Importance  Nonpharmacologic methods of reducing the risk of new chronic opioid use among patients with musculoskeletal pain are important given the burden of the opioid epidemic in the United States.

Objective  To determine the association between early physical therapy and subsequent opioid use in patients with new musculoskeletal pain diagnosis.

Design, Setting, and Participants  This cross-sectional analysis of health care insurance claims data between January 1, 2007, and December 31, 2015, included privately insured patients who presented with musculoskeletal pain to an outpatient physician office or an emergency department at various US facilities from January 1, 2008, to December 31, 2014. The sample comprised 88 985 opioid-naive patients aged 18 to 64 years with a new diagnosis of musculoskeletal shoulder, neck, knee, or low back pain. The data set (obtained from the IBM MarketScan Commercial database) included person-level International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis codes, Current Procedural Terminology codes, and date of service as well as pharmaceutical information (National Drug Code, generic name, dose, and number of days supplied). Early physical therapy was defined as at least 1 session received within 90 days of the index date, the earliest date a relevant diagnosis was provided. Data analysis was conducted from March 1, 2018, to May 18, 2018.

Main Outcomes and Measures  Opioid use between 91 and 365 days after the index date.

Results  Of the 88 985 patients included, 51 351 (57.7%) were male and 37 634 (42.3%) were female with a mean (SD) age of 46 (11.0) years. Among these patients, 26 096 (29.3%) received early physical therapy. After adjusting for potential confounders, early physical therapy was associated with a statistically significant reduction in the incidence of any opioid use between 91 and 365 days after the index date for patients with shoulder pain (odds ratio [OR], 0.85; 95% CI, 0.77-0.95; P = .003), neck pain (OR, 0.92; 95% CI, 0.85-0.99; P = .03), knee pain (OR, 0.84; 95% CI, 0.77-0.91; P < .001), and low back pain (OR, 0.93; 95% CI, 0.88-0.98; P = .004). For patients who did use opioids, early physical therapy was associated with an approximately 10% statistically significant reduction in the amount of opioid use, measured in oral morphine milligram equivalents, for shoulder pain (−9.7%; 95% CI, −18.5% to −0.8%; P = .03), knee pain (−10.3%; 95% CI, −17.8% to −2.7%; P = .007), and low back pain (−5.1%; 95% CI, −10.2% to 0.0%; P = .046), but not for neck pain (−3.8%; 95% CI, −10.8% to 3.3%; P = .30).

Conclusions and Relevance  Early physical therapy appears to be associated with subsequent reductions in longer-term opioid use and lower-intensity opioid use for all of the musculoskeletal pain regions examined.

Published: December 14, 2018. doi:10.1001/jamanetworkopen.2018.5909

{{cta(‘c6ecd159-44e1-4eb3-9940-fbb5cb2761d5’)}}

INTRODUCTION:

A variety of musculoskeletal disorders (MS) have been associated with diabetes mellitus (DM). This study aimed at assessing the prevalence and associated factors of MS disorders in Moroccan diabetic patients.

METHODS:

A cross-sectional study enrolled consecutive patients with DM. We recorded demographic features of patients and characteristics of DM. MS disorders and vascular complications were assessed by clinical examinations and investigations. Associated factors of MS disorders were assessed by univariate and multivariate analyses.

RESULT:

376 subjects were included; 84.6% had type 2 DM. The participants’ median age was 54 years [45-62]; 41% had one or more vascular complications. 34.4% had one or more MS disorders. Osteoarthritis was present in 19.4% of patients. Hand disorders were seen in 14.4%. Shoulder capsulitis was present in 12.5%. Long duration of diabetes and dyslipidemia were associated with increased prevalence of hand abnormalities (P = 0.017; P = 0.019, respectively). Age and dyslipidemia were associated with shoulder capsulitis (P = 0.019; P = 0.047, respectively). Female gender, overweight, and nephropathy were associated with increased odds of osteoarthritis (P = 0.009, P = 0.004, and P = 0.032, respectively).

CONCLUSION:

MS disorders are frequent in this population and associated with various factors. HbA1c level does not appear to be associated with development of MS disorders.

Int J Rheumatol. 2018 Jun 19;2018:3839872. doi: 10.1155/2018/3839872. eCollection 2018.

{{cta(‘c6ecd159-44e1-4eb3-9940-fbb5cb2761d5’)}}

OBJECTIVES:

To determine and compare estimates of the smallest worthwhile effect (SWE) for physiotherapy in neck, shoulder and low back patients, and to investigate the influence of socio-demographic, clinical and psychological factors on these estimates.

METHODS:

A structured telephone interview was conducted before treatment was commenced in 160 patients referred for primary care physiotherapy. The benefit-harm trade-off method was used to estimate the SWE of physiotherapy for the following outcomes; pain, disability and time to recovery, compared with the improvement achieved without any treatment (natural course). Regression analyses were used to assess the influence of socio-demographics, clinical variables and intake scores on pain, disability and psychological scales.

RESULTS:

The median SWE for improvements on pain and disability was 20% (interquartile range [IQR] 10-30%) and the SWE for time to recovery was 10 days (IQR 7-14 days) over a period of six weeks. These estimates did not differ with respect to pain location (neck, shoulder or back) and were generally unaffected by socio-demographic, clinical and psychological factors.

CONCLUSION:

People with neck, shoulder and low back pain need to see at least 20% of additional improvement on pain and disability compared with natural recovery to consider that the effect of physiotherapy is worthwhile, given its costs, potential side effects and inconveniences.

J Clin Epidemiol. 2018 May 28. pii: S0895-4356(17)31379-3. doi: 10.1016/j.jclinepi.2018.05.019. [Epub ahead of print]

{{cta(‘c6ecd159-44e1-4eb3-9940-fbb5cb2761d5’)}}

Emergency department-initiated physical therapy (ED PT) is an emerging resource in the United States, with the number of ED PT programs in the United States growing rapidly over the last decade. In this collaborative model of care, physical therapists are consulted by the treating ED physician to assist in the evaluation and treatment of a number of movement and functional disorders, such as low back pain, peripheral vertigo, and various gait disturbances. Patients receiving ED PT benefit from the physical therapist’s expertise in musculoskeletal and vestibular conditions and from the individualized attention provided in a typical bedside evaluation and treatment session, which includes education on expected symptom trajectory, recommendations for activity modulation, and facilitated outpatient follow-up. Early data suggest that both physicians and patients view ED PT services favorably, and that ED PT is associated with improvement of several important clinical and operational outcomes. Hospital systems interested in building their own ED PT program may benefit from the key steps outlined in this review, as well as a summary of the typical clinical volumes and practice patterns encountered at existing programs around the country.

Am J Emerg Med. 2018 May 24. pii: S0735-6757(18)30432-7. doi: 10.1016/j.ajem.2018.05.053. [Epub ahead of print]

{{cta(‘c6ecd159-44e1-4eb3-9940-fbb5cb2761d5’)}}

Headache and musculoskeletal pain are associated with both physical and mental health symptoms, which together are mutually reinforcing. Addressing mental and physical health symptoms (including pain) concomitantly may provide an effective and efficient way to improve outcomes in this population. We tested an evidence-based, eight-session multimodal group program, the Relaxation Response Resiliency Program (3RP), in patients with headache and musculoskeletal pain. A total of 109 adults (30 with headaches, 79 with musculoskeletal pain). Participant were 109 adults (30 with headaches, 79 with musculoskeletal pain) referred by their medical doctor, who completed a battery of questionnaires before and after completion of the 3RP. On average, patients with headache and musculoskeletal pain had higher pretreatment scores for anxiety, depression, and somatization symptoms than the nonpatient normative sample for the Symptom Checklist 90-Revised. Significant improvements were identified from pre- to post-treatment in all mental health symptoms (moderate to large effects) and frequency of pain and co-occurring physical health symptoms (small to moderate effects). Patients also reported significant decreases in degree of discomfort and life interference, which were relatively more modest in the musculoskeletal pain group compared with the headache group. Overall, results of this study suggest that the 3RP may be an effective treatment for reducing pain and psychological symptoms in patients with headaches and musculoskeletal pain. Future work is needed to evaluate the 3RP via a randomized clinical trial in these patient populations.

Pain Manag Nurs. 2018 May 14. pii: S1524-9042(17)30608-2. doi: 10.1016/j.pmn.2018.04.003. [Epub ahead of print]

{{cta(‘c6ecd159-44e1-4eb3-9940-fbb5cb2761d5’)}}

Joint conditions incapacitate free movement driving to a sedentary lifestyle, a major risk factor for chronic diseases. Regenerative procedures, involving the use of mesenchymal stem/stromal cells along with platelet-rich plasma (PRP), can help patients with these conditions. We describe the main characteristics of cellular products (bone marrow concentrate, stromal vascular fraction of adipose tissue, and mesenchymal stem/stromal cells derived from these tissues), and the potential benefits of combination with PRP in 3 scenarios: PRP lysates used during laboratory cell expansion; PRP to prime cellular products or the host tissue before cell implantation; PRP used as a vehicle for cell transplantation and to provide trophic signals. Clinical studies exploring the benefits of combination products are limited to case series and few controlled studies, involving either arthroscopy or percutaneous injections. Combination products are making their way to clinics but further experimental and clinical research is needed to establish protocols and indications.

Sports Med Arthrosc Rev. 2018 Jun;26(2):59-63. doi: 10.1097/JSA.0000000000000191.