Early Physical Therapy For Musculoskeletal Pain Reduces Likelihood of Opioid Use

Peer Reviewed

Use of physical therapy (PT) within 3 months of being diagnosed with musculoskeletal pain of the shoulder, neck, knee, and low back was link to a significantly lower likelihood (7% to 16% reduction) of subsequent opioid use in an analysis of health insurance claims from 89,000 U.S. adults. Even among patients who did use opioids, early PT was linked to reduced opioid use (5% to 10% reduction) for shoulder, knee and low back pain but not neck pain, according to the observational study published in JAMA Network Open.
Woman using a theraband with the assistance of a physical therapist.Among patients who did use opioids, early PT was linked to reduced opioid use. Photo Source: 123RF.com.“The main clinical implication of these findings is that patients with musculoskeletal pain may benefit from early PT where possible as this is associated with reduced opioid use longer term,” lead author Eric Sun, MD, PhD, told SpineUniverse. Dr. Sun is Assistant Professor of Anesthesiology, Perioperative and Pain Medicine as well as Health Research and Policy (by courtesy) at Stanford University.

The study was designed in response to current concerns regarding opioid overuse and the push from the Centers for Disease Control and Prevention as well as other groups to use nonpharmacologic pain management whenever possible for chronic noncancer pain. Previous findings suggest that earlier delivery of PT services is better than later delivery in terms of opioid use and patient-reported outcomes for low back pain.

The current study examined whether the same positive effect of early PT delivery on opioid use was found in other common musculoskeletal pain conditions, explained senior author Steven Z. George, PT, PhD, FAPTA, Professor and Director of Musculoskeletal Research at Duke Clinical Research Institute, and Vice Chair of Clinical Research and Orthopaedic Surgery at Duke University.

“We asked ourselves, ‘How can we address the pain that people are having, while not increasing their risk of needing opioids?’” Dr. Sun said in statement to the press. “And what our study found was that if you can get these patients on PT reasonably quickly, that reduces the probability that they’ll be using opioids in the longer term.”

Study Methods

The researchers analyzed private health care insurance claims data from 88,985 opioid-naive patients (ages 18 to 64 years) who were diagnosed with musculoskeletal pain (shoulder, neck, knee, or low back) at outpatient physician offices or emergency departments at various U.S. facilities between January 1, 2008, and December 31, 2014. None of the patients had been prescribed an opioid in the year prior to the diagnosis.

Approximately 29% of patients underwent early physical therapy, defined as at least one PT session within 90 days of the initial pain diagnosis.

Early Physical Therapy Significantly Reduced Opioid Use

As shown in the Table, patients who used early PT were significantly less likely to receive one or more opioid prescriptions between 90 days to one year following the initial diagnosis after adjusting for a number of potentially confounding factors. In addition, among patients who did fill opioid prescriptions, the amount of opioid use was significantly lower among those who underwent early PT.
Table. Opioid Use After Early Physical Therapy for Musculoskeletal PainTable. Opioid Use After Early Physical Therapy for Musculoskeletal Pain.

Patterns in Early Physical Therapy Use

A trend toward increased use of early PT was found over the study period, with a range of 27% in 2008 and 31% in 2014. Patients with neck pain were most likely to use early PT (37%) and those with knee pain were the least likely to do so (20%) in this cohort. The median number of physical therapy sessions ranged 5 for knee pain and low back pain to 8 for neck pain.

Furthermore, patients who started PT within the first month after diagnosis had the greatest reductions in the probability of any opioid use for all pain sites except knee pain. Among opioid users, larger reductions in the amount of opioid use was found in those with low back pain those who started PT within one month versus later. In contrast, starting physical therapy within 31 to 90 days after diagnosis was linked to stronger reductions in opioid use for those with neck and knee pain.

Similar findings were noted when the researchers adjusted their definition of early physical therapy to include at least 2 PT sessions.

Which Physical Therapy Treatments Are Best?

Previous studies have not shown superiority of one PT modality over another in terms of reducing opioid needs in patients with musculoskeletal pain, explained Dr. George. While the current study was not designed to study the effectiveness of individual PT therapies, Dr. George noted that there are a wide variety of physical therapy modalities that can potentially lead to positive treatment outcomes, including exercise, manual therapy, and physical modalities such as TENS.

“However, systematic reviews indicate that treatment effects for these options are often small so there is no obvious “go to” treatment,” Dr. George added.


The observational study design does not rule out the possibility of other potential mitigating factors that could help to explain the results, the researchers noted. In addition, the researchers did not have sufficient data on the type or approach to PT used by each patient.

“Also, the study did not randomize the timing of PT services or capture patient outcomes; thus, we can’t comment on pain or functional levels for any of the patients included in the analysis,” Dr. George told SpineUniverse.

The study was funded by grants from the National Institute on Drug Abuse and the National Center for Complementary and Integrative Health.

Dr. Sun has no relevant disclosures.
Dr. George has received personal fees from Rehab Essentials.

Updated on: 01/02/19
Continue Reading
Physical Therapy for Cervical Radiculopathy Linked to Improved Post-surgical Outcomes
Eric Sun, MD, PhD
Assistant Professor
Anesthesiology, Perioperative and Pain Medicine
Health Research & Policy Stanford University
Steven Z. George, PT, PhD
Professor and Director of Musculoskeletal Research
Duke Clinical Research Institute
Vice Chair of Clinical Research
Orthopaedic Surgery
Duke University

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