Physical Therapy as an Alternative to Opioids for Chronic Pain Management

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By Meggie Morley, DPT Student

In recent years there has been a rise of prescription opioid use in the United States. On the average day, 650,000 opioid prescriptions are dispensed and between the years 2000 and 2010 the amount of opioid prescriptions nearly doubled from 11.3% to 19.6% among all pain visits .  There are patient scenarios when opioid prescription and use is appropriate such as hospice, palliative care, and acute pain management, but for the treatment of chronic pain (pain lasting three months or greater) there is not clear evidence suggesting that opioid use is beneficial.

As the rise in opioid use becomes a national epidemic, the CDC has released guidelines for prescribing opioids for chronic pain.  The guidelines also recommend chronic pain management with non-drug choices such as physical therapy, cognitive behavioral therapy and weight loss. As opioids have side effects such as sedation, dizziness, nausea, dependence and respiratory depression, treatments such as physical therapy may be a beneficial alternative.

In a systematic review by Hayden et al, sixty-six studies were reviewed to examine the effects of exercise therapy for low back pain versus other conservative treatments or no treatment. 

Sixty-one randomized control trials met the inclusion criteria of evaluating the effectiveness of exercise on acute, sub-acute, and chronic low back pain. The outcome measures for patient improvement were both pain and functional scales. The authors concluded that exercise therapy is effective for decreasing pain and improving patient function among adults with chronic low back pain. The results for sub-acute low back pain were inconclusive, and exercise therapy for acute low back pain was determined to have the same effectiveness of other conservative treatments or no treatment.

The management of chronic pain is a complex issue, but education for both healthcare providers and patients on the various treatment options is critical for addressing the rise of opioid use in the United States. More information can be found on the APTA website, where they have started a campaign titled #ChoosePT to further discuss physical therapy as a method for treating chronic pain.

FullSizeRender 9Blog Post written by Meggie Morley, DPT Student at Columbia University. Meggie is currently in her final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources

Daubresse M, Chang HY, Yu Y, Viswanathan S, Shah ND, Stafford RS, Kruszewski SP, Alexander GC. Ambulatory diagnosis and treatment of non-malignant pain in the United States, 2000–2010. Medical care. 2013 Oct;51(10).

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opiods for Chronic Pain –  United Staes, 2016. MMWR Recomm Rep 2016;65(No. RR-1):49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.

Hayden J, Van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non‐specific low back pain. The Cochrane Library. 2005 Jul 20.

http://www.moveforwardpt.com/Resources/Detail/physical-therapy-vs-opioids-when-to-choose-physica

Movement of the Week: Pitching Lateral Speed Lunge

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This movement is part of a pitching deceleration series. Pitchers need to be able to decelerate not only their arm but their entire body. I like to use this not only for deceleration but also for training: foot placement, coordination, hip/shoulder disassociation and agility.

How it’s done:

Hold a pair of lighter dumbbells at shoulder height in 90 degrees of external rotation.  Shuffle once to the side and open up towards the shuffle direction leading with the foot followed by the hip, trunk and finally allow the opposite arm to fall across the body in a pitching motion. The key is allowing the arm to fall, this should not be an active throw, it should be a faster but controlled fall. The trunk should hinge forward at the hip over a flexed knee and ankle. Keep the opposite arm up in an externally rotated position, reverse the motion and repeat in the opposite direction.

Standing Multi-Plane Core Stability

Dead Bugs, Bird Dogs, Bridges & Plank variations are a great place to start a core stability routine.  The problem is that we don’t live our lives on a table.  Once the core musculature is activated and we can move our limbs while stabilizing our spine in a safe gravity reduced position its time to get off the table and introduce gravity and resistance.  This routine is a nice place to start because the majority of these movements are isometric at the spine yet they are able to introduce stability in 3 stances and 3 planes.  This is the environment that most of us live and play in.  The upper extremities do the majority of the movement while the spine and core musculature need to respond the increasing demands created by the changing lever arms of the band resistance.  This routine works well as a second step to traditional core stability movements because it complies with post-op restrictions and provides a more challenging environment where safety is still a priority.

Movement of the Week: Band Resisted Lunge + Reach

This is a more advanced version of a standing core stability series I take many of my lumbar patients through. I like this for clients with hip & pelvic stability issues as well as for athletes having difficulty controlling frontal plane knee forces during lunge tasks. The purpose of these movements is to maintain posture through the ankles, knees, hips, trunk and shoulders while performing a single plane movement and resisting isometric multi-plane forces applied by the horizontal pull of the band as the lever arm.

How it’s done:

Start with the hands against the body and take a fencing lunge forward, once the lunge posture is stable reach the hands forward or overhead. Make sure the hands go straight forward or straight upwards and there is no deviation towards or away from the pull of the band, then reverse the sequence back to the starting position. After the desired number of reps turn and face the opposite direction and repeat.

Movement flaws can easily be observed from side and front views, look for over compensation strategies as well. Modifications can be made by changing the band resistance or shortening the lever arm by remaining in the starting position with the hands close to the body during the entire task.

Below are a few additional variations:

1. Overhead Stick Reach: This makes it easier to get overhead, sometimes clients have difficulty getting overhead witch the narrow grip.

2. Long Arm Rotational Lunge +  Reach:  This is a more advanced version of the rotational lunge + reach movement. The longer lever arm intensifies the rotational core demand.

There are many other variations, feel free to share some of yours with me in the comments.

Basic Scapular Loading & Stability

In order to progress to more complex shoulder loading its important build a solid base.  Here are a few simple scapular loading and shoulder stability exercises that can be made more challenging and once mastered will help with the performance heavier and more dynamic overhead activities.  These exercises are part of a larger arm care routine I have my overhead athletes perform after the manual tissue and joint prep, and prior to a full body movement prep.

These can be easily replicated out on the field using the dugout bench.

The Human Movement System

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Before I get into what the ‘Human Movement System’ is, let start with a more important question. Why should you see a Physical Therapist? This sounds like a question that may need more context because PTs work in a variety of settings: hospitals, convalescent facilities, outpatient clinics, home therapy, sports teams and the list goes on.  But in actuality the answer is simple. Continue reading “The Human Movement System”