shared approach to the use of opioids that recognizes their potential for harm and looks to nonopioid options whenever possible. Those actions are:

    • Promoting leadership commitment and culture that support nonopioid pain treatments and demonstrates that support through allocation of resources
    • Implementing organizational policies to support evidence-based approaches to multimodal pain management
    • Advancing clinical knowledge, expertise, and practice to ensure that clinicians understand the science of pain and techniques for patient communication
    • Enhancing patient and family caregiver education and engagement around pain management and the risks of opioids
    • Tracking, monitoring, and reporting performance data on opioid prescribing, patient-reported outcomes, and adverse events
    • Establishing accountability around communicating and maintaining "a culture of opioid stewardship"
    • Supporting collaboration with community leaders and stakeholders to achieve maximum impact

    "The playbook highlights the importance of incorporating a multidimensional approach to pain management, including physical therapy, as a critical component of addressing this epidemic in a meaningful way," said Bell. "The diverse group of organizations and individuals who contributed brought a comprehensive perspective and a real commitment to providing a useful and effective tool to health care organizations and providers."

    The recommendations from the NQF group are consistent with APTA's #ChoosePT opioid awareness campaign, which stresses the importance of clinician-patient communication about pain management. Many of the playbook's themes were also echoed by participants in a recent live FaceBook broadcast from APTA, "Beyond Opioids: Transforming Pain Management to Improve Health."

    "It's critical that health care organizations and providers examine their approaches to pain management to ensure that individuals are aware of all of their options, including more active approaches to care, such as physical therapy," Bell said. "The playbook creates a pathway for making these needed changes at such a critical time—this epidemic continues to impact so many, and the need for a collaborative solution is clear."

    The playbook was released in conjunction with the opening day of the NQF annual conference, which features a panel discussion on the resource. Additionally, NQF will host a public webinar on March 29 and an in-person workshop on May 1 in Washington, DC.

    NQF is a nonprofit organization known for developing resources in the areas of health care quality measurement and improvement. The opioid playbook was 1 of 2 such resources released on March 12; the second is a playbook addressing shared decision-making in health care.

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    Study: Falls Among US Adults 65 and Older Cost $50 Billion in 2015

    The US health care system spent an estimated $50 billion on falls in 2015, an amount representing 6% of all Medicare payments and 8% of all Medicaid payments, according to a new study. Authors say that unless the US steps up its game when it comes to falls risk assessment and prevention, costs are certain to climb steadily higher as the baby boomer generation continues to age.

    Researchers based their estimates on data from the Medicare Current Beneficiaries Survey (MCBS), then applied these data to data from the National Health Expenditures Accounts (NHEA) to estimate nonfatal falls expense. For fata falls, they used the Web-based Injury Statistics Query and Reporting System (WISQARS) to assess expense. The final MCBS sample included 3,460 community-dwelling individuals 65 and older. Respondents who were employed, died during the survey period, or lived in Puerto Rico were excluded.

    Results of the study were published in the Journal of the American Geriatrics Society. Among the findings:

    • Based on the survey, researchers estimate total 2015 health care expenditures for nonfatal falls in the US at $49.5 billion--$28.9 billion for Medicare, $8.7 billion for Medicaid, and $12 billion for other payment sources including private insurance and out-of-pocket expense.
    • Nearly 1 in 4 adults in the survey reported a fall in the past year. Of those, 52.1% fell once, 21.3% fell twice, and 24.1% fell 3 or more times.
    • Individuals who reported falls had significantly lower self-rated health and more chronic conditions, and were more likely to be female, white, and from lower income levels.
    • Estimated costs were not distributed equally among service types, with an "other" category—spending in areas such as home health services, long-term care facilities, and durable medical equipment—leading the way at $29.2 billion. That amount was more than double hospital-related spending, which was second at $12.9 billion, followed by physician/other provider spending ($10.8 billion), prescription drugs ($2.1 billion), and dental ($400 million).
    • Unintentional fall deaths were recorded at a rate of 59.64 per 100,000 population in 2015, with associated medical costs of $754 million—about 1% of the total estimated expenditures.
    • Overall, spending on falls in 2015 increased by nearly 32% from 2013, when total spending was estimated at $38 billion.

    "The economic burden from falls is likely to increase substantially in the coming years," authors write. "Monitoring cost trends is important, because 75% of the cost of older adult falls is financed through public health insurance programs that are already financially stressed."

    Authors believe that given the undeniable demographic pressure that will increase as baby boomers age, it's imperative that more attention be given to falls assessment and prevention.

    "Preventive strategies that reduce falls in older adults could lead to a substantial reduction in health care spending," authors write.

    The researchers stress that "evidence-based strategies including medication management and strength and balance exercises…have been associated with reductions in older adult falls," and point to guidelines such as those included in the US Centers for Disease Control and Prevention's Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative as a good place to start

    But there's no time to lose, they add. Authors of the study believe that providers need to act with urgency and do a better job of identifying falls risk, assessing which risk factors may be modified and providing evidence-based interventions to decrease that risk.

    "Clinical care is an important component of falls prevention," they write. "By broadly implementing and scaling up initiatives like STEADI, we can improve health and decrease the future economic burden of older adult falls."

    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.

    Editor's note: Want more on falls prevention? Check out the falls-related resources at PTNow, including a unilateral vestibular hypofunction clinical summary, a summary on falls risk in community-dwelling elders, an osteoporosis clinical summary, and tests and measures such as a fracture risk assessment, a clinical test of sensory interaction and balance, and a self-paced walk test. APTA also offers resources on its Balance and Falls webpage.

    JAMA Study: Opioids No Better Than Nonopioids in Improving Pain-Related Function, Intensity for Chronic Back Pain, Hip/Knee OA

    In brief:

    • 240 patients with chronic back pain or hip or knee osteoarthritis pain were divided into 2 treatment groups: 1 group received opioids, 1 group received nonopioid medications
    • After 12 months, researchers found no differences between the groups' reported improvement in function, and a slightly better improvement rate in pain intensity for the nonopioid group
    • Among individuals who achieved improvements of 30% or more, numbers were nearly equal for the 2 groups in terms of function, and better for the nonopioid group in terms of pain intensity
    • Authors conclude that given the potential risks associated with opioids, results of the study do not support opioid prescription for chronic back pain or knee or hip osteoarthritis pain

    APTA's #ChoosePT opioid awareness campaign makes the case that opioids simply "mask" pain—but a new study in JAMA has concluded that the drugs probably don't even do that much, at least not any more effectively than nonopioid medications. The research, which focused on individuals with chronic back pain or hip or knee osteoarthritis (OA) pain, led authors to an unequivocal conclusion: there's no support for opioid therapy for moderate-to-severe cases of those types of pain.

    The published findings (abstract only available for free) are based on a study of 240 randomized patients in the Minneapolis, Minnesota, Veterans Affairs (VA) health care system who reported chronic back pain or knee or hip OA pain, defined as daily moderate-to-severe pain for 6 months or more with no relief provided by analgesic use. Participants were divided into 2 groups: 1 that received an opioid regimen, and a second group that received nonopioid drugs.

    To more closely resemble real-world treatment, researchers used a "treat-to-target" approach that stepped up the drugs as needed for participants to reach identified goals. The opioid regimen began with immediate-release morphine, hydrocodone/acetaminophen, and oxycodone, but the regimen could advance to sustained-action morphine and oxycodone, and on to transdermal fentanyl. The nonopioid approach began with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS), but it could move on to topical analgesics and finally to drugs requiring prior authorization (such as pregabalin and duloxetine), including tramadol. All participants also were permitted to pursue nondrug treatment during the study, but researchers did not evaluate data related to those treatments.

    Participants were monitored throughout the study and evaluated at 12 months using a range of tests, with the primary focus on how pain interfered with function, assessed through the Brief Pain Inventory (BPI); and pain intensity, measured using the BPI severity scale. Both measures are 10-point scales, with higher numbers indicating more pain-related interference or pain intensity. Other areas assessed as secondary outcomes included quality of life, depression, sleep disturbance, headache, anxiety, sexual function, and fatigue.

    At the 12-month mark, researchers found no significant differences in pain-related interference between the 2 groups (average BPI function scores of 3.4 in the opioid group and 3.3 in the nonopioid group), and a greater reduction of pain intensity among the nonopioid group (average of 3.5 in the nonopioid group vs 4.0 in the opioid group).

    When it came to the achievement of what authors called a "functional response"—a 30% or better improvement in a BPI score—the number of participants who achieved that level of improvement in function was roughly equal among groups, with 69 patients in the opioid group and 71 patients in the nonopioid group reaching the threshold. But the difference was notable in pain intensity scores, with 63 participants in the nonopioid group reporting improvement of 30% or more, compared with 48 participants in the opioid group reaching that level of improvement.

    The researchers also analyzed group differences by the type of pain treated:

    Back pain

    • Average score, interference with function: 2.9 in opioid group; 3.3 in nonopioid group
    • Average score, pain intensity: 3.7 in opioid group; 3.6 in nonopioid group

    Hip or knee OA

    • Average score, interference with function: 4.4 in opioid group; 3.4 in nonopioid group
    • Average score, pain intensity: 4.5 in opioid group; 3.4 in nonopioid group

    Similar to a study published recently, researchers also found that quality-of-life measures did not differ significantly between the 2 groups. The only area in which results from the opioid group bettered the nonopioid group in a notable way was in reduction of anxiety symptoms, although authors point out the only a small number—9% of all participants—reported moderate-to-severe anxiety at baseline.

    Authors acknowledged observational studies that associate long-term use of opioids with poor pain outcomes but say that those outcomes may not tell the whole story.

    "In this trial, pain-related function improved for most patients in each group," authors write. "Poor pain outcomes associated with long-term opioids in observational studies may be attributable to overprescribing and insufficient pain management resources rather than to direct negative effects of opioids."

    Still, they argue, given the "risk for serious harms without sufficient evidence for benefits," there seems to be no compelling reason to even begin a course of opioid-based treatment for certain conditions

    Among patients with chronic back pain or hip or knee osteoarthritis pain, treatment with opioids compared with nonopioid medications did not result in significantly better pain-related function over 12 months," authors write. "Overall, opioids did not demonstrate any advantage over nonopioid medications that could potentially outweigh their greater risk of harms."

    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

    APTA's award-winning #ChoosePT campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Members can also learn more about the PT's role in pain management through offerings on PTNow, including a webpage with resources for pain management and an opioid awareness checklist.

    Easier Said than Done: A Third of Patients Told to Lose Weight Have Functional Limitations That Could Make Exercise Difficult or Unsafe

    Physicians increasingly may be prescribing exercise for patients who need to lose weight, but nearly a third of those patients have functional limitations that could interfere with their ability to safely follow those recommendations, according to new study. Researchers see physical therapists (PTs) as providers who are uniquely positioned to help fix that disconnect.

    The study's findings, published in Physiotherapy Theory and Practice (abstract only available for free) are based on data from 5,480 participants in 2 rounds of National Health and Nutrition Examination Surveys (NHANES) who answered yes to 1 or more of 3 questions about whether a doctor or health professional had recommended physical activity or weight loss in the past 12 months. Researchers looked at how this group answered other questions about functional limitations—activities such as walking for a quarter mile, walking up 10 steps without resting, preparing meals, dressing, standing up from an armless chair, and pushing or pulling large objects—as well as questions about past attempts at weight loss. Here's what they found:

    • Among respondents (56.5% female, 43.5% male ranging in age from 40 to 65) who were told to lose weight, nearly 1 in 3 (31%) reported 1 or more functional limitations.
    • More than 20% reported difficulties with instrumental and basic activities of daily living (IADL and BADL) and with lifting, pushing, or pulling objects.
    • More than 90% of respondents who reported difficulties with IADL and BADL also had a history of obesity, prediabetes, diabetes, hypertension, heart failure, angina, or a myocardial infarction, either alone or in combination.
    • Among the functional limitation group, 57.6% reported intentionally attempting weight loss, with 40.7% using exercise as a weight-loss method.
    • Only 9.9% of respondents who were told to lose weight reported seeking professional advice for weight loss: 48% of that group sought advice from a nutritionist or dietitian, 26% sought out a personal trainer, 23.5% met with a "doctor," and 2% reported "other." Physical therapists were not listed as a separate option.

    Authors of the study acknowledge that while the relationship between functional limitations and lower levels of physical activity (PA) may be a 2-way street, with low levels of PA leading to functional limitations and vice-versa, this relationship only underscores the need for carefully planned and monitored prescriptions for exercise in this population. That's where they believe PTs can play an important role.

    "Physical therapists are well-suited to manage the PA and exercise programs of individuals with functional limitations given [their] education, expertise, and documented self-efficacy in primary, secondary, and tertiary prevention with exercise testing, prescription, and implementation," authors write. "This perspective is strengthened by the documented low self-efficacy of physicians with PA counseling."

    Authors acknowledge that their study may have limitations, including the "bidirectional" relationship between low PA and functional limitations and the NHANES loose use of provider terminology—specifically its reliance on the generic term "doctor." Additionally, they write, more research is needed to assess the impact of functional limitations on the ability to exercise, as well as to explore why PTs don't seem to be a regular part of prescribed weight-loss efforts.

    Nevertheless, they argue, the data in the study point to the need for a more thoughtful approach to weight-loss recommendations.

    "Individuals with these limitations should be identified at the time of health professional recommendation to increase exercise or lose weight and referred to an appropriate health professional for exercise testing, prescription, and program implementation," authors write. "Physical therapists have an opportunity to assist with these efforts."

    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.

    Editor's note: APTA offers resources on encouraging healthy, active lifestyles at APTA's Prevention, Wellness, and Disease Management webpage as well as its webpage on arthritis management through community programs. The association has also launched a new knowledge-sharing opportunity: The Council on Prevention, Health Promotion, and Wellness in Physical Therapy.