Relationships between physical therapy intervention and opioid use: A scoping review

A Scoping Review of the Predictive Qualities of Walking Speed in Older Adults

BACKGROUND AND PURPOSE

Walking speed (WS) is an easily assessable and interpretable functional outcome measure with great utility for the physical therapist providing care to older adults. Since WS was proposed as the sixth vital sign, research into its interpretation and use has flourished. The purpose of this scoping review is to identify the current prognostic value of WS for the older adult.

METHODS

A scoping review was conducted using PubMed, CINAHL, and SPORTDiscus to find relevant articles highlighting the predictive capabilities of WS for older adults. Titles and abstracts were reviewed to identify relevant articles. Articles were excluded based on the following criteria: sample included both younger and older adults without separate analyses, sample was focused on a particular disease, if the study was published before 2017, or if the study did not report relevant cut points for interpretation of WS. The search returned 1064 results. Following removal of articles not meeting inclusion criteria and critical appraisal, relevant cut points were extracted from 47 original research publications.

RESULTS AND DISCUSSION

A preliminary review of the included articles showed that WS is a valuable prognostic tool across many health domains, including mental health, mortality, disability, pain, bone and joint health, falls, cognition, physical activity, metabolic health, risk for cardiovascular disease, socialization, and metabolic health. The fastest WS of 1.32 meters per second (m/s) served as a cutoff for decreased risk for incident development of type 2 diabetes, while the slowest WS of less than 0.2 m/s was associated with increased duration of hospitalization. Multiple studies reported on the prognostic value of WS slower than 1.0 m/s.

CONCLUSION

Although the reported range of predictive WS values was broad, multiple studies found WS of approximately 1.0 m/s to be a useful marker for delineating risk or decline across a variety of health domains. Clinicians may find it useful to use a WS slower than 1.0 m/s as a "yellow flag" to guide evaluation and intervention for their older adult clients.

Delayed timing of physical therapy initiation increases the risk of future opioid use in individuals with knee osteoarthritis: a real-world cohort study

OBJECTIVE

We assessed whether late versus early initiation of physical therapy (PT) was related to greater risk of future opioid use in people with knee osteoarthritis (OA) who receive PT.

METHODS

We used Commercial and Medicare Advantage claims data from 1999 to 2018 from American adults with incident knee OA referred for PT within 1 year of diagnosis. We categorised people as opioid naïve or opioid experienced based on prior prescriptions. We examined the association of timing of PT initiation with any and chronic opioid use over 1 year.

RESULTS

Of the 67 245 individuals with incident knee OA, 35 899 were opioid naïve and 31 346 were opioid experienced. In the opioid naïve group, compared with PT within 1 month, PT 1 to <3, 3 to <6, 6 to <9, 9-12 months from diagnosis was associated with adjusted risk ratio (aRR (95% CIs)) for any opioid use of 1.18 (1.10 to 1.28), 1.49 (1.37 to 1.61), 1.73 (1.58 to 1.89) and 1.93 (1.76 to 2.12), respectively; aRRs (95% CIs) for chronic opioid use were 1.25 (1.01 to 1.54), 1.83 (1.48 to 2.26), 2.29 (1.82 to 2.89) and 2.50 (1.96 to 3.19). Results were similar among opioid experienced; aRRs (95% CIs) for any opioid use were 1.19 (1.14 to 1.24), 1.32 (1.26 to 1.37), 1.39 (1.32 to 1.45) and 1.54 (1.46 to 1.61); aRRs (95% CIs) for chronic opioid use were 1.25 (1.17 to1.34), 1.43 (1.33 to 1.54), 1.53 (1.41 to 1.66) and 1.65 (1.51 to 1.80).

CONCLUSION

Compared with PT initiation within 1 month, delayed PT initiation was associated with higher risk of opioid use in people with incident knee OA. The longer the delay in PT initiation, the greater was the risk.

Opioid Initiation Within One Year After Starting a Digital Musculoskeletal (MSK) Program: An Observational, Longitudinal Study with Comparison Group

Background

In-person, conservative care may decrease opioid use for chronic musculoskeletal (MSK) pain, but the impact of digitally delivered conservative care on opioid use is unknown. This study examines associations between a digital MSK program and opioid initiation and prescriptions among opioid naive adults with chronic MSK pain.

Methods

This observational study used commercial medical and pharmacy claims data to compare digital MSK program members to matched physical therapy (PT) patients. Outcomes were any opioid prescriptions and opioid prescriptions per 100 participants within the 12-months after starting a digital MSK program. After propensity-score matching, we conducted multivariate regression models that controlled for demographic, comorbidity, and baseline MSK healthcare use.

Results

The study included 4195 members and 4195 matched PT patients. For opioid initiation, 7.89% (95% Confidence Interval [CI]: 7.07%, 8.71%) of members had opioid prescriptions within 12 months after starting the digital MSK program versus 13.64% (95% CI: 12.60%, 14.67%) of matched PT patients (p < 0.001). Members had significantly fewer opioid prescriptions (16.73 per 100 participants; 95% CI: 14.11, 19.36) versus PT patients (22.36 per 100 participants; 95% CI: 19.99, 24.73). Members had lower odds (OR: 0.52, 95% CI: 0.45, 0.60) of initiating opioids and significantly fewer prescriptions per 100 participants (beta: -6.40, 95% CI: -9.88, -2.93) versus PT patients after controlling for available confounding factors.

Conclusion

An MSK program that delivers conservative care digitally may be a promising approach for decreasing opioid initiation among individuals with chronic MSK pain given the limitations of the observational design and matching on only available covariates.

Application of risk assessment tools to predict opioid usage after shoulder surgery

Background

Currently 128 people die daily from opioid-related overdoses in the United States. This burden has instigated a search for viable means to guide postoperative prescription decision-making. The Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patient with Pain (SOAPP) are validated risk assessment tools to predict opioid usage in high-risk populations. The purpose of this study was to evaluate the accuracy of these opioid risk assessments and pain intensity scores, including the Patient-Reported Outcomes Measurement Information System (PROMIS), to predict postoperative opioid use and dependence in shoulder surgery.

Methods

A retrospective review of 81 patients who underwent shoulder surgery and completed 3 preoperative risk and pain assessments within a single hospital system from 2018 to 2020 was performed. Demographic variables and ORT-O, SOAPP-R (the revised version of the SOAPP assessment), and PROMIS 3a scores were recorded from preoperative assessments. Opioid prescriptions were recorded from Electronic-Florida Online Reporting of Controlled Substances Evaluation. Dependence was defined as opioid prescriptions at or greater than 3 months after surgery. Risk assessment scores were compared and tested against postoperative opioid prescriptions using statistical analyses and logistic regression modeling.

Results

In the cohort, there were 36 female and 45 male patients with an average age of 64.5 years and body mass index of 28.0. Preoperatively, the average pain score was 6.2, and 7.8% of patients reported prolonged preoperative narcotics use. The average ORT-O score was 3.0, with 35.8% of patients defined as either medium or high risk, and the average PROMIS pain intensity preoperatively was 10.8. Neither the ORT-O nor the PROMIS pain score were good predictors of postoperative opioid dependence (area under curve = 0.39 and 0.43, respectively). The SOAPP-R performed slightly better (area under curve = 0.70) and was the only assessment with significantly different mean scores between patients with postoperative opioid dependence and those without (33.4 and 24.5, respectively, P = .049) and a moderate correlation to postoperative total morphine equivalents (R = 0.46, P = .007).

Conclusion

With recent focus on preoperative risk assessments to predict postoperative opioid use and dependence, it is important to understand how well these tools work when applied to orthopedic patients. While the ORT may be helpful in other fields, it does not seem to be a strong predictor of postoperative opioid use or dependence in patients undergoing various types of shoulder surgery. Future studies are needed to explore the utility of the SOAPP-R in a larger sample and identify tools applicable to the orthopedic population to assist surgeons in screening at-risk patients.