Physical Therapy Over Opioid Use

A 2015 study conducted by the National Institute of Health estimated that approximately 50 million people in the United States suffer from acute pain to severe pain (American Physical Therapy Association, 2018). Many people take prescribed pain relievers like oxycodone and hydrocodone primarily to manage this health condition. The unprecedented overuse of opioids as the best intervention for pain management has led to a national public health epidemic with the CDC reporting over 52,404 deaths related to an opioid overdose in the United States in 2015 (Rudd, 2015). Opioids prescribed by a qualified doctor are appropriate for managing different types of pain, but the American Physical Therapy Association (APTA) states that these drugs just mask the pain (American Physical Therapy Association, 2018). Depression, overdose and additional risks linked to opioid use make physical therapy a better alternative for pain management. No person wants to live in pain, but they also shouldn’t put their health at risk in the process of fighting pain. There are numerous benefits of physical therapy over opioid use as an alternative to pain management.

What is pain? Pain refers to unpleasant sensations in human beings and other animals that is caused by either actual or perceived injury to body tissues, consequently producing physical and emotional reactions. Generally, the perception of pain is an important mechanism that supports the protection of human bodies from harm by causing them to do certain actions and avoid others (Fritz, Childs, Wainner, & Flynn, 2012). In all cases, pain has become a significant and costly and public health problem not only in the United States but across many other industrialized countries (Gatchel, McGeary, McGeary, & Lippe, 2014).

In the past decade, many patients, practitioners, and agencies turned to traditional interventions for dealing with pain. Unfortunately, a lot of concerns have emerged over traditional medical interventions, a trend that Gatchel et al. (2014) believe indicated the need for more effective alternative chronic pain management strategies. The traditional pain treatment approaches, including the use of opioids, have continuously failed to yield better health outcomes. This current opioid epidemic has necessitated the development and implementation of more integrated, effective and research-based interventions for treating pain. Particularly, non-pharmacological therapy and non-opioid pharmacological interventions have gained a lot of attention as effective approaches for treating chronic pain.

When something hurts either from a known or unknown injury we all want relief. In most cases an individual will first seek pain relief by seeing a doctor, who may prescribe an opioid to help relieve the pain, they make seek to find the source of the pain and may even recommend surgery. This seems to be the basic steps without trying physical therapy when it can be an effective and safer alternative.

I suffered from chronic pain in my right knee, and sought treatment. My treatment involved an MRI which showed a problem that they determined could be treated by surgery. A year later I still have pain in that knee. The following year I suffered pain in my other knee and an MRI showed another problem, chrondomalacia and a torn meniscus. I was prescribed high dose anti-inflammatories and surgery was discussed again. After having gone through surgery and still feeling pain in that knee I wanted a different option this time. After seeking a second opinion, I was given a cortisone shot in my knee to assist in the healing as well as prescribed physical therapy. I wondered if physical therapy could really heal a tear, but decided to give it a try. The physical therapist and I first had a lengthy discussion regarding my injury, my pain, my history, and my activities. They then did a thorough evaluation of my muscles in my legs, analyzed how I walk, stand and move in general. After this evaluation it was determined that I have a muscle imbalance in my thigh area. What does that mean? I am destined to have chronic knee problems if I do not fix this muscle imbalance because it is causing my knee cap to not track properly which is creating the injuries to my knee. This proves to me at least why physical therapy is so important. I have been to 4 different knee doctors over the last 2 years. Everyone one of them could tell you what was causing the pain in my knee, but not one of them offered a reason as to why my meniscus was torn, why I developed hoffas syndrome, or why I developed chrondomalacia. All of these injuries can be repaired through surgery, BUT, all of them will return because of the muscle imbalance. Aside from the one doctor who suggested intensive physical therapy, not one of them took a step back to really analyze what was the underlying problem that was causing these injuries to me.

I am not alone in this belief as research studies are increasingly presenting evidence in support of the higher efficiency of physical therapy in the management of chronic pain and other types of pain compared to opioids. Gellhorn, Chan, Martin, and Friedly (2012) determined the effect of physical therapy on acute low back pain. The study also evaluated the impact of the subsequent use of opioids, including lumbosacral injections, lumbar surgery and frequent physician office visits for the same back problem. The findings established a significant relationship between physical therapy and reduced low back pain. The researchers concluded that patients who receive physical therapy early following an episode of acute low back pain have a lower risk of subsequent medical service usage than their counterparts who receive the therapy at later times. Another study showed that “PT early in the management of LBP is associated with reductions in subsequent health care utilization and LBP related costs.” (Thackeray, Hess, Dorius, Brodke, & Fritz, 2017, p.785) The investigation further found out that early physical therapy strongly relates to the decreased risk of advanced imaging, subsequent physician visits, injections, and use of opioids than delayed administration of the non-pharmacological intervention. Another federally funded study showed that with meniscus tears after six months, those who had physical therapy has the same or better rates of functional improvement compared to those who had surgery. The surgery group was given opioids after surgery to combat the pain from surgery while the physical therapy group was not given any pain medications. These studies among the many available confirm that physical therapy provides an effective means for pain management.

Physical therapy can also help improve the physical function of patients suffering from chronic pain. The American Physical Therapy Association (2018) asserts that there exists significant evidence indicating that exercise therapy — a central component of physical therapy — specifically designed for hip or knee osteoarthritis not only diminishes pain but also improves functions immediately following the treatment. In my situation I can attest to this improved functions. My nonsurgical knee has greater movement than my surgical knee. These claims can also be seen in the findings of a study conducted by Bennell, Egerton, Martin, Abbott, Metcalf, McManus, … and Smith (2014). The randomized clinical trial determined the effectiveness of physical therapy on pain and physical function in individuals suffering from hip osteoarthritis. The investigation documented that physical therapy not only diminishes pain but also improves functions immediately following the treatment (Bennell et al., 2014). The resultant improvements have also been found to be sustained for a long period (2 to 6 months) after the treatment. This evidence indicates that physical therapy improves physical functional and overall well-being, and thus it is a better option over the use of opioids.

Physical therapy provides a more comprehensive and integrated care to patients with pain than opioids use. In a typical care setting, physical therapists strive to establish working relationships and partnerships with their patients, their families, and other healthcare professionals in the process of managing the pain (American Physical Therapy Association, 2018). If implemented appropriately, these partnerships reduce or eliminate the need for pharmacological interventions. According to the American Physical Therapy Association (2018), a simple education session with a physical therapist can result in significant improvement in the patients’ physical function, the range of motion, and decreased pain. The importance of education in facilitating the requisite cultural transformation constitutes a primary recommendation to address the public health problem of pain (American Physical Therapy Association, 2018). Effective pain management begins with helping the patient to be better informed about pain and appropriate pain treatment strategies. Most important, the person in pain needs to recognize and understand that an individual’s beliefs, attitudes, and perceptions regarding pain can bear a significant impact on the outcome of the treatment. I personally walked into physical therapy skeptical on whether this would benefit me. The evaluation and education I was given was enlightening to me and gave me a positive outlook and a desire to attend physical therapy to fix what could become a life-long problem leading to chronic pain. Physical therapy creates an environment for achieving such improvements by enabling the patient to play a more active role in managing their own pain.

Another factor that makes physical therapy a better option over opioid use is the risks associated with taking prescription medications. Non-pharmacologic and non-opioid therapies are largely preferred for chronic pain management over medical treatment strategies. Despite being appropriate in some cases such as including cancer treatment, palliative care, and end-of-life care, prescribed opioids have serious risks to the patient, including depression, overdose, addiction, intolerance to drugs, and withdrawal symptoms (Chou, Turner, Devine, Hansen, Sullivan, Blazina,… & Deyo, 2015). Additionally, research has established an association between long-term opioid use with increased motor accidents, cardiovascular events, endocrinological harms, and fractures (Chou et al., 2015). The CDC proclaimed that overuse of addictive prescription painkillers specifically for the management of chronic pain is increasingly becoming a national public health epidemic in the United States with drug overdose death rate increased significantly from 12.3 per 100,000 populations in 2010 to 16.3 in 2015 (Rudd, 2016). The CDC further reported that 52,404 Americans succumbed to opioid overdose in 2015, a significant increase from 47,055 in 2014 (Rudd, 2016). 33,091 people, representing 63.1% of the deaths, involved opioid use. 1 in 4 people who are prescribed opioids will struggle with addiction. Think about that statistic, there is a high probability that popping that pill will lead you down a path of addiction. That is playing Russian roulette with your life, with the only benefit of masking a problem, not solving a problem. Scour the internet with a simple search for opioid, the statistics and studies and facts on the problems with opioids is staggering and heartbreaking. Consider Laura who died at age 17 from an overdose of alcohol, morphine and cocaine. Those are not opioids, true but given that “Laura became addicted to powerful painkiller opiates prescribed to her after an injury for a broken jaw she got playing soccer.” (Laura Hope Laws, 2017), it traces back to opiates as the start of the problem. There’s also Chris who overdosed on opiates at 22 years old. “When he was 20 years old, Christopher was in a minor car crash and was prescribed opioids for back pain following the crash.” (RXAwareness, 2017) There is case after case of similar heartbreaking stories. I doubt anyone who got addicted to opioids believed when they took that first prescribed pill that their life would change for the worse so dramatically.

In response to the prevalent overuse of opioids in the U.S., CDC published specific guidelines for prescribing opioids for the purpose of managing chronic pain. The guidelines stress the use of nondrug treatment approaches such as physical therapy over using long-term or high-dosage addictive prescription drugs. According to CDC’s guidelines, clinicians are expected to consider prescribing opioids in limited cases. Particularly, the health professionals are directed to pursue opioid treatment only if the anticipated benefits for both pain management and function are likely to overweigh the risks to the patient (American Physical Therapy Association, 2018). CDC also requires physicians to combine opioid use with non-pharmacologic and non-opioid pharmacologic treatments to help patients to effectively deal with pain. In advocating for the adoption of nondrug therapies, the CDC has documented several cases where traditional medical treatment strategies could be significantly reduced or avoided altogether.

This reliance on opiod has become so significant that the American Physical Therapy Association in conjunction with the CDC launched a campaign, #choosept, in support of physical therapy. The website www.moveforwardpt.com is filled with information on physical therapy and the benefits of it over opioid use. “According to the Centers for Disease Control and Prevention (CDC), sales of prescription opioids have quadrupled in the United States, even though ‘there has not been an overall change in the amount of pain that Americans report.’ (Moveforwardpt). Along with this national campaign individual states also have similar campaigns.

There are still many arguments people would make against physical therapy therefore preferring opioids. Many people see opioids and medications as an easy route when dealing with chronic pain. Although taking a pill instead of driving somewhere and doing rehabilitative exercises at least twice a week does sound a lot easier, at the end of the day it won’t truly solve the problem. Taking time to figure out what is causing the pain and solving it in the long run is more worth it. Time is another argument people will make against physical therapy. They don’t have enough time in a week, that’s just a lazy excuse. The majority of Physical Therapist offices have evening and early morning appointments to accommodate working individuals. Cost is another big argument against PT. It can be costly when looking at how many appointments it takes to complete but looking at it in the long run it will most likely be cheaper than the total cost of all the pain medications prescribed and filled, along with possible surgery, and also taking into consideration that you could end up with the same injury at a later date or worse end up addicted to opioids. These arguments against physical therapy can all be countered, there is no reason to not give physical therapy a try. It’s not going to make the situation worse, so the only harm could be time.

Physical therapy is a preferred treatment strategy for pain over opioid use. Opioids may result in desirable outcomes in some situations such as cancer treatment, palliative care, and end-of-life care. However, physical therapy provides a more comprehensive, integrated and cost-effective care that helps patients alleviate pain and improve physical function. The higher risks that accrue to opioid use, including depression, overdose, addition, intolerance to drugs, and withdrawal symptoms render physical therapy a relatively safer and effective pain management method over opioid use. The nondrug intervention enables the patients to develop a deeper understanding of their body, movement, and how physical movement can provide an effective solution to eliminating chronic pain. Physical therapy allows patients to actively take part in their recovery and outcome, as well as interact with the physical therapists on a daily basis, which help wean patients off pain medications.

Rhetorical Situation

The rhetorical situation involves an argument between me and a classmate who is taking medications for lower back pain but is not attending physical therapy. Many people often consider medication as their primary treatment for back pain and other different types of pains. I believe that physical therapy is a very effective intervention for pain management over opioid use. When you have shoulder, neck, joint, and pelvic pain, compression fractures, arm strings, and headaches, proper exercise can help alleviate your pain, improve your physical function and even build your tolerance reduce your pain. While medication may result in positive outcomes in pain management, physical therapy may lead to more desirable effects.

References

1. American Physical Therapy Association. (2018). CDC recommends physical therapy and other nondrug options for chronic pain. Retrieved June 4, 2018 from https://www.moveforwardpt.com/DidYouKnow/Detail.aspx?cid=cd52bad5-f4a3-4f1f-a387-9cd4a3bc1842
2. Bennell, K. L., Egerton, T., Martin, J., Abbott, J. H., Metcalf, B., McManus, F., … & Smith, C. (2014). Effect of physical therapy on pain and function in patients with hip osteoarthritis: A randomized clinical trial. Jama, 311(19), 1987-1997.
3. Chou, R., Turner, J. A., Devine, E. B., Hansen, R. N., Sullivan, S. D., Blazina, I., … & Deyo, R. A. (2015). The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a National Institutes of Health Pathways to Prevention Workshop. Annals of Internal Medicine, 162(4), 276-286.
4. Fritz, J. M., Childs, J. D., Wainner, R. S., & Flynn, T. W. (2012). Primary care referral of patients with low back pain to physical therapy: Impact on future health care utilization and costs. Spine, 37(25), 2114-2121.
5. Gatchel, R. J., McGeary, D. D., McGeary, C. A., & Lippe, B. (2014). Interdisciplinary chronic pain management: Past, present, and future. American Psychologist, 69(2), 119-130.
6. Gellhorn, A. C., Chan, L., Martin, B., & Friedly, J. (2012). Management patterns in acute low back pain: The role of physical therapy. Spine, 37(9), 775-782.
7. Rudd, R. A. (2016). Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. MMWR. Morbidity and mortality weekly report, 65. Retrieved from https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm
8. American Physical Therapy Association. Vision Statement for the Physical Therapy Profession and Guiding Principles to Achieve the Vision. Available at: http://www.apta.org/Vision/ Accessed June 17, 2016.
9. American Physical Therapy Association. (2018). 7 Staggering Statistics About America’s Opioid Epidemic Retrieved June 4, 2018 from
10. https://www.moveforwardpt.com/Resources/Detail/7-staggering-statistics-about-america-s-opioid-epi
11. Laura Hope Laws, 17, Morphine and Cocaine. (2017, April3). Retrieved June 4, 2018 from
12. https://www.getsmartaboutdrugs.gov/consequences/true-stories/laura-hope-laws-17-morphine-and-cocaine
13. Rx Awareness. (2017, September 22). Retrieved June 4, 2018, from
14. https://www.cdc.gov/rxawareness/stories/annmarie.html
15. Thackeray, A., Hess, R., Dorius, J., Brodke, D., & Fritz, J. (2017). Relationship of Opioid Prescriptions to Physical Therapy Referral and Participation for Medicaid Patients with New-Onset Low Back Pain. The Journal of the American Board of Family Medicine,30(6), 784-794. doi:10.3122/jabfm.2017.06.170064
16. Marchionne, M. (2013, March 19). Study: Therapy as good as surgery for knee repair. USA Today. Retrieved June 4, 2018, from https://www.usatoday.com/story/news/nation/2013/03/19/knee-surgery-therapy/1999603/