For years, opioids for acute, chronic, and post-surgery pain were considered an affordable and effective pain management solution. That view ended once it became clear these medications were leading to rampant abuse and addiction, contributing to more than 47,600 overdose deaths in the United States in 2017.
“We know that opioids have been the go-to for chronic pain and acute pain for many years, and more recently, we’re learning that opioids are not effective for chronic pain,” says Michelle Despres, PT, CEAS II, vice president at One Call in Jacksonville, FL. One Call provides workers’ compensation care management services.
“Opioids give brief relief early on, but they have no lasting effect,” Despres says. “It doesn’t help people, but they continue to follow that course and then get addicted and have all these other problems that continue to grow once they’re addicted to opioids.” (More information is available at: http://bit.ly/2RNG0nf.)
Brief treatment with opioids post-surgery and opioid treatment for cancer pain still work well, but clinicians increasingly are looking for alternatives for chronic pain. This is where physical therapy sessions can be of benefit, Despres says.
Before the late 1990s, when physicians began to prescribe opioids for noncancer pain more readily, doctors would treat back pain and chronic pain with acetaminophen, nonsteroidal anti-inflammatories, and recommend heat, ice, physical therapy, and self-massage, says Marcos Iglesias, MD, FAAFP, FACOEM, senior vice president and chief medical officer at Broadspire, a Crawford company and third-party administrator in Sunrise, FL.
Many physicians have used physical therapy as an alternative to medication in treating musculoskeletal pain, he notes.
“I’m a proponent of active methods of dealing with pain, and by that I mean something that engages the patient, as opposed to something done passively to the patient,” Iglesias says.
The active approach includes exercise, physical, and social activities.
“Physical therapy, exercise, and returning to normal activities have the best long-term outcomes, and that’s what we should be doing,” Iglesias says. “It’s a matter of what the evidence points to.”
But it’s not easy to convince patients to try these alternatives to opioids for their pain, and physicians are not always aware of nonmedication pain modalities. This is where case managers can help, Iglesias says.
“Case managers have a wonderful opportunity to influence both patients and physician drivers of opioid use,” he says.
For example, when a hospital patient is prescribed opioids post-surgery or after a painful illness, the case manager can educate and explain the proper use and disposal of the drug: “If you take this medication home, make sure it’s in a safe or locked place. Do you have children at home, or are there other people who will have access to your medication? How will you protect those people? What do you do with leftover medication? How do you dispose of it?” Iglesias says.
Case managers also can talk to patients about how they feel about shorter prescriptions of opioids and share patients’ desires with physicians.
“You can tell the physician that the patient doesn’t think there will be a need for more than two or three days of the medication,” he says.
Case managers can ask doctors whether they’d be willing to prescribe the opioid for three days, then schedule a follow-up appointment to check on the patients’ pain level, Iglesias explains.
“Physicians think they’d rather the patient didn’t return to the hospital or emergency room because of pain, so they prescribe one to three weeks of opioids. But here’s an opportunity to reduce the number of days the drug is prescribed and dispensed,” he says.
Providers’ attitudes about opioids have shifted over the decades, and the nation is in the middle of another big change.
“When I worked at an urgent care center in the 1990s, we had a lot of people coming in because of pain and, usually, seeking an opioid,” Iglesias says. “Before the doctor saw the patient, someone would have a conversation with them, saying, ‘We’re happy to see you for your pain, but please be advised that we don’t use opioids.’”
When a patient decided to stay at the center for pain treatment, physicians would offer nonopioid treatments, he says. In those days, doctors were reluctant to prescribe opioids for noncancer pain. They worried about its addictive quality and the side effects, which include constipation, itching, and sexual dysfunction, Iglesias says.
“It’s not that opioids just cause adverse effects, potential addiction, and overdose deaths,” he explains. “But they’re not that effective for some pain, including orthopedic and musculoskeletal pain, which does not improve as much as we thought compared with over-the-counter measures like ibuprofen and Tylenol.”
These concerns began to fade after Purdue came out with OxyContin in the mid-1990s, and this drug was marketed as a safe treatment for noncancer and chronic pain. Societal views about pain began to shift toward thinking of pain as the fifth vital sign and that patients should be pain-free, he says.
“My colleagues started prescribing more opioids, higher doses, longer prescriptions, and even using methadone for musculoskeletal pain. And that’s when I knew we were in deep trouble,” Iglesias says.
“Methadone had only been used in helping individuals overcoming heroin addiction,” he adds. “It’s a strong medication with complex pharmacology, and it can cause adverse effects that other opioids don’t cause — and now it was being used for low back pain.”
Two decades later, and the medical community and society have shifted again. Opioids have proven devastating to many communities, with mortality rates that continue to rise. Physicians, insurers, and regulators have cracked down on opioid prescriptions, and nonopioid pain therapies are gaining more attention again, Iglesias says.
Look to Physical Therapy as Alternative
When people experience chronic pain, their bodies are out of balance. It might be that the initial acute pain from an injury has caused them to limit their movement, protecting their injury site. This causes pain to dig in, instead of to ease, Despres says.
“Once you get moving, sometimes that pain starts to feel better,” Despres says.
Physical therapists help people achieve physical balance. “If something is too tight or too loose, if someone’s joint is too mobile, physical therapists look to stabilize it, to balance it,” she says. “If a person is out of shape, physical therapists work to help the person build up tolerance and strength.”
The goal is to get patients moving and to help them change habits that are leading to pain. For example, if a worker experiences chronic pain due to their lifting mechanics, a physical therapist shows them how to lift properly, she adds.
Physical therapy also can help patients post-surgery, sometimes even replacing opioids for acute pain. For example, women who undergo a cesarean section delivery often are prescribed opioids despite these being problematic for nursing mothers. A physical therapist could help the recovering woman move, get out of bed, and recover mobility and strength.
“When I worked as a physical therapist in a hospital, we’d get people moving as quickly as possible,” Despres says. “We’d get them to move all their limbs so things don’t get stiff and they don’t get blood clots.”
What needs to happen more often in hospital and community settings is a conversation between patients and their case managers and physicians about what to expect with pain relief and why alternatives to opioids might work best in the long run, she explains.
“If a patient tries physical therapy first, there is no downside,” Despres says. “Physical therapists can do things to help patients with pain. They have ultrasound, heat, all kinds of ways to give people relief right then.”
When a physical therapist helps a patient get up, move around, and feel less pain due to motion and healing, they’ll be more likely to continue to move and improve. “Then patients will think, ‘These things work, and I can move and get out of here, and life will be fine,’” she explains. “This experience just reinforced the whole emotional side of their injury and that they can get relief.”
But if patients start off with opioids and receive instant gratification, it’s more difficult to get them to try alternatives, she notes.
Depres suggests physical therapy as an alternative to opioids for the following:
• Cesarean section. “A physical therapist can teach protection of the surgical site, teaching the patient the correct body mechanics to protect the incision,” she says. “They teach the woman how to get out of bed, how to cradle her baby, and they educate on the importance of early movement — not lying in bed all day, but being active.”
Physical therapists also can teach recovering mothers how to protect their surgery site while returning to normal activity. They can teach leg exercises and low-level, graduated exercises, including range of motion and movement. They can teach light strengthening, body mechanics, and even how to care for the scar, Despres says.
• Post-surgery pain. Physical therapists can teach post-surgery patients body mechanics, how to transfer safely from the bed to the floor and bathroom, how to get in and out of a car, and how to go up and down a curb or step, she says.
“We teach post-surgery patients the things they need to protect themselves so they don’t fall and are safe doing any daily activities,” Despres explains. “For pain management, we teach them strategies of using ice without harming their skin; we might teach tissue mobilization.”
To prevent surgery patients from developing chronic pain, physical therapists teach them how to balance their movements. If pain causes patients to bend forward while sitting, the physical therapist will teach them to arch their backs backward after sitting for a long time, she says.
“We teach them how to allow their scars to heal and how to protect healing,” she adds. “Once they’ve healed after the surgery, we can provide body mechanics training and how to mitigate swelling and manage pain, preventing further issues like blood clots and muscles from atrophying.”
As patients continue to heal and improve, physical therapists can help with low-level strengthening and improving their range of motion, eventually moving into supporting patients’ functioning.
• Chronic pain. From a physical therapy perspective, chronic pain can be a mystery to solve.
“The first thing we have to do is jump in and figure out what’s causing the problem,” Despres says. “Look at the big picture: Why is the person still hurting today when the injury was two years ago?”
Physical therapists evaluate patients’ joint tissues and assess their clinical status and ability to engage in daily activities.
For example, a patient with chronic pain might be unable to cook a meal because he or she cannot bend down to pick up pots and pans and can’t stand for more than a minute at a time.
“So we’d say, ‘OK, cooking a meal is our goal,’ and we break it down into smaller steps,” Despres says. “Standing is a problem, so how can we get the patient from one minute of standing to five minutes of standing?”
And therapists will help patients change the narrative and description of success. Rather than focus on becoming pain-free as the only viable outcome, they can be taught to focus on achieving small-step success, such as standing for five minutes at a time, bending down to pick up a pot, and cooking a meal, she explains.
“That person realizes that she can do those things and can tolerate standing long enough to cook, and then the pain fades into the background,” Despres says. “Then they’ll do these activities more and more because they’re feeling better and because they have less pain.”
• Chronic illness pain. Patients with chronic illnesses often experience chronic pain, as well.
For instance, diabetic patients might suffer pain caused by circulation problems, neuropathy, and weight gain.
“Movement helps improve balance, endurance, and strength,” Despres says. “Your muscle mass starts to decline as a function of aging, and unless you are doing something to keep strong, you’ll lose that muscle mass.”
A focus on strengthening and balance can help all patients, including those with chronic illnesses, with their circulation and overall health, she adds.
• Sepsis. After a patient survives sepsis, there will be a long recovery period from the infection. These patients need to rebuild their endurance and strength to get back to their baseline health, and physical therapy can help with that, Despres says.
“You want to keep a person moving, so physical therapy comes in and moves all of their joints to make sure they’re not atrophied and tightened,” she says. “We work with them to do simple things.”
Despres once worked with a patient whose abdominal infection required several surgeries. She was bedridden for months and could not stand. “It was a matter of getting her to sit up to tolerate sitting upright, and then to stand and build up the strength she had lost,” she recalls.
• Car accidents. Patients who are hospitalized after a car accident need physical therapy early on to help them improve imbalances, Despres notes.
“They’ve been struck and jerked around and have massive impact on soft tissue in their bodies, and a physical therapist can figure out what might be torn, what is more injured and what is less injured, and it helps to manage that early on,” she explains.
Chronic pain often develops after car accidents because of imbalances. But physical therapy to help with imbalances and prevent and improve pain can help people recovering from accidents, she adds.
“We give people strategies and specific exercises to manage their pain,” she says.
The key is to teach patients life-long strategies to manage their symptoms and prevent chronic pain from occurring, Despres says.