PHYSICAL THERAPY
by Jeffrey Kozlik, PT, DPT
The numbers are staggering, the situation is disheartening and the pandemic is alarming. Anyone with access to a newspaper, television, radio or social media has likely heard about the opioid problem our country is battling. Open any obituary section of a local newspaper on any given day and chances are there was someone lost to this crisis. The reality is that opioid addiction is a real problem and it doesn’t discriminate. Check out these statistics from the Centers for Disease Control and Prevention: (1)
1. As many as 1 in 4 people who receive prescription opioids long term for non-cancer pain in primary care settings struggle with addiction.
2. From 1999-2015, more than 183,000 people have died in the US from overdoses related to prescription opioids.
3. While opioid abuse is down in younger Americans, it has doubled in adults 50 years or older from 1% to 2%.
4. More than 1000 people are treated in emergency departments every day for misusing prescription opioids.
5. In 2016, health care providers across the US wrote more than 214 million prescriptions for opioids, a rate of 66.5 prescriptions per 100 people.
6. Opioid related hospitalizations among women in the US increased by 75% between 2005 and 2014.
7. Veterans are twice as likely to die from accidental opioid overdose as non-veterans.
8. According to the CDC, among new heroin users, about 3 out of 4 report abusing prescription opioids before using heroin
9. Rhode Island had the 5th highest rate of drug overdose deaths in 2015.
Use of prescription opioids are common in orthopedic care. They often go by the names codeine, oxycodone, oxycodone/acetaminophen, hydrocodone, hydrocodone/acetaminophen, naloxone and fentanyl. Some may be more familiar with the names Vicodin, Percocet, OxyContin and Norco. They are often prescribed to manage pain associated with surgery or injury, however, for many, pain can be difficult to manage. In response to the opioid crisis, the CDC issued guidelines for prescription opioids in 2016. Those guidelines recognize opioid use as appropriate for the management of pain in certain cases including cancer treatment, end of life care, palliative care and in certain acute care situations, if properly dosed. However for other pain management cases, the CDC recommends non-opioid alternatives, including physical therapy. (2)
How can Physical Therapy Help?
Physical therapy has been shown to be effective in managing pain and improving function in many common orthopedic injuries. For instance, physical therapy as a first line of treatment for low back pain has been proven to lower healthcare related costs and the use of opioid medications. In 2015, BMC Health Services Research published a study investigating the implications of early and guideline adherent physical therapy for low back pain on utilization and costs. The researchers reviewed 122,723 Military Health System patient records and compared patients that received adherent, or evidence based, physical therapy to patients that received non-adherent physical therapy. The lead author, John D. Childs, PT, PhD concluded that, “Physical therapy as a starting point of care in your low back pain episode can have significant impact.” (3)
Another study, published in the New England Journal of Medicine in 2013, investigated patients over 45 years of age with meniscal tears and mild to moderate arthritis. The researchers randomly assigned patients to surgery and post-operative physical therapy, or a standardized non-operative physical therapy regimen. The authors concluded that there was no statistically significant difference between those patients that received surgery plus physical therapy to physical therapy alone. (4) This finding supports physical therapy as a successful approach for managing knee pain without the risks associated with surgery and unnecessary post-surgery opioid prescriptions. There are many other peer reviewed studies that support the utilization of physical therapy as a successful tool in the management of pain associated with orthopedic injury. More information can found online at the American Physical Therapy Association, http://www.apta.org/.
Physical therapy is an effective strategy in the management of pain. PTs are highly educated, licensed health care professionals with advanced training in anatomy, physiology and movement science. Merriam-Webster defines physical therapy as: “therapy for the preservation, enhancement or restoration of movement and physical function impaired or threatened by disease, injury or disability.” (5)
Four ways a Physical Therapist can help manage pain are:
1. Exercise: PTs are skilled in exercise prescription. With advanced understanding of the body’s movement design, a physical therapist can teach specific exercises to improve an injured joint’s range of motion and strength to restore normalized movement and decrease pain.
2. Manual Therapy: Physical therapists have enhanced knowledge and experience with “hands on” treatment strategies. Through joint manipulation or mobilization, soft tissue mobilization, massage, myofascial release, trigger point release and dry needling, a physical therapist can accurately identify and target impaired tissue to reduce swelling and pain, accelerate healing and normalize movement.
3. Education: Physical therapists are highly educated health care professionals. They have advance education and training in anatomy, physiology, kinesiology, pharmacology and chemistry. PTs are positioned to work one-on-one with patients. Through teaching and education, they can help you understand your pain and give you realistic expectations about your recovery and prognosis.
4. Teamwork: In most clinical settings, physical therapists work closely with doctors, nurses, social workers, case managers. Through teamwork and communication with others involved in your care, they can help set a plan to appropriately address your pain needs and can accurately assess your response to treatment interventions.
When to Choose Physical Therapy?
There has not been a significant change in the amount of pain that Americans report, yet sales of prescription opioids have quadrupled in the United States. (6) So when should you consider physical therapy as an option for pain management over prescription opioids? First, when the risks outweigh the rewards. Opioid use comes with side effects including depression, addiction, overdose risk and withdrawal. These risks are much lower with non-opioid pain management strategies including physical therapy. Second, when you don’t want to mask the pain. Opioid use does little to address the issue causing your pain. It just interrupts pain signals in your brain. Physical therapists can identify the issues contributing to your pain cycle and help you resolve your injury and restore pain-free movement. Finally, if your pain lasts more than 90 days. At this point, your pain is considered “chronic” and the risk for long term opioid use is high. Physical therapy is one non-opioid preferred alternative to address and correct lingering issues contributing to pain.
Before considering opioid use for pain management, consider talking with your doctor about a referral to a Physical Therapist. Given the substantial statistics and alarming risks associated with long term opiate use, care should be taken when prescribing an opioid for pain management. Physical therapists can play an integral role in the education and pain management process to minimize the potential negative consequences of long term opioid use.
The American Physical Therapy Association is a valuable resource for patient education on this topic.
More information can be found here at www.apta.org.
1 http://www.moveforwardpt.com/Resouces/Detail/opioid -abuse-statistics-of-50-states-2. 7 Staggering Statistics About America’s Opioid Epidemic. Accessed online: March 30, 2018.
2 http://www.moveforwardpt.com/Resources/Detail/physical-therapy-vs-opioids-when-to-choose-physica. Physical Therapy vs Opioids: When to Choose Physical Therapy for Pain Management. Accessed online: March 30, 2018
3 http://www.biomedcentral.com/1472-6963/15/150/abstract. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. Accessed online: March 31, 2018.
4 http://www.nejm.org/doi/full/10.1056/NEJMoa1301408. Surgery versus physical therapy for a Meniscal tear and Osteoarthritis. Accessed online: March 31, 2018.
5 https://www.merriam-webster.com/dictionary/physical%20therapy. Accessed online: April 1, 2018.
6 http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm?s_cid=rr6501e1er_w. CDC Guideline for Prescribing Opioids for Chronic Pain-United States, 2016. Accessed online: April 1,
