People who get prompt physical therapy for pain in the knee, shoulder or lower back may have less need for opioid painkillers, new research suggests.
The study, of nearly 89,000 U.S. patients, found that people given physical therapy for their pain were 7 percent to 16 percent less likely to fill a prescription for an opioid.
The researchers said the findings suggest that early physical therapy is one way to reduce Americans’ use of the risky, potentially addictive painkillers.
“For people dealing with these types of musculoskeletal pain, it may really be worth considering physical therapy — and suggesting that your health care provider give you a referral,” said lead researcher Dr. Eric Sun. He is an assistant professor of anesthesiology, perioperative and pain medicine at Stanford University.
Dr. Houman Danesh, a pain management specialist who was not involved in the study, agreed.
“This study shows how important physical therapy can be,” said Danesh, who directs the division of integrative pain management at Mount Sinai Hospital, in New York City.
Physical therapy does require a much bigger investment than taking pain medication — and, he said, patients may have to travel to find a therapist who is the best fit for them.
“Physical therapy is highly variable,” Danesh said. “Not all physical therapists are equal — just like not all doctors are.”
But the effort can be worth it, according to Danesh, because unlike painkillers, physical therapy can help people get at the root of their pain — such as imbalances in muscle strength.
“You can take an opioid for a month, but if you don’t get at the underlying issue [for the pain], you’ll go back to where you started,” he explained.
The findings, published online Dec. 14 in JAMA Network Open, come amid a growing national opioid epidemic. While many people who abuse opioids are hooked on illegal versions — like heroin and illicitly manufactured fentanyl — prescription opioid abuse remains a major concern.
Medical guidelines, from groups like the American College of Physicians, now urge doctors to first offer non-drug options for muscle and joint pain. Opioids, such as Vicodin and OxyContin, should be reserved as a last resort.
The new findings support those guidelines, according to Sun’s team.
The results are based on insurance records from nearly 89,000 Americans who were diagnosed with pain affecting the lower back, knee, shoulder or neck.
All of the patients had a second doctor visit within a month of the diagnosis, and an opioid prescription within 90 days. So the group included only people with significant pain, the researchers said.
Overall, 29 percent of the patients started physical therapy within 90 days of being diagnosed. Compared with those who did not have physical therapy, the therapy patients were 7 percent to 16 percent less likely to fill an opioid prescription — depending on the type of pain they had.
And when physical therapy patients did use opioids, they tended to use a little less — about 10 percent less, on average, the researchers found.
The findings do not prove that physical therapy directly prevented some opioid use.
Sun explained that, “since physical therapy is more work than simply taking an opioid, patients who are willing to try physical therapy may be patients who are more motivated in general to reduce opioid use.”
But his team did account for some other factors — such as a patient’s age and any chronic medical conditions. And physical therapy was still linked to less opioid use.
While this study focused on physical therapy, Danesh said, there are other opioid alternatives with evidence to support them.
Depending on the cause of the pain, he said, people may find relief from acupuncture; exercises to strengthen particular muscle groups; injections of anti-inflammatory steroids or other medications; platelet-rich plasma — where a patient’s own platelets (a type of blood cell) are injected into an injured tendon or cartilage; and nerve ablation, where precisely controlled heat is used to temporarily disable nerves causing the pain.
It’s also possible that some simple lifestyle adjustments will help, Danesh pointed out. An old worn-out mattress could be part of your back pain woes, for instance. Ill-fitting, non-supportive or worn shoes could be feeding your knee pain.
What’s important, Danesh said, is to get at the underlying issues.
“We have to match patients with the right treatment for them,” he said.
The U.S. National Center for Complementary and Integrative Health has more on managing pain.
SOURCES: Eric Sun, M.D., Ph.D., assistant professor, anesthesiology, perioperative and pain medicine, Stanford University School of Medicine, Stanford, Calif.; Houman Danesh, M.D., assistant professor, anesthesiology, perioperative and pain medicine, and director, division of integrative pain management, Mount Sinai Hospital, New York City; Dec. 14, 2018, JAMA Network Open, online
While people typically associate osteoporosis with women, men aren’t immune.
Osteoporosis commonly leads to weakening of the skeleton and fractures. According to the U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases, by the age of 70, men and women are losing bone mass at about the same rate.
The institute mentions these factors that raise a man’s chances of developing osteoporosis:
- Having a chronic disease affecting the kidneys, lungs, stomach or intestines.
- Taking certain medications regularly.
- Having low testosterone.
- Smoking, drinking alcohol excessively, getting insufficient calcium or failing to get enough exercise.
- Getting older.
As if older women didn’t already worry enough about their bone health, new research suggests that anxiety may up their risk for fractures.
Based on an analysis involving almost 200 postmenopausal Italian women, the finding builds upon previous research linking anxiety to a higher risk for heart disease and gastrointestinal problems.
“Our findings are quite surprising because an association between anxiety levels and bone health was not reported before,” said study author Dr. Antonino Catalano, though the study did not prove that anxiety caused fracture risk to rise.
Catalano is an expert in internal medicine, bone metabolism and osteoporosis with the department of clinical and experimental medicine at the University Hospital of Messina in Italy.
As to what might explain the association, Catalano pointed to a number of factors.
“Our opinion is that anxious women are more likely to engage in poor health behaviors, such as smoking or a poor diet,” he said. “Moreover, the negative effects of stress hormones on bone status may be considered as also enhancing fracture risk.”
Catalano added that women who struggle with higher levels of anxiety were also found to have lower levels of vitamin D. “Poor vitamin D status has been previously associated with increased fracture risk,” he said.
The researchers noted that osteoporosis is the most common metabolic bone disease in the world. An estimated 33 percent of women and 20 percent of men will suffer from an osteoporosis-related fracture at some point in their lives.
The research team also noted that 7 percent of the world’s population suffers from anxiety disorders.
To see how the two issues might intersect, the researchers focused on patients attending one Italian osteoporosis clinic in 2017.
On average, participants were nearly 68 years old. All underwent in-depth health screenings to assess, among other things, prior fracture history, arthritis diagnoses, heart and lung health, and smoking and alcohol habits. Bone mineral density exams were also done.
A wide range of mental health concerns were also explored, including depression, tension, insomnia, memory and anxiety levels ranging from moderate to severe.
The investigators determined that women who had the most anxiety faced a noticeably higher fracture risk, compared with women with the lowest degree of anxiety.
Higher anxiety was linked to a 4 percent greater risk for a major fracture over a 10-year period, and a 3 percent greater risk for a hip fracture in the same time frame, said Dr. JoAnn Pinkerton, executive director of the North American Menopause Society.
The study was published online May 9 in the society’s journal Menopause.
Higher anxiety was also linked to lower bone mineral density scores in both the lower back area (known as the lumbar spine) and in the femoral neck area (just below the ball of the hip joint).
The findings should encourage physicians to explore anxiety levels among older women when assessing fracture risk, the researchers said.
Pinkerton highlighted a number of steps women can take to minimize fracture risk as they age.
“Women reach peak bone mass around age 35,” Pinkerton noted. “So it becomes important for perimenopausal women and menopausal women to get adequate amounts of calcium.” Experts recommend 1,200 milligrams a day, between diet and supplements, she said.
Getting sufficient magnesium and vitamin D — from either sun exposure or supplements — is also critical, she added, alongside routine strength and resistance training. That, she said, can include walking, lifting weights or using elliptical machines.
Women should also avoid smoking, drinking too much, being sedentary, taking excessive thyroid replacement medications, and/or medications such as steroids or proton pump inhibitors, Pinkerton said.
For women particularly concerned about anxiety, she suggested turning to “mindfulness, cognitive therapy, self-calming strategies, yoga, or seeking help through counseling or, if needed, medications,” she said.
As for hormone therapy, Pinkerton stressed that while it’s not a treatment for depression or anxiety, “it can sometimes be helpful in women, and is sometimes used alone or in combination, depending on whether women have menopausal symptoms or respond favorably to a trial of hormone therapy.”
There’s more on bone health at the U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases.
SOURCES: Antonino Catalano, M.D., Ph.D., expert in internal medicine, bone metabolism, and osteroporosis, department of clinical and experimental medicine, University Hospital of Messina, Italy; JoAnn Pinkerton, M.D., executive director, North American Menopause Society, and professor, obstetrics and gynecology, University of Virginia Health System, Charlottesville; May 9, 2018, Menopause, online
Osteoporosis patients who take “holidays” from bisphosphonate drugs are at increased risk for fractures, a new study finds.
A six-year follow-up of patients who took a break from the bone-building drugs found 15 percent of them suffered fractures, according to researchers at Loyola University in Maywood, Ill.
“Fracture risk needs to be regularly assessed during the drug holiday and treatment resumed accordingly,” said Dr. Pauline Camacho and her colleagues.
Bisphosphonates, such as alendronate (Fosamax) and risedronate (Actonel), are the most widely prescribed osteoporosis drugs. They are designed to slow or prevent bone loss.
But patients who take these drugs for long periods are typically told to take temporary breaks to prevent rare but serious side effects to the jaw and thighs.
However, there is little data on how long these breaks should last, the researchers explained.
To shed light on the issue, they examined the medical records of patients (371 women, 30 men) with osteoporosis or osteopenia (weak bones but not osteoporosis). Patients took bisphosphonates for an average of 6.3 years before beginning breaks from the drugs.
Over six years, 15.4 percent of the patients suffered fractures after going on their drug holiday. The most common fracture sites were the wrist, foot, ribs and spine. However, foot fractures are not currently considered osteoporosis-related fractures, the researchers noted.
The patients most likely to suffer fractures were older and had lower bone mineral density at the beginning of the study. Patients who suffered fractures were put back on bisphosphonates.
The yearly incidence of fractures ranged from about 4 percent to almost 10 percent, with most occurring during the fourth and fifth years.
“Patients who begin drug holidays at high risk for fracture based on bone mineral density, age or other clinical risk factors warrant close follow-up during the holiday, especially as its duration lengthens,” the researchers said in a university news release.
The study was published recently in Endocrine Practice.
The U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases has more on osteoporosis.
SOURCE: Loyola University Health System, news release, May 4, 2018