This study evaluated the impact of preoperative opioid use on pain outcomes following total knee arthroplasty (TKA). The study analyzed data from 156 patients who underwent TKA. Twenty-three percent of patients had used opioids prior to surgery. Patients who used opioids preoperatively experienced less pain relief from TKA, with a mean reduction in pain of 27.0 points compared to 33.6 points for patients who did not use opioids preoperatively. The study concludes that preoperative opioid use is associated with less pain relief from TKA and clinicians should consider limiting opioid prescriptions prior to surgery to optimize outcomes.
This randomized controlled trial compared the effectiveness of corticosteroid injections (CSI) and manual physical therapy (MPT) for treating unilateral shoulder impingement syndrome over one year. 104 patients were randomly assigned to receive either a subacromial CSI or 6 sessions of MPT. Both groups experienced approximately 50% improvement in shoulder pain and disability scores that was maintained at one year, with no significant differences between groups. Both groups also improved on global rating of change and pain scales, again with no significant between-group differences. However, the CSI group used more shoulder-related healthcare resources and received additional steroid injections more frequently over the year than the MPT group. The study found that CSI and MPT produced similar
Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain ...Nelson Hendler
The Pain Validity Test can predict which patient will have abnormal medical test results with 95% accuracy, and surgical abnormalities with 94% accuracy. This on-line questionnaire takes only 5 minutes of staff time to administer, and takes only 15 minutes of patient time.Results are available immediately. This test can be used to document "medical necessity" for insurance pre-authorization for testing and surgery.
Pilot Study of Massage in Veterans with Knee OsteoarthritisMichael Juberg
This pilot study assessed the feasibility and preliminary efficacy of Swedish massage therapy for 25 veterans with knee osteoarthritis. The study found high retention and adherence rates, suggesting massage was feasible and acceptable for veterans. Veterans receiving 8 weekly one-hour massage sessions experienced statistically significant improvements in self-reported knee pain, stiffness, function, and quality of life, as well as trends toward improved range of motion. The results support further study of massage as a treatment approach for knee osteoarthritis in veterans.
1) This randomized clinical trial compared opioid vs nonopioid medication therapy over 12 months for patients with chronic back, hip, or knee pain.
2) It found no significant difference in pain-related function between the two groups, but pain intensity was significantly better in the nonopioid group. Adverse effects were significantly more common in the opioid group.
3) The study concludes that opioid therapy was not superior to nonopioid medications for improving pain-related function over 12 months, and the results do not support initiating opioids for moderate to severe chronic musculoskeletal pain.
This document provides an overview of arthritis pain management strategies without compromising patient safety. It discusses the disease states and diagnostic criteria for osteoarthritis and rheumatoid arthritis. It then reviews the goals and treatment options for managing the pain and symptoms of osteoarthritis and rheumatoid arthritis, including both non-pharmacologic and pharmacologic approaches. It also discusses the efficacy and gastrointestinal safety profile of the drug celecoxib for treating arthritis pain.
The effect of hot intermittent cupping on pain, stiffness and disability of p...LucyPi1
Abstract Objective: The aim of this study was to investigate the effect of hot intermittent cupping on pain, stiffness and inability of patients with knee osteoarthritis (KO). Methods: The present study was a clinical trial, which was performed on 38 patients with KO referring to Gonabad Rheumatology Specialty Clinic. Based on permutation block method, the research units were divided into cupping therapy and control groups. For the cupping therapy group, four sessions of cupping therapy were performed every four days. To collect data, the form of demographic information, Visual Analogue Scale (VAS) and the Western Ontario and McMaster (WOMAC) osteoarthritis scale were used, and the data were analyzed by SPSS software v. 16 using descriptive statistics and independent t-test, paired t-test, Chi-square test and Fishers exact test with a significance level of P < 0.05. Results: Findings showed that there was no significant difference between the cupping therapy and control groups in terms of demographic characteristics and they were homogeneous. Findings indicated that, based on VAS, the mean pain intensity in the left (P < 0.001) and the right knees (P < 0.001), as well as based on WOMAC, stiffness (P = 0.006), pain intensity (P < 0.001) and disability (P < 0.001) in the cupping therapy group significantly decreased compared to the control group. Conclusion: Findings showed that hot intermittent cupping therapy reduced the pain intensity, stiffness and disability in patients with KO.
The clinical study evaluated the efficacy, safety, and disease-modifying effect of Arthrella tablets compared to diclofenac sodium in treating rheumatoid arthritis. 80 patients were divided into two groups, with one group taking Arthrella tablets and the other diclofenac sodium. Both drugs showed comparable efficacy in reducing pain, swelling, and joint tenderness based on various clinical measures. Arthrella was found to be well-tolerated with fewer side effects compared to diclofenac. The study concluded that Arthrella has equivalent efficacy to diclofenac in treating rheumatoid arthritis symptoms but with superior safety profile.
Nejm journal watch practice changing articles 2014Jaime dehais
This document provides a compilation of summaries of the latest practice-changing articles from NEJM Journal Watch. It includes summaries of articles on topics such as delayed or no antibiotic prescriptions for respiratory infections, physical therapy being beneficial for knee osteoarthritis, low-dose steroids being better than high-dose for COPD exacerbations, a diagnostic algorithm for upper-extremity deep vein thrombosis, evidence that meniscal tears may not require surgery, improvements in mental health with smoking cessation, doubts cast on flu drugs by meta-analyses, the 2014 recommended childhood immunization schedule, sentinel lymph node biopsies for thin melanomas, age-specific d-dimer cutoffs for pulmonary embolism, evidence that FOD
This randomized controlled trial compared the effectiveness of corticosteroid injections (CSI) and manual physical therapy (MPT) for treating unilateral shoulder impingement syndrome over one year. 104 patients were randomly assigned to receive either a subacromial CSI or 6 sessions of MPT. Both groups experienced approximately 50% improvement in shoulder pain and disability scores that was maintained at one year, with no significant differences between groups. Both groups also improved on global rating of change and pain scales, again with no significant between-group differences. However, the CSI group used more shoulder-related healthcare resources and received additional steroid injections more frequently over the year than the MPT group. The study found that CSI and MPT produced similar
Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain ...Nelson Hendler
The Pain Validity Test can predict which patient will have abnormal medical test results with 95% accuracy, and surgical abnormalities with 94% accuracy. This on-line questionnaire takes only 5 minutes of staff time to administer, and takes only 15 minutes of patient time.Results are available immediately. This test can be used to document "medical necessity" for insurance pre-authorization for testing and surgery.
Pilot Study of Massage in Veterans with Knee OsteoarthritisMichael Juberg
This pilot study assessed the feasibility and preliminary efficacy of Swedish massage therapy for 25 veterans with knee osteoarthritis. The study found high retention and adherence rates, suggesting massage was feasible and acceptable for veterans. Veterans receiving 8 weekly one-hour massage sessions experienced statistically significant improvements in self-reported knee pain, stiffness, function, and quality of life, as well as trends toward improved range of motion. The results support further study of massage as a treatment approach for knee osteoarthritis in veterans.
1) This randomized clinical trial compared opioid vs nonopioid medication therapy over 12 months for patients with chronic back, hip, or knee pain.
2) It found no significant difference in pain-related function between the two groups, but pain intensity was significantly better in the nonopioid group. Adverse effects were significantly more common in the opioid group.
3) The study concludes that opioid therapy was not superior to nonopioid medications for improving pain-related function over 12 months, and the results do not support initiating opioids for moderate to severe chronic musculoskeletal pain.
This document provides an overview of arthritis pain management strategies without compromising patient safety. It discusses the disease states and diagnostic criteria for osteoarthritis and rheumatoid arthritis. It then reviews the goals and treatment options for managing the pain and symptoms of osteoarthritis and rheumatoid arthritis, including both non-pharmacologic and pharmacologic approaches. It also discusses the efficacy and gastrointestinal safety profile of the drug celecoxib for treating arthritis pain.
The effect of hot intermittent cupping on pain, stiffness and disability of p...LucyPi1
Abstract Objective: The aim of this study was to investigate the effect of hot intermittent cupping on pain, stiffness and inability of patients with knee osteoarthritis (KO). Methods: The present study was a clinical trial, which was performed on 38 patients with KO referring to Gonabad Rheumatology Specialty Clinic. Based on permutation block method, the research units were divided into cupping therapy and control groups. For the cupping therapy group, four sessions of cupping therapy were performed every four days. To collect data, the form of demographic information, Visual Analogue Scale (VAS) and the Western Ontario and McMaster (WOMAC) osteoarthritis scale were used, and the data were analyzed by SPSS software v. 16 using descriptive statistics and independent t-test, paired t-test, Chi-square test and Fishers exact test with a significance level of P < 0.05. Results: Findings showed that there was no significant difference between the cupping therapy and control groups in terms of demographic characteristics and they were homogeneous. Findings indicated that, based on VAS, the mean pain intensity in the left (P < 0.001) and the right knees (P < 0.001), as well as based on WOMAC, stiffness (P = 0.006), pain intensity (P < 0.001) and disability (P < 0.001) in the cupping therapy group significantly decreased compared to the control group. Conclusion: Findings showed that hot intermittent cupping therapy reduced the pain intensity, stiffness and disability in patients with KO.
The clinical study evaluated the efficacy, safety, and disease-modifying effect of Arthrella tablets compared to diclofenac sodium in treating rheumatoid arthritis. 80 patients were divided into two groups, with one group taking Arthrella tablets and the other diclofenac sodium. Both drugs showed comparable efficacy in reducing pain, swelling, and joint tenderness based on various clinical measures. Arthrella was found to be well-tolerated with fewer side effects compared to diclofenac. The study concluded that Arthrella has equivalent efficacy to diclofenac in treating rheumatoid arthritis symptoms but with superior safety profile.
Nejm journal watch practice changing articles 2014Jaime dehais
This document provides a compilation of summaries of the latest practice-changing articles from NEJM Journal Watch. It includes summaries of articles on topics such as delayed or no antibiotic prescriptions for respiratory infections, physical therapy being beneficial for knee osteoarthritis, low-dose steroids being better than high-dose for COPD exacerbations, a diagnostic algorithm for upper-extremity deep vein thrombosis, evidence that meniscal tears may not require surgery, improvements in mental health with smoking cessation, doubts cast on flu drugs by meta-analyses, the 2014 recommended childhood immunization schedule, sentinel lymph node biopsies for thin melanomas, age-specific d-dimer cutoffs for pulmonary embolism, evidence that FOD
This study examined the effectiveness of platelet-rich plasma (PRP) injections for chronic lumbar diskogenic pain. 47 participants with chronic low back pain received either an intradiskal PRP injection or a control injection after provocative diskography. Participants who received PRP reported significantly greater improvements in pain, physical function, and satisfaction over the 8 week period compared to the control group. At the 1 year follow up, those receiving PRP maintained significant improvements in physical function. No serious adverse events were reported. The study provides preliminary evidence that PRP injections may effectively treat chronic low back pain caused by damaged disks. Larger and more standardized studies are still needed.
This randomized, double-blind pilot study examined the effects of pulsed electromagnetic field (PEMF) therapy on pain in patients with early knee osteoarthritis. 34 patients were randomly assigned to either an active PEMF device group (n=15) or a sham device group (n=19). The PEMF signal was designed to modulate the calcium/calmodulin dependent nitric oxide signaling pathway. Results showed a 50% reduction in pain scores from baseline in the active group starting on day 1 and persisting to day 42, while no significant reduction was seen in the sham group. The overall decrease in pain was nearly threefold greater in the active group. The rapid and sustained pain relief seen with PEMF therapy suggests it may reduce inflammation
Medical shockwaves for chronic low back pain - a case seriesKenneth Craig
This case series examines the use of medical shockwave therapy for 10 patients with chronic low back pain. Shockwave therapy involves using focused acoustic pulses to target deep tissue. After 3 sessions of 1000 pulses each over 3 weeks, 8 of the 9 patients showed excellent improvement in pain levels, functional disability, and reduced need for pain medication that was maintained at the 12 week follow up. This positive preliminary outcome supports further investigation of shockwave therapy as a potential disease-modifying treatment for chronic low back pain.
This meta-analysis reviewed 22 randomized controlled trials involving 1014 patients to determine the effectiveness of low-level laser therapy (LLLT) for pain relief in various joint areas. The average methodological quality score of the trials was 7.96 out of 10. The analysis found that 11 trials reported positive effects of LLLT for pain relief while 11 reported negative effects. However, when pooling the results, the mean weighted difference in pain reduction on a visual analogue scale was 13.96 mm in favor of the active LLLT groups, indicating LLLT provides statistically significant pain relief for joints. Restricting the analysis to trials using energy doses within previously suggested therapeutic windows produced even greater mean pain relief of 19.88-21
The article discusses the impacts of the COVID-19 pandemic on physiatry and rehabilitation medicine. It highlights how physiatrists played a vital role in the front lines during the pandemic by converting rehabilitation units and innovating care delivery. However, the pandemic has also caused significant disruptions and stress for medical practices through reduced patient volumes, higher costs, and threats of reimbursement cuts from insurers and governments. Moving forward, physicians are questioning the level of support they will receive from their employers and the government given the sacrifices many have made during the pandemic.
Evaluating Chronic Pain Patients Using Methods from Johns Hopkins Hospital Ph...Nelson Hendler
This article describes the use of physiological testing, instead of anatomical testing, to evaluate chronic pain. The efficacy of this approach is documented by published outcome studies.,, Patient require surgery 50%-63% of the time to improve.
This document summarizes and discusses several articles on physical medicine and rehabilitation (PMR) topics that were published in recent issues of various journals. The articles cover a range of topics including the treatment of 12th rib syndrome, the use of the tourniquet ischemia test to diagnose complex regional pain syndrome, physiotherapy interventions for treating spasticity, a telehealth intervention to increase fitness for those with spinal cord injuries, spinal cord involvement in COVID-19, the use of local anesthetic injections in athletes, and a comparison of video-based and text-based physical activity interventions. The document also provides an introduction and welcome from the editor as well as information about new contributors.
Three randomized controlled trials were reviewed to determine the efficacy of kinesio tape for shoulder impingement pathologies. Two studies found that kinesio tape used in conjunction with therapeutic exercises was more effective at reducing pain and improving function and range of motion, as measured by DASH and VAS scores, than exercises alone. One study found no significant differences between kinesio tape and sham taping without additional interventions. Overall, the evidence suggests kinesio tape combined with exercises may provide better outcomes than exercises alone for shoulder impingement, though more research is still needed.
This study aimed to assess the long-term outcomes of lumbar fusion versus non-specific physiotherapy for chronic low back pain. 294 patients were randomized to fusion or physiotherapy and followed for an average of 12.8 years.
Using various analytic approaches, success rates based on patient's global assessment of improvement were in the 65% range for fusion patients, compared to 31-37% for physiotherapy patients. However, secondary outcomes like disability and pain scales showed similar levels of improvement between groups. The discrepancies between primary and secondary outcomes means the study provides only Level II evidence regarding recommending fusion for non-specific low back pain.
Austin Journal of Musculoskeletal Disorders is a peer-reviewed, open access journal published by Austin Publishers. It provides easy access to high quality Manuscripts in all related aspects of diseases and disorders that may adversely affect the function and overall effectiveness of the musculoskeletal system. The Journal focuses upon all the related aspects of musculoskeletal system disorders and the new advancements in the related treatments including Complex issues and injuries involving the musculoskeletal system and surgeries.
Austin Publishing Group is a successful host of more than hundred peer reviewed, open access journals in various fields of science and technology with intent to bridge the gap between academia and research access.
Austin Journal of Musculoskeletal Disorders accepts original research articles, review articles, case reports, mini reviews, rapid communication, opinions and editorials on all related aspects of diseases and disorders that may adversely affect the function and overall effectiveness of the musculoskeletal system.
Efficacy,and safety of intravenous zoledronic acid in treatment+of+pediatric+...Abdulmoein AlAgha
Zoledronic acid is an effective treatment for pediatric osteoporosis. A 13-year study of 131 children with primary or secondary osteoporosis found that intravenous zoledronic acid significantly reduced fractures, bone pain, and bone turnover markers. While acute side effects like fever and hypocalcemia occurred after the first infusion, no chronic adverse events were reported. Zoledronic acid should be considered as an important treatment for improving outcomes in pediatric osteoporosis.
This document reviews current treatment strategies for spinal compression fractures and potential future directions. The major current treatment strategies are conservative pain management and vertebral augmentation procedures like vertebroplasty and kyphoplasty. However, there is a lack of consensus on the optimal treatment approach. Prospective clinical trials with new biomarkers are needed to better assess treatment efficacy and develop clearer guidelines. The document provides an overview of common pain management strategies like NSAIDs, opioids, and bisphosphonates as well as vertebral augmentation procedures and calls for future research to establish standardized treatment pathways.
Treating patients of size in the ICU presents many challenges including difficulties with positioning, skin integrity, respiratory function, and safety concerns for both patients and caregivers. Obesity does not independently increase mortality in the ICU but is associated with longer ICU and hospital stays as well as increased need for mechanical ventilation. A multidisciplinary approach is needed utilizing special equipment, techniques to prevent complications, and a culture of sensitivity.
This study compared the effectiveness of low-dose aspirin (81 mg twice daily) to high-dose aspirin (325 mg twice daily) for preventing venous thromboembolism (VTE) following total joint arthroplasty. The study included over 4,600 patients undergoing primary total joint replacement who received either low-dose or high-dose aspirin for 4 weeks post-operatively. The results found no significant difference in VTE rates between the low-dose and high-dose aspirin groups, indicating low-dose aspirin is not inferior to high-dose aspirin for VTE prophylaxis after total joint arthroplasty.
This document contains abstracts from multiple studies related to alemtuzumab treatment for relapsing-remitting multiple sclerosis (RRMS). Key findings from the studies include:
1) Alemtuzumab improved quality of life measures in RRMS patients with an inadequate response to prior therapies, and these benefits were maintained at 4-year follow up.
2) Administering alemtuzumab over non-consecutive days did not impact lymphocyte depletion, infusion reactions, or efficacy compared to consecutive day administration.
3) Alemtuzumab treatment resulted in durable disability improvement in treatment-naive RRMS patients, with mean disability scores remaining below pretreatment levels at 4-year follow up.
This document outlines the process for setting up and managing an alemtuzumab service for treating multiple sclerosis. It discusses selecting appropriate patients, monitoring treatment and side effects, and establishing protocols. It also describes challenges such as ensuring long-term follow up and managing side effects like autoimmune diseases. Case studies demonstrate both successful outcomes and complications from alemtuzumab treatment.
1) The study evaluated the impact of early physiotherapy evaluation and treatment (EPET) compared to standard care (SC) for patients presenting to the emergency department with non-traumatic neck and back pain.
2) 125 patients were included in the study, with 62 receiving EPET at a median of 4 days from their ED visit and 63 receiving SC at a median of 34 days from their ED visit.
3) The results showed that EPET patients had significantly lower levels of disability (9.0% vs 33.4%) and pain (median of 1 vs 4) compared to SC patients, as measured by standardized questionnaires approximately 1 month after their initial ED visit.
- This study evaluated 120 elderly patients with intertrochanteric hip fractures who were randomized to receive either zoledronic acid or a placebo after surgical treatment.
- Outcome measures including functional scores and bone mineral density were higher in the treatment group who received zoledronic acid compared to the placebo group.
- Mortality rates at 12 months were lower in the treatment group at 24.5% compared to the placebo group.
- The study concluded that the use of zoledronic acid after surgical treatment of intertrochanteric hip fractures in osteoporotic elderly patients over 65 years old is a safe treatment modality.
This study investigated the efficacy of pulsed electromagnetic field therapy (PEMF) in reducing delayed onset muscle soreness (DOMS) in marathon runners. A double-blind randomized controlled trial assigned 133 marathon runners to either an active PEMF device or placebo device to use for 20 minutes, 4 times per day for 5 days after a marathon. The primary outcome was thigh pain assessed using a visual analog scale during squats. Subjects using the active PEMF device had significantly lower pain scores compared to the placebo group, indicating PEMF reduced DOMS in marathon runners.
Physical Therapy in the Emergency Departmentchristaloyd
At the Heart of the Rockies Regional Medical Center in Salida, CO, I got the opportunity to take the lead on doing research and analyzing data to create a presentation describing the benefits of Physical Therapy in an emergency department.
This study examined whether higher scores on a fibromyalgia survey were associated with increased opioid consumption after hysterectomy, while accounting for known risk factors. The study found:
1) Higher scores on the fibromyalgia survey were independently associated with greater postoperative opioid use, with opioid consumption increasing by 7 mg of oral morphine equivalents for every 1-point increase on the 31-point survey scale.
2) In addition to fibromyalgia survey scores, factors like more severe medical comorbidities, greater catastrophizing, laparotomy surgical approach, and preoperative opioid use predicted increased postoperative opioid needs.
3) These results suggest that the fibromyalgia survey may help identify patients at high risk for needing more opioids after surgery, and that
Dose Escalations In the First Year For CNP = AberrancyPaul Coelho, MD
This study analyzed data from 246 opioid-naive patients with chronic musculoskeletal pain who were prescribed long-term opioids for one year to identify factors associated with opioid dose escalation during the first year of treatment. The study found that 9% of patients experienced a dose escalation of at least 30 mg morphine equivalents over the year. Patients with dose escalation had higher rates of substance use disorders and more frequent non face-to-face outpatient encounters compared to patients without escalation. Differences in demographics like age and race between the groups were not statistically significant.
This study examined the effectiveness of platelet-rich plasma (PRP) injections for chronic lumbar diskogenic pain. 47 participants with chronic low back pain received either an intradiskal PRP injection or a control injection after provocative diskography. Participants who received PRP reported significantly greater improvements in pain, physical function, and satisfaction over the 8 week period compared to the control group. At the 1 year follow up, those receiving PRP maintained significant improvements in physical function. No serious adverse events were reported. The study provides preliminary evidence that PRP injections may effectively treat chronic low back pain caused by damaged disks. Larger and more standardized studies are still needed.
This randomized, double-blind pilot study examined the effects of pulsed electromagnetic field (PEMF) therapy on pain in patients with early knee osteoarthritis. 34 patients were randomly assigned to either an active PEMF device group (n=15) or a sham device group (n=19). The PEMF signal was designed to modulate the calcium/calmodulin dependent nitric oxide signaling pathway. Results showed a 50% reduction in pain scores from baseline in the active group starting on day 1 and persisting to day 42, while no significant reduction was seen in the sham group. The overall decrease in pain was nearly threefold greater in the active group. The rapid and sustained pain relief seen with PEMF therapy suggests it may reduce inflammation
Medical shockwaves for chronic low back pain - a case seriesKenneth Craig
This case series examines the use of medical shockwave therapy for 10 patients with chronic low back pain. Shockwave therapy involves using focused acoustic pulses to target deep tissue. After 3 sessions of 1000 pulses each over 3 weeks, 8 of the 9 patients showed excellent improvement in pain levels, functional disability, and reduced need for pain medication that was maintained at the 12 week follow up. This positive preliminary outcome supports further investigation of shockwave therapy as a potential disease-modifying treatment for chronic low back pain.
This meta-analysis reviewed 22 randomized controlled trials involving 1014 patients to determine the effectiveness of low-level laser therapy (LLLT) for pain relief in various joint areas. The average methodological quality score of the trials was 7.96 out of 10. The analysis found that 11 trials reported positive effects of LLLT for pain relief while 11 reported negative effects. However, when pooling the results, the mean weighted difference in pain reduction on a visual analogue scale was 13.96 mm in favor of the active LLLT groups, indicating LLLT provides statistically significant pain relief for joints. Restricting the analysis to trials using energy doses within previously suggested therapeutic windows produced even greater mean pain relief of 19.88-21
The article discusses the impacts of the COVID-19 pandemic on physiatry and rehabilitation medicine. It highlights how physiatrists played a vital role in the front lines during the pandemic by converting rehabilitation units and innovating care delivery. However, the pandemic has also caused significant disruptions and stress for medical practices through reduced patient volumes, higher costs, and threats of reimbursement cuts from insurers and governments. Moving forward, physicians are questioning the level of support they will receive from their employers and the government given the sacrifices many have made during the pandemic.
Evaluating Chronic Pain Patients Using Methods from Johns Hopkins Hospital Ph...Nelson Hendler
This article describes the use of physiological testing, instead of anatomical testing, to evaluate chronic pain. The efficacy of this approach is documented by published outcome studies.,, Patient require surgery 50%-63% of the time to improve.
This document summarizes and discusses several articles on physical medicine and rehabilitation (PMR) topics that were published in recent issues of various journals. The articles cover a range of topics including the treatment of 12th rib syndrome, the use of the tourniquet ischemia test to diagnose complex regional pain syndrome, physiotherapy interventions for treating spasticity, a telehealth intervention to increase fitness for those with spinal cord injuries, spinal cord involvement in COVID-19, the use of local anesthetic injections in athletes, and a comparison of video-based and text-based physical activity interventions. The document also provides an introduction and welcome from the editor as well as information about new contributors.
Three randomized controlled trials were reviewed to determine the efficacy of kinesio tape for shoulder impingement pathologies. Two studies found that kinesio tape used in conjunction with therapeutic exercises was more effective at reducing pain and improving function and range of motion, as measured by DASH and VAS scores, than exercises alone. One study found no significant differences between kinesio tape and sham taping without additional interventions. Overall, the evidence suggests kinesio tape combined with exercises may provide better outcomes than exercises alone for shoulder impingement, though more research is still needed.
This study aimed to assess the long-term outcomes of lumbar fusion versus non-specific physiotherapy for chronic low back pain. 294 patients were randomized to fusion or physiotherapy and followed for an average of 12.8 years.
Using various analytic approaches, success rates based on patient's global assessment of improvement were in the 65% range for fusion patients, compared to 31-37% for physiotherapy patients. However, secondary outcomes like disability and pain scales showed similar levels of improvement between groups. The discrepancies between primary and secondary outcomes means the study provides only Level II evidence regarding recommending fusion for non-specific low back pain.
Austin Journal of Musculoskeletal Disorders is a peer-reviewed, open access journal published by Austin Publishers. It provides easy access to high quality Manuscripts in all related aspects of diseases and disorders that may adversely affect the function and overall effectiveness of the musculoskeletal system. The Journal focuses upon all the related aspects of musculoskeletal system disorders and the new advancements in the related treatments including Complex issues and injuries involving the musculoskeletal system and surgeries.
Austin Publishing Group is a successful host of more than hundred peer reviewed, open access journals in various fields of science and technology with intent to bridge the gap between academia and research access.
Austin Journal of Musculoskeletal Disorders accepts original research articles, review articles, case reports, mini reviews, rapid communication, opinions and editorials on all related aspects of diseases and disorders that may adversely affect the function and overall effectiveness of the musculoskeletal system.
Efficacy,and safety of intravenous zoledronic acid in treatment+of+pediatric+...Abdulmoein AlAgha
Zoledronic acid is an effective treatment for pediatric osteoporosis. A 13-year study of 131 children with primary or secondary osteoporosis found that intravenous zoledronic acid significantly reduced fractures, bone pain, and bone turnover markers. While acute side effects like fever and hypocalcemia occurred after the first infusion, no chronic adverse events were reported. Zoledronic acid should be considered as an important treatment for improving outcomes in pediatric osteoporosis.
This document reviews current treatment strategies for spinal compression fractures and potential future directions. The major current treatment strategies are conservative pain management and vertebral augmentation procedures like vertebroplasty and kyphoplasty. However, there is a lack of consensus on the optimal treatment approach. Prospective clinical trials with new biomarkers are needed to better assess treatment efficacy and develop clearer guidelines. The document provides an overview of common pain management strategies like NSAIDs, opioids, and bisphosphonates as well as vertebral augmentation procedures and calls for future research to establish standardized treatment pathways.
Treating patients of size in the ICU presents many challenges including difficulties with positioning, skin integrity, respiratory function, and safety concerns for both patients and caregivers. Obesity does not independently increase mortality in the ICU but is associated with longer ICU and hospital stays as well as increased need for mechanical ventilation. A multidisciplinary approach is needed utilizing special equipment, techniques to prevent complications, and a culture of sensitivity.
This study compared the effectiveness of low-dose aspirin (81 mg twice daily) to high-dose aspirin (325 mg twice daily) for preventing venous thromboembolism (VTE) following total joint arthroplasty. The study included over 4,600 patients undergoing primary total joint replacement who received either low-dose or high-dose aspirin for 4 weeks post-operatively. The results found no significant difference in VTE rates between the low-dose and high-dose aspirin groups, indicating low-dose aspirin is not inferior to high-dose aspirin for VTE prophylaxis after total joint arthroplasty.
This document contains abstracts from multiple studies related to alemtuzumab treatment for relapsing-remitting multiple sclerosis (RRMS). Key findings from the studies include:
1) Alemtuzumab improved quality of life measures in RRMS patients with an inadequate response to prior therapies, and these benefits were maintained at 4-year follow up.
2) Administering alemtuzumab over non-consecutive days did not impact lymphocyte depletion, infusion reactions, or efficacy compared to consecutive day administration.
3) Alemtuzumab treatment resulted in durable disability improvement in treatment-naive RRMS patients, with mean disability scores remaining below pretreatment levels at 4-year follow up.
This document outlines the process for setting up and managing an alemtuzumab service for treating multiple sclerosis. It discusses selecting appropriate patients, monitoring treatment and side effects, and establishing protocols. It also describes challenges such as ensuring long-term follow up and managing side effects like autoimmune diseases. Case studies demonstrate both successful outcomes and complications from alemtuzumab treatment.
1) The study evaluated the impact of early physiotherapy evaluation and treatment (EPET) compared to standard care (SC) for patients presenting to the emergency department with non-traumatic neck and back pain.
2) 125 patients were included in the study, with 62 receiving EPET at a median of 4 days from their ED visit and 63 receiving SC at a median of 34 days from their ED visit.
3) The results showed that EPET patients had significantly lower levels of disability (9.0% vs 33.4%) and pain (median of 1 vs 4) compared to SC patients, as measured by standardized questionnaires approximately 1 month after their initial ED visit.
- This study evaluated 120 elderly patients with intertrochanteric hip fractures who were randomized to receive either zoledronic acid or a placebo after surgical treatment.
- Outcome measures including functional scores and bone mineral density were higher in the treatment group who received zoledronic acid compared to the placebo group.
- Mortality rates at 12 months were lower in the treatment group at 24.5% compared to the placebo group.
- The study concluded that the use of zoledronic acid after surgical treatment of intertrochanteric hip fractures in osteoporotic elderly patients over 65 years old is a safe treatment modality.
This study investigated the efficacy of pulsed electromagnetic field therapy (PEMF) in reducing delayed onset muscle soreness (DOMS) in marathon runners. A double-blind randomized controlled trial assigned 133 marathon runners to either an active PEMF device or placebo device to use for 20 minutes, 4 times per day for 5 days after a marathon. The primary outcome was thigh pain assessed using a visual analog scale during squats. Subjects using the active PEMF device had significantly lower pain scores compared to the placebo group, indicating PEMF reduced DOMS in marathon runners.
Physical Therapy in the Emergency Departmentchristaloyd
At the Heart of the Rockies Regional Medical Center in Salida, CO, I got the opportunity to take the lead on doing research and analyzing data to create a presentation describing the benefits of Physical Therapy in an emergency department.
This study examined whether higher scores on a fibromyalgia survey were associated with increased opioid consumption after hysterectomy, while accounting for known risk factors. The study found:
1) Higher scores on the fibromyalgia survey were independently associated with greater postoperative opioid use, with opioid consumption increasing by 7 mg of oral morphine equivalents for every 1-point increase on the 31-point survey scale.
2) In addition to fibromyalgia survey scores, factors like more severe medical comorbidities, greater catastrophizing, laparotomy surgical approach, and preoperative opioid use predicted increased postoperative opioid needs.
3) These results suggest that the fibromyalgia survey may help identify patients at high risk for needing more opioids after surgery, and that
Dose Escalations In the First Year For CNP = AberrancyPaul Coelho, MD
This study analyzed data from 246 opioid-naive patients with chronic musculoskeletal pain who were prescribed long-term opioids for one year to identify factors associated with opioid dose escalation during the first year of treatment. The study found that 9% of patients experienced a dose escalation of at least 30 mg morphine equivalents over the year. Patients with dose escalation had higher rates of substance use disorders and more frequent non face-to-face outpatient encounters compared to patients without escalation. Differences in demographics like age and race between the groups were not statistically significant.
The document summarizes a study that reviewed charts of 86 patients discharged from an Opioid Renewal Clinic (ORC) over 22 months to examine outcomes two years after discharge. The most common reason for discharge was recurrent positive urine drug screens for illicit substances (47%). Only 17% received addiction treatment in the two years after discharge. 41% were prescribed opioids within two years of discharge, and those prescribed opioids tended to have longer stays in the ORC and more primary care visits after discharge. The outcomes reveal a need to improve addiction management for this patient population.
This study assessed long-term outcomes of surgical versus nonsurgical treatment of sciatica caused by a herniated lumbar disc. Over 10 years:
- 69% of surgically treated patients reported improved symptoms versus 61% nonsurgically treated, and 56% of surgical patients reported much better or resolved leg and back pain versus 40% nonsurgical.
- Surgically treated patients also reported greater satisfaction and improved functional status compared to nonsurgical patients, though work disability outcomes were similar between groups.
- By 10 years, 25% of each group had additional lumbar spine surgeries, though surgical patients initially had worse symptoms and findings.
This systematic review examined 67 studies on strategies to reduce or discontinue long-term opioid therapy (LTOT) for chronic pain and the effect of dose reduction on patient outcomes. The key findings were:
1) Interdisciplinary pain programs had the highest completion and opioid discontinuation rates, ranging from 76-100% and 29-100% respectively across 31 studies of varying quality.
2) Buprenorphine-assisted dose reduction resulted in opioid discontinuation rates ranging from 33-100% in 10 poor quality studies.
3) Among 40 studies of varying quality examining patient outcomes after dose reduction, improvement was reported in pain severity, function, and quality of life, though the overall evidence quality was very
This study examined health insurance claims data from over 10 million patients who were prescribed opioids to evaluate how opioid receipt differed based on preexisting psychiatric conditions and medications. The study found that patients with a variety of psychiatric conditions and those prescribed various psychoactive medications were more likely to receive opioids, particularly long-term opioid therapy. The increased risk for long-term opioid therapy ranged from 1.5 times higher for those previously prescribed ADHD medications, to over 8 times higher for those with prior opioid use disorder diagnoses. The results provide evidence that commercially insured patients with psychiatric conditions receive opioids more than those without such conditions.
Incident opioid abuse and dependence sullivan 2014Paul Coelho, MD
This study investigated the association between prescription opioid exposure and risk of opioid use disorder (OUD) among individuals with chronic noncancer pain (CNCP). The study used claims data from 2000-2005 for over 500,000 individuals with a new CNCP diagnosis and no recent opioid use or OUD. The results showed significantly higher rates of OUD among those prescribed opioids compared to those not prescribed opioids. Risk increased with longer duration of therapy and higher daily doses. Chronic opioid therapy, even at low doses, was associated with substantially increased risk of OUD compared to acute therapy or no opioids. Duration of opioid therapy was more important than daily dose in determining OUD risk.
Incident opioid abuse and dependence sullivan 2014 (2)Paul Coelho, MD
This study investigated the association between opioid prescription and subsequent opioid use disorder (OUD) diagnoses among 568,640 individuals with chronic noncancer pain. The results showed that prescription opioid exposure significantly increased the risk of OUD compared to no opioid exposure. The risk was highest with longer duration of therapy (chronic vs acute) rather than daily dose. Specifically, the odds of OUD were over 100 times higher for those receiving high-dose opioids chronically compared to no opioid exposure. Duration of opioid therapy was more important than daily dose in determining OUD risk.
- 49% of chronic pain patients taking opioids reported severe pain (≥7/10).
- Patients reporting higher pain were more likely to have characteristics associated with centralized pain processing, including higher fibromyalgia survey scores, more neuropathic pain symptoms, and higher depression levels.
- While only 3.2% were diagnosed with fibromyalgia by their doctor, 40.8% met criteria for fibromyalgia based on a validated survey questionnaire. This suggests centralized pain characteristics are underrecognized.
This study examined psychological factors that may predict problematic outcomes following total knee arthroplasty (TKA). 75 patients completed measures of pain catastrophizing, pain-related fears, depression, and pain/function before and 6 weeks after TKA surgery. Results showed that pre-surgical pain and pain catastrophizing uniquely predicted greater post-surgical pain severity. Pre-surgical pain-related fears predicted worse function at follow-up in initial analyses but not when accounting for other medical factors. The findings suggest different psychological factors may influence post-surgical pain versus function. Targeting psychological risk factors could potentially improve outcomes after TKA.
This systematic review and meta-analysis evaluated the efficacy and tolerability of opioid analgesics for low back pain. The analysis included 20 randomized clinical trials involving nearly 8,000 participants. The review found that within recommended doses, opioids provided only modest short-term pain relief for chronic low back pain, with the effect unlikely to be clinically meaningful. Approximately half of trial participants withdrew from studies due to adverse effects or lack of efficacy. The review concluded that opioids provide limited benefit for chronic low back pain within guideline doses and that evidence for long-term efficacy is lacking.
To Determine Preference of Shoulder Pain Management by General Physicians in ...suppubs1pubs1
Rotator cuff muscles are functionally active and provide stability to the shoulder joint and also thereby allow the full Range of Motion (ROM) by moving the head of humerus in the glenoid cavity. Any tear or fragility of the rotator cuff muscles can cause the dislocation or instability and hence damaging other muscles specially the long head of biceps muscle. The diseases related to the supraspinatus tendon are frequently linked with the long head of the biceps tendon. Other cause of chronic shoulder pain is the adhesive capsulitis with large prevalence rates of more than 5.3% in the general target population [3].
This systematic review and meta-analysis examined the efficacy and safety of selective cannabinoids for the treatment of neuropathic pain. Eleven randomized controlled trials including over 1200 patients were analyzed. The results showed that patients receiving selective cannabinoids reported a small but statistically significant reduction in pain scores compared to other treatments or placebo. Use of selective cannabinoids was also associated with improvements in quality of life and sleep with no major adverse effects reported. However, there was significant heterogeneity across the studies in terms of quality, populations, cannabinoid types and doses used. More high-quality research is still needed to better evaluate the effects of specific cannabinoid treatments.
This study assessed outcomes of physical therapy and surgery for 150 patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported measures. 40 patients (27%) had satisfactory improvement with a 6-week physical therapy trial, while 90 (60%) underwent surgery after physical therapy failed. Patients who underwent surgery had greater reductions in disability scores and better patient-rated outcomes compared to those who received only physical therapy. However, pre-treatment factors did not reliably predict who would benefit from each treatment. This study provides information on contemporary outcomes for physical therapy and surgery for NTOS.
The document summarizes a systematic review that analyzed 15 randomized controlled trials on the use of acupuncture and related techniques for postoperative pain management. The review found that acupuncture was associated with significant reductions in postoperative opioid consumption, pain intensity, and opioid-related side effects such as nausea, dizziness, and sedation, compared to sham controls. Specifically, acupuncture reduced opioid use by 23-29 mg at 8-72 hours postoperatively and decreased pain scores at 8 and 72 hours. The studies involved a variety of surgeries and acupuncture methods.
This systematic review examined the evidence for the efficacy of cannabis in treating chronic pain and the potential harms of cannabis use. Regarding chronic pain, the review found:
1) Low-strength evidence that cannabis may alleviate neuropathic pain in some patients based on 13 trials, but studies did not generally find clinically significant differences in continuous pain scales.
2) Insufficient evidence for the effects of cannabis on pain in patients with multiple sclerosis due to small, inconsistent studies with short follow-up.
3) Insufficient evidence for the effects of cannabis on other types of chronic pain.
Regarding harms, the review found:
1) Limited evidence that cannabis is associated with increased risk for adverse mental health effects
This document provides a literature review on opioid use for chronic noncancer pain. It discusses how opioid prescriptions and related harms have increased substantially in recent decades. Several studies highlighted found higher opioid doses were associated with greater risks of overdose and other adverse outcomes. The document also reviews literature on risk evaluation strategies like urine drug testing and treatment agreements. It identifies a need for more research on nurse practitioner-specific guidelines and long-term opioid effectiveness for chronic pain.
Pressures sensitivity & phenotypic changes in patients with suspected oih bei...Paul Coelho, MD
1) The study assessed changes in pain phenotype and pressure sensitivity in 20 patients with suspected opioid-induced hyperalgesia (OIH) after transitioning from full mu opioid agonists to buprenorphine therapy.
2) Patients on higher opioid doses (≥100 mg oral morphine equivalents) had significant improvements in measures of pain, mood, and function 1 week after starting buprenorphine, with eventual return to baseline.
3) Patients on higher opioid doses also showed a non-significant trend of decreased pressure pain sensitivity 1 week after starting buprenorphine, eventually returning to baseline.
Long-Term Effect of Exercise Therapyand Patient Education on.docxwkyra78
Long-Term Effect of Exercise Therapy
and Patient Education on Impairments
and Activity Limitations in People
With Hip Osteoarthritis: Secondary
Outcome Analysis of a Randomized
Clinical Trial
Ida Svege, Linda Fernandes, Lars Nordsletten, Inger Holm, May Arna Risberg
Background. The effect of exercise on specific impairments and activity limitations in
people with hip osteoarthritis (OA) is limited.
Objective. The study objective was to evaluate the long-term effect of exercise therapy and
patient education on range of motion (ROM), muscle strength, physical fitness, walking
capacity, and pain during walking in people with hip OA.
Design. This was a secondary outcome analysis of a randomized clinical trial.
Setting. The setting was a university hospital.
Participants. One hundred nine people with clinically and radiographically evident hip
OA were randomly allocated to receive both exercise therapy and patient education (exercise
group) or patient education only (control group).
Intervention. All participants attended a patient education program consisting of 3 group
meetings led by 2 physical therapists. Two other physical therapists were responsible for
providing the exercise therapy program, consisting of 2 or 3 weekly sessions of strengthening,
functional, and stretching exercises over 12 weeks. Both interventions were conducted at a
sports medicine clinic.
Measurements. Outcome measures included ROM, isokinetic muscle strength, predicted
maximal oxygen consumption determined with the Astrand bicycle ergometer test, and
distance and pain during the Six-Minute Walk Test (6MWT). Follow-up assessments were
conducted 4, 10, and 29 months after enrollment by 5 physical therapists who were unaware
of group allocations.
Results. No significant group differences were found for ROM, muscle strength, predicted
maximal oxygen consumption, or distance during the 6MWT over the follow-up period, but
the exercise group had less pain during the 6MWT than the control group at 10 months (mean
difference��8.5 mm; 95% confidence interval��16.1, �0.9) and 29 months (mean differ-
ence��9.3 mm; 95% confidence interval��18.1, �0.6).
Limitations. Limitations of the study were reduced statistical power and 53% rate of
adherence to the exercise therapy program.
Conclusions. The previously described effect of exercise on self-reported function was
not reflected by beneficial results for ROM, muscle strength, physical fitness, and walking
capacity, but exercise in addition to patient education resulted in less pain during walking in
the long term.
I. Svege, PT, PhD, Norwegian
Research Center for Active Reha-
bilitation, Department of Ortho-
paedics, Oslo University Hospital,
Kirkeveien 166, 0450 Oslo, Nor-
way. Address all correspondence
to Dr Svege at: [email protected]
ous-hf.no.
L. Fernandes, PT, PhD, Norwegian
Research Center for Active Reha-
bilitation, Department of Ortho-
paedics, Oslo University Hospital,
and Department of Orthopaedic
Surgery and T.
Similar to Preop opioid use and catastrophizing. (20)
This document contains summaries of several research papers on topics related to chronic pain, suicide risk, and bipolar disorder:
1) One study found that tapering opioid doses for chronic pain patients was associated with increased risks of overdose and mental health crisis compared to patients who did not taper. Higher tapering speeds were linked to even greater risks.
2) Another study observed chronic pain patients undergoing opioid tapering or transition to buprenorphine treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine use predicted dropout. Pain levels varied after treatment.
3) Research on combat veterans found that those exposed to combat had higher rates of PTSD, suicide attempts, strokes and chronic pain
Labeling Woefulness: The Social Construction of FibromyalgiaPaul Coelho, MD
This document discusses the social construction of fibromyalgia and how it has been established as a legitimate disease label despite a lack of clear biological or clinical evidence. It argues that fibromyalgia serves social and economic purposes for various groups, including patients, doctors, pharmaceutical companies, and the media, but poses risks by medicalizing psychosocial problems. The document proposes that widespread pain is a normal human experience for some that is best addressed by exploring psychosocial factors rather than believing the solution lies in neurobiology. Examining fibromyalgia as a social construct may be more helpful for patients than continuing to medicalize their experiences.
Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrosp...Paul Coelho, MD
This study analyzed outcomes for 240 patients with chronic pain who were prescribed long-term opioid therapy above 90 mg morphine-equivalent daily doses. Patients were offered an outpatient opioid taper or transition to buprenorphine if taper was not tolerated. 44.6% successfully tapered, 18.8% transitioned to buprenorphine, and 36.6% dropped out of treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine/z-drug use predicted greater dropout. Pain intensity changes after treatment were mixed, with over half of tapered patients reporting increased pain and about half of transitioned patients reporting decreased pain.
This document appears to be a questionnaire assessing symptoms of widespread pain and calculating a WPI (Widespread Pain Index) score and SS (Symptom Severity) score. It asks the respondent to indicate areas of pain on a diagram and rate the severity of symptoms like fatigue, thinking difficulties, and unrefreshed sleep. It also inquires about additional symptoms like abdominal pain, depression, and headaches. The final section rates pain-related worry and fear on a scale. Additional questions determine if the respondent has a workers compensation or disability claim related to their pain complaint.
Fibromyalgia is a condition that causes chronic aches and pains all over the body, fatigue, and often a sleep disorder. The doctor diagnosed the patient with fibromyalgia based on a score of 13 or more on the fibromyalgia questionnaire from the American College of Rheumatology, which is consistent with the syndrome. By focusing on and managing the diagnosis of fibromyalgia, the patient's other pain symptoms can decrease.
This document contains two studies related to psychological treatments for chronic conditions:
1) A study of chronic fatigue syndrome patients found that poorer outcomes were predicted by membership in a self-help group, receiving sickness benefits, and symptoms of dysphoria. Severity and duration of symptoms did not predict response.
2) A randomized controlled trial of 125 fibromyalgia patients compared operant behavioral therapy, cognitive behavioral therapy, and attention placebo. Both behavioral therapies significantly reduced pain intensity while cognitive therapy improved cognitive and affective variables and operant therapy improved physical functioning and behaviors. The attention placebo resulted in no improvement or deterioration.
This document summarizes three studies on the risks and efficacy of opioids for chronic non-cancer pain (CNP). The first study finds that while opioids were associated with small improvements in pain and physical functioning compared to placebo, they also increased the risk of vomiting. Comparisons to other medications found similar benefits to pain and functioning. The second study finds no difference in pain-related function between opioid and non-opioid groups over 12 months, and higher rates of adverse effects and pain intensity in the opioid group. The third study finds limited effectiveness of opioids for CNP, as opioid users did not report improvements in outcomes after 2 years. Regarding risks, higher opioid doses are associated with increased overdose risk across several patient groups in
Mortality quadrupled among opioid-driven hospitalizations notably within lowe...Paul Coelho, MD
This study analyzed national hospitalization data from 1993-2014 to examine trends in mortality and characteristics of hospitalizations related to opioids compared to other drug and non-drug hospitalizations. The key findings were:
1) Mortality among opioid-related hospitalizations quadrupled from 0.43% before 2000 to 2.02% in 2014, increasing 0.12 percentage points per year relative to other drug hospitalizations.
2) While total opioid-related hospitalizations remained stable, diagnoses shifted from opioid dependence/abuse to opioid/heroin poisoning, which have higher mortality rates. Hospitalizations for poisoning grew by 0.01 per 1,000 people annually after 2000.
3) Patients hospitalized for opioid/
Prescriptions filled following an opioid-related hospitalization.Paul Coelho, MD
This study analyzed prescription drug fills within 30 days of discharge for 36,719 patients hospitalized for opioid misuse. Only 16.7% received medications approved for opioid dependence, while 40.3% filled antidepressant prescriptions and 22.4% filled opioid pain medication prescriptions. Concurrently, 13.9% filled benzodiazepine prescriptions and 7.4% filled both benzodiazepine and opioid prescriptions, indicating a need for improved education on risks. Overall, more effort is required to ensure patients receive recommended post-hospitalization treatment and support services.
This study examined the risk of psychiatric hospitalization in the offspring (second generation) of Finns who were evacuated to Sweden without parents during World War II (first generation), compared to offspring of Finns who were not evacuated. The study found that daughters of mothers who were evacuated during childhood had an elevated risk of psychiatric hospitalization, especially for mood disorders. However, there was no increased risk found for offspring of evacuated fathers or for male offspring of evacuated mothers. This suggests that early childhood adversity experienced by the first generation, such as war-related trauma, may be associated with mental health problems that persist into the second generation.
Correlation of opioid mortality with prescriptions and social determinants -a...Paul Coelho, MD
This study analyzed Medicare Part D data from 2013-2014 to examine the relationship between opioid prescription rates, socioeconomic factors, and opioid-related mortality rates at the county level in the United States. The results showed that higher county-level opioid prescription rates, especially those from emergency medicine, family medicine, internal medicine, and physician assistants, were associated with higher opioid-related mortality rates. Higher poverty levels and proportions of white populations in counties also correlated with increased mortality. Additionally, prescribers in the highest quartile of opioid prescription rates had a disproportionate impact on mortality compared to the remaining 75% of prescribers.
This report examines CMS's oversight of Medicare Part D beneficiaries who receive opioid prescriptions and providers who prescribe opioids to these beneficiaries. It finds that while CMS provides guidance to Part D plan sponsors on monitoring beneficiaries at high risk of opioid overuse, it lacks complete data on the full population of beneficiaries at risk. It also finds that CMS oversees prescribing through its contractor NBI MEDIC but does not specifically analyze opioid prescription data or require reporting on actions taken regarding inappropriate opioid prescribing. The report concludes that CMS needs more comprehensive oversight to reduce the risks of opioid misuse, overdose, and inappropriate prescribing among Medicare beneficiaries.
This study analyzed opioid prescription trends among medical specialties in the U.S. from 2007-2012 using a national prescription database. The key findings were:
- Primary care specialties (family practice, internal medicine, general practice) accounted for nearly half of all dispensed opioid prescriptions in 2012.
- Specialties treating pain conditions like pain medicine, surgery, and physical medicine had the highest rates of opioid prescribing.
- Overall opioid prescribing rates increased from 2007-2010 but stabilized from 2010-2012 as most specialties reduced rates.
- The greatest increase in opioid prescribing was among physical medicine specialists, while the largest decreases were in emergency medicine and dentistry.
The place-of-antipsychotics-in-the-therapy-of-anxiety-disorders-and-obsessive...Paul Coelho, MD
This document summarizes a research article about the use of antipsychotic drugs in the treatment of anxiety disorders and obsessive-compulsive disorders. The review finds evidence that certain second-generation antipsychotics (SGAPs), like quetiapine, risperidone, and aripiprazole, can be effective for generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD). Quetiapine in particular receives a recommendation as a first-line treatment for GAD. However, the review finds insufficient evidence for SGAPs in the treatment of social anxiety disorder and panic disorder. First-generation antipsychotics are not recommended for any anxiety disorders based on their side effect profiles
Structured opioid refill clinic epic smartphrases Paul Coelho, MD
#*** I explained to the patient the risks of combining opioids and benzodiazepines based on medical literature. We agreed to slowly taper the patient off benzodiazepines and trial safer alternatives for sleep and anxiety issues.
#*** I showed the patient their fibromyalgia screening questionnaire results, which were consistent with a fibromyalgia diagnosis. Fibromyalgia can amplify other painful conditions and is often the primary source of morbidity when present with other chronic pain diagnoses.
#*** We discussed the patient's high risk opioid regimen based on their dose exceeding CDC guidelines. While willing to work on a harm reduction plan, it will require a taper or switching to buprenorphine due to safety concerns.
Opioids for the Treatment of Chronic Pain: Mistakes Made, Lessons Learned, an...Paul Coelho, MD
This document summarizes the key issues regarding the use of opioids for chronic pain treatment:
1) An overreliance on opioids to treat chronic pain has contributed to the prescription opioid abuse epidemic in the US, as outpatient use allows for abuse and diversion of these addictive drugs.
2) While clinical trials show opioids effectively treat acute pain and are initially effective for chronic pain, real-world use reveals increased risks of abuse, addiction, and poor functional outcomes over the long-term.
3) The evidence supporting chronic opioid therapy was limited and observational in nature, yet convinced the medical community until larger population studies showed increased abuse rates contrary to initial assumptions.
The potential adverse influence of physicians’ words.Paul Coelho, MD
The physician's words can inadvertently amplify patients' symptoms and increase somatic distress if not carefully considered. Learning about potential side effects from medications, procedures, or test results can lead patients to experience and report those effects more frequently through psychological mechanisms like misattribution and increased attention to bodily sensations. Discussing concepts like nocebo and viscerosomatic amplification with patients can help provide reassuring explanations for symptoms and make them feel less intrusive. Physicians should thoughtfully consider their word choices and focus on benefits as well as side effects to minimize undue distress.
This document is an evidence report published by the Institute for Clinical and Economic Review (ICER) that evaluates the comparative clinical effectiveness and value of cognitive and mind-body therapies for chronic low back and neck pain. It was authored by Jeffrey Tice and others from ICER. The report assesses the clinical evidence on therapies such as cognitive behavioral therapy and mindfulness-based stress reduction and presents economic analyses of the long-term cost-effectiveness and potential budget impact of these therapies. It also incorporates input from clinical experts and stakeholders.
The conundrum of opioid tapering in long term opioid therapy for chronic pain...Paul Coelho, MD
The document discusses the challenges clinicians face when tapering patients off long-term opioid therapy for chronic pain. It explains that opioid dependence can cause worsening pain, psychiatric symptoms, and functioning during tapering due to neuroplastic changes. While tapering seems logical to address risks of high-dose opioids, it may paradoxically make a patient's issues worse due to protracted abstinence syndrome. The document provides guidance for managing these complex patients focused on both pain and opioid dependence.
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Emotional and Behavioural Problems in Children - Counselling and Family Thera...PsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Ensure the highest quality care for your patients with Cardiac Registry Support's cancer registry services. We support accreditation efforts and quality improvement initiatives, allowing you to benchmark performance and demonstrate adherence to best practices. Confidence starts with data. Partner with Cardiac Registry Support. For more details visit https://cardiacregistrysupport.com/cancer-registry-services/
Solution manual for managerial accounting 18th edition by ray garrison eric n...rightmanforbloodline
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Digital Health in India_Health Informatics Trained Manpower _DrDevTaneja_15.0...DrDevTaneja1
Digital India will need a big trained army of Health Informatics educated & trained manpower in India.
Presently, generalist IT manpower does most of the work in the healthcare industry in India. Academic Health Informatics education is not readily available at school & health university level or IT education institutions in India.
We look into the evolution of health informatics and its applications in the healthcare industry.
HIMMS TIGER resources are available to assist Health Informatics education.
Indian Health universities, IT Education institutions, and the healthcare industry must proactively collaborate to start health informatics courses on a big scale. An advocacy push from various stakeholders is also needed for this goal.
Health informatics has huge employment potential and provides a big business opportunity for the healthcare industry. A big pool of trained health informatics manpower can lead to product & service innovations on a global scale in India.
The Ultimate Guide in Setting Up Market Research System in Health-TechGokul Rangarajan
How to effectively start market research in the health tech industry by defining objectives, crafting problem statements, selecting methods, identifying data collection sources, and setting clear timelines. This guide covers all the preliminary steps needed to lay a strong foundation for your research.
"Market Research it too text-booky, I am in the market for a decade, I am living research book" this is what the founder I met on the event claimed, few of my colleagues rolled their eyes. Its true that one cannot over look the real life experience, but one cannot out beat structured gold mine of market research.
Many 0 to 1 startup founders often overlook market research, but this critical step can make or break a venture, especially in health tech.
But Why do they skip it?
Limited resources—time, money, and manpower—are common culprits.
"In fact, a survey by CB Insights found that 42% of startups fail due to no market need, which is like building a spaceship to Mars only to realise you forgot the fuel."
Sudharsan Srinivasan
Operational Partner Pitchworks VC Studio
Overconfidence in their product’s success leads founders to assume it will naturally find its market, especially in health tech where patient needs, entire system issues and regulatory requirements are as complex as trying to perform brain surgery with a butter knife. Additionally, the pressure to launch quickly and the belief in their own intuition further contribute to this oversight. Yet, thorough market research in health tech could be the key to transforming a startup's vision into a life-saving reality, instead of a medical mishap waiting to happen.
Example of Market Research working
Innovaccer, founded by Abhinav Shashank in 2014, focuses on improving healthcare delivery through data-driven insights and interoperability solutions. Before launching their platform, Innovaccer conducted extensive market research to understand the challenges faced by healthcare organizations and the potential for innovation in healthcare IT.
Identifying Pain Points: Innovaccer surveyed healthcare providers to understand their difficulties with data integration, care coordination, and patient engagement. They found widespread frustration with siloed systems and inefficient workflows.
Competitive Analysis: Analyzed competitors offering similar solutions in healthcare analytics and interoperability. Identified gaps in comprehensive data aggregation, real-time analytics, and actionable insights.
Regulatory Compliance: Ensured their platform complied with HIPAA and other healthcare data privacy regulations. This compliance was crucial to gaining trust from healthcare providers wary of data security issues.
Customer Validation: Conducted pilot programs with several healthcare organizations to validate the platform's effectiveness in improving care outcomes and operational efficiency. Gathered feedback to refine features and user interface.
The Importance of Black Women Understanding the Chemicals in Their Personal C...bkling
Certain chemicals, such as phthalates and parabens, can disrupt the body's hormones and have significant effects on health. According to data, hormone-related health issues such as uterine fibroids, infertility, early puberty and more aggressive forms of breast and endometrial cancers disproportionately affect Black women. Our guest speaker, Jasmine A. McDonald, PhD, an Assistant Professor in the Department of Epidemiology at Columbia University in New York City, discusses the scientific reasons why Black women should pay attention to specific chemicals in their personal care products, like hair care, and ways to minimize their exposure.
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Sectional dentures for microstomia patients.pptxSatvikaPrasad
Microstomia, characterized by an abnormally small oral aperture, presents significant challenges in prosthodontic treatment, including limited access for examination, difficulties in impression making, and challenges with prosthesis insertion and removal. To manage these issues, customized impression techniques using sectional trays and elastomeric materials are employed. Prostheses may be designed in segments or with flexible materials to facilitate handling. Minimally invasive procedures and the use of digital technologies can enhance patient comfort. Education and training for patients on prosthesis care and maintenance are crucial for compliance. Regular follow-up and a multidisciplinary approach, involving collaboration with other specialists, ensure comprehensive care and improved quality of life for microstomia patients.
NURSING MANAGEMENT OF PATIENT WITH EMPHYSEMA .PPTblessyjannu21
Prepared by Prof. BLESSY THOMAS, VICE PRINCIPAL, FNCON, SPN.
Emphysema is a disease condition of respiratory system.
Emphysema is an abnormal permanent enlargement of the air spaces distal to terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
Emphysema of lung is defined as hyper inflation of the lung ais spaces due to obstruction of non respiratory bronchioles as due to loss of elasticity of alveoli.
It is a type of chronic obstructive
pulmonary disease.
It is a progressive disease of lungs.
Basics of Electrocardiogram
CONTENTS
●Conduction System of the Heart
●What is ECG or EKG?
●ECG Leads
●Normal waves of ECG.
●Dimensions of ECG.
● Abnormalities of ECG
CONDUCTION SYSTEM OF THE HEART
ECG:
●ECG is a graphic record of the electrical activity of the heart.
●Electrical activity precedes the mechanical activity of the heart.
●Electrical activity has two phases:
Depolarization- contraction of muscle
Repolarization- relaxation of muscle
ECG Leads:
●6 Chest leads
●6 Limb leads
1. Bipolar Limb Leads:
Lead 1- Between right arm(-ve) and left arm(+ve)
Lead 2- Between right arm(-ve) and left leg(+ve)
Lead 3- Between left arm(-ve)
and left leg(+ve)
2. Augmented unipolar Limb Leads:
AvR- Right arm
AvL- Left arm
AvF- Left leg
3.Chest Leads:
V1 : Over 4th intercostal
space near right sternal margin
V2: Over 4th intercostal space near left sternal margin
V3:In between V2 and V4
V4:Over left 5th intercostal space on the mid
clavicular line
V5:Over left 5th intercostal space on the anterior
axillary line
V6:Over left 5th intercostal space on the mid
axillary line.
Normal ECG:
Waves of ECG:
P Wave
•P Wave is a positive wave and the first wave in ECG.
•It is also called as atrial complex.
Cause: Atrial depolarisation
Duration: 0.1 sec
QRS Complex:
•QRS’ complex is also called the initial ventricular complex.
•‘Q’ wave is a small negative wave. It is continued as the tall ‘R’ wave, which is a positive wave.
‘R’ wave is followed by a small negative wave, the ‘S’ wave.
Cause:Ventricular depolarization and atrial repolarization
Duration: 0.08- 0.10 sec
T Wave:
•‘T’ wave is the final ventricular complex and is a positive wave.
Cause:Ventricular repolarization Duration: 0.2 sec
Intervals and Segments of ECG:
P-R Interval:
•‘P-R’ interval is the interval
between the onset of ‘P’wave and onset of ‘Q’ wave.
•‘P-R’ interval cause atrial depolarization and conduction of impulses through AV node.
Duration:0.18 (0.12 to 0.2) sec
Q-T Interval:
•‘Q-T’ interval is the interval between the onset of ‘Q’
wave and the end of ‘T’ wave.
•‘Q-T’ interval indicates the ventricular depolarization
and ventricular repolarization,
i.e. it signifies the
electrical activity in ventricles.
Duration:0.4-0.42sec
S-T Segment:
•‘S-T’ segment is the time interval between the end of ‘S’ wave and the onset of ‘T’ wave.
Duration: 0.08 sec
R-R Interval:
•‘R-R’ interval is the time interval between two consecutive ‘R’ waves.
•It signifies the duration of one cardiac cycle.
Duration: 0.8 sec
Dimension of ECG:
How to find heart rhytm of the heart?
Regular rhytm:
Irregular rhytm:
More than or less than 4
How to find heart rate using ECG?
If heart Rhytm is Regular :
Heart rate =
300/No.of large b/w 2 QRS complex
= 300/4
=75 beats/mins
How to find heart rate using ECG?
If heart Rhytm is irregular:
Heart rate = 10×No.of QRS complex in 6 sec 5large box = 1sec
5×6=30
10×7 = 70 Beats/min
Abnormalities of ECG:
Cardiac Arrythmias:
1.Tachycardia
Heart Rate more than 100 beats/min
2024 Media Preferences of Older Adults: Consumer Survey and Marketing Implica...Media Logic
When it comes to creating marketing strategies that target older adults, it is crucial to have insight into their media habits and preferences. Understanding how older adults consume and use media is key to creating acquisition and retention strategies. We recently conducted our seventh annual survey to gain insight into the media preferences of older adults in 2024. Here are the survey responses and marketing implications that stood out to us.
2024 Media Preferences of Older Adults: Consumer Survey and Marketing Implica...
Preop opioid use and catastrophizing.
1. Impact of Preoperative Opioid Use on Total Knee
Arthroplasty Outcomes
Savannah R. Smith, BA*, Jennifer Bido, BA*, Jamie E. Collins, PhD, Heidi Yang, MS, MPH,
Jeffrey N. Katz, MD, MSc, and Elena Losina, PhD
Investigation performed at the Orthopaedic and Arthritis Center for Outcomes Research (OrACORe),
Brigham and Women’s Hospital, Boston, Massachusetts
Background: There is growing concern about the use of opioids prior to total knee arthroplasty (TKA), and research has
suggested that preoperative opioid use may lead to worse pain outcomes following surgery. We evaluated the pain relief
achieved by TKA in patients who had and those who had not used opioids use before the procedure.
Methods: We augmented data from a prospective cohort study of TKA outcomes with opioid-use data abstracted from
medical records. We collected patient-reported outcomes and demographic data before and 6 months after TKA. We used
the Pain Catastrophizing Scale and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to
quantify the pain experiences of patients treated with TKA who had had a baseline score of ‡20 on the WOMAC pain scale
(a 0 to 100-point scale, with 100 being the worst score), who provided follow-up data, and who had not had another
surgical procedure within the 2 years prior to TKA. We built a propensity score for preoperative opioid use based on the
Pain Catastrophizing Scale score, comorbidities, and baseline pain. We used a general linear model, adjusting for the
propensity score and baseline pain, to compare the change in the WOMAC pain score 6 months after TKA between
persons who had and those who had not used opioids before TKA.
Results: The cohort included 156 patients with a mean age of 65.7 years (standard deviation [SD] = 8.2 years) and a
mean body mass index (BMI) of 31.1 kg/m2 (SD = 6.1 kg/m2); 62.2% were female. Preoperatively, 36 patients (23%) had
had at least 1 opioid prescription. The mean baseline WOMAC pain score was 43.0 points (SD = 12.8) for the group that
had not used opioids before TKA and 46.9 points (SD = 15.7) for those who had used opioids (p = 0.12). The mean
preoperative Pain Catastrophizing Scale score was greater among opioid users (15.5 compared with 10.7 points among
non-users, p = 0.006). Adjusted analyses showed that the opioid group had a mean 6-month reduction in the WOMAC pain
score of 27.0 points (95% confidence interval [CI] = 22.7 to 31.3) compared with 33.6 points (95% CI = 31.4 to 35.9)
in the non-opioid group (p = 0.008).
Conclusions: Patients who used opioids prior to TKA obtained less pain relief from the operation. Clinicians should
consider limiting pre-TKA opioid prescriptions to optimize the benefits of TKA.
Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
K
nee osteoarthritis is associated with substantial activity
limitation and chronic pain. While total knee arthro-
plasty (TKA) is an effective treatment to relieve pain
and restore function, patients spend an average of 13 years
undergoing nonoperative therapies such as nonsteroidal anti-
inflammatory drugs, physical therapy, and intra-articular in-
jections before ultimately undergoing TKA; this highlights the
need for effective analgesics1
. Although treatment guidelines
regarding the role of opioids for management of pain caused
by knee osteoarthritis prior to TKA have been inconsistent2-4
,
*Savannah R. Smith, BA, and Jennifer Bido, BA, contributed equally to the writing of this article.
Disclosure: This study was funded by National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIH/NIAMS)
Grant K24AR057827 and Partners HealthCare. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article
(http://links.lww.com/JBJS/D274).
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor
reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or
more exchanges between the author(s) and copyeditors.
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2. in the U.S. over $1.5 billion is spent annually on prescription
opioids for people with knee osteoarthritis5
. Furthermore,
opioid utilization has increased drastically, with nearly 40%
of Medicare beneficiaries with knee osteoarthritis receiving at
least 1 opioid prescription in 20096
.
Increased utilization of opioids has been accompanied by
concerns about their adverse effects on surgical outcomes
when they are taken prior to total joint arthroplasty (TJA). High
doses of opioids have been associated with the development of
opioid dependence and hyperalgesia, which could contribute to
intractable pain following TJA7
. Prior studies have shown that
patients who use opioids preoperatively are more likely to con-
tinue to use them after TJA7-10
. The growing concern over opioid
use has led to multiple studies comparing clinical outcomes
between patients treated with opioids and those treated without
opioids prior to TJA. Studies have shown an association between
preoperative opioid use and increased pain as well as worse
functional outcomes within the first week following TJA8,9,11
.
Preoperative opioid use has also been associated with impaired
long-term clinical outcomes of various types of orthopaedic
surgery, particularly spinal procedures12-15
.
Although recent studies have suggested that patients who
use preoperative opioids have worse outcomes of TKA9,16,17
,
they were based on limited sample sizes and the authors did
not consider pain catastrophizing or use appropriate analytic
methods to address confounding by indications that could
contribute to poorer pain and functional outcomes. To address
these gaps, we used restricted propensity score methodology to
adjust for confounding by indication in our study comparing
the reduction of pain after TKA between patients who had used
opioids preoperative and those without prior opioid treatment.
Materials and Methods
Sample
This study was conducted at Brigham and Women’s Hospital, a tertiary-care
academic medical center in Boston, Massachusetts. We used data from the
Adding Value in Knee Arthroplasty (AViKA) Postoperative Care Navigation
Trial, a randomized controlled trial evaluating motivational interviewing to
enhance TKA outcomes
18,19
. The study included patients who had undergone
primary unilateral TKA for osteoarthritis when they were at least 40 years old.
Each subject had completed, within 6 weeks before and again 6 months after
TKA, a questionnaire consisting of validated measures to assess clinical out-
comes, including the Western Ontario and McMaster Universities Osteoar-
thritis Index (WOMAC)
20
, 5-question Mental Health Inventory (MHI-5), Pain
Catastrophizing Scale, and questions about comorbidities. The Pain Cata-
strophizing Scale quantifies the degree to which an individual has exaggerated
negative thoughts as a response to pain on a scale of 0 to 52, with higher scores
indicating worse catastrophizing
21
.
Medical Record Review
To obtain detailed information on opioid use, we reviewed the electronic
medical record of each enrolled AViKA Trial subject to determine opioid
utilization from 2 years before to 1 year after TKA. Multiple sources of data
were reviewed for each patient, including clinical visit notes, anesthesiology
reports, discharge notes, prescription history, and medication list. We re-
corded information for 6 opioids: oxycodone, hydrocodone, hydromorphone,
morphine, tramadol, and codeine. Other opioids were rarely found and were
recorded as “other.” For each mention of an opioid prescription in the medical
record, we abstracted whether the opioid was prescribed before TKA, after
TKA, or both. We further documented any additional surgical procedures
in the period from 2 years prior to TKA to 1 year after TKA and the type of
medical insurance.
Literature Review
We conducted a systematic literature search to identify published studies on the
effects of preoperative opioids on postoperative orthopaedic outcomes for
comparison with our study. Our primary source for identifying publications
was PubMed, which we searched with the following queries: orthopaedic
outcomes and opioids, surgical outcomes and opioids, and arthroplasty and
opioids. Additionally, we searched through the references of the identified
papers to identify any publications missed by the queries. We then read the titles
and abstracts of the 1,700 results to include papers relevant to orthopaedics and
preoperative opioid use. We chose 26 studies and then excluded those in which
validated outcome measure questionnaires had not been used. This left 5 publi-
cations with which to compare our own study. The questionnaires used in these
studies were the Knee Society objective score
16
, Harris hip score
10
, WOMAC
17
,
American Shoulder and Elbow Surgeons (ASES) score
15
, and Oswestry Disability
Index (ODI)
22
. All preoperative and postoperative scores were transformed into
a 0 to 100-point scale with 100 being the worst. We calculated a relative re-
duction in pain benefits due to opioids as the relative difference between the
opioid users and non-users in the change in pain from before TKAto after TKA.
Statistical Analysis
We compared demographic and clinical characteristics between subjects with
and those without pre-TKA opioid use. We used the chi-square test to compare
Fig. 1
Selection process for analytic cohort.
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3. across categorical factors (sex, type of insurance, and education level), the t test
to compare across continuous variables with normal distribution (age, baseline
WOMAC pain score, and baseline WOMAC function score), and the Wilcoxon
rank sum test to compare across continuous variables with skewed distribution
(body mass index [BMI], number of comorbidities, and baseline Pain Cata-
strophizing Scale score).
To adjust for potential confounding by the indication for opioid use, we
built a propensity score for opioid use, using logistic regression with pre-TKA
opioid use as an outcome. The independent variables were the Pain Cata-
strophizing Scale score, Charlson Comorbidity Index (grouped as 0, 1 to 3, and
>3), and baseline WOMAC pain score. The model had a c-statistic of 0.682. We
identified a common use area as a set of propensity scores that were common
between subjects who did and those who did not use opioids prior to TKA (0.12
to 0.50) and excluded subjects with propensity scores greater or less than this
common range from our analytical sample.
We then built a general linear model with the change in the WOMAC
pain score over the 6 months following the TKA as the outcome variable and
with the propensity for opioid use described above, use of opioids before TKA,
and baseline WOMAC pain score as the independent variables.
We conducted a sensitivity analysis using marginal structural models,
with inverse probability weighting according to the likelihood of opioid use
prior to TKA. All analyses were conducted with SAS 9.4 software, and p < 0.05
indicated significant results.
Results
Sample Characteristics
From August 2011 to November 2013, 308 patients were
enrolled in the AViKA study and 252 of them had a pre-
TKAWOMAC pain score of ‡20. Of those subjects, 221 (88%)
provided 6-month data. We excluded 44 subjects because they
had had surgery within 2 years prior to TKA, to minimize
misattribution of opioid use to another surgical procedure. Of
the remaining 177 subjects, 156 were included in the analysis
based on the common use area of the propensity score values
(0.12 to 0.50) (Fig. 1).
The mean age at the time of TKA was 65.7 years (standard
deviation [SD] = 8.2 years), 62.2% of the patients were female,
and the mean BMI was 31.1 kg/m2 (SD = 6.1 kg/m2). The
majority (60.4%) of the patients had graduated from college,
53% of the cohort had at least 1 comorbid condition, and 32.7%
had ‡2 comorbidities. The baseline Pain Catastrophizing Scale
score was 11.8 (SD = 8.6) (Table I).
Opioid Utilization
Thirty-six (23%) of the 156 patients in the cohort had had at
least 1 opioid prescription within the 2 years prior to TKA. The
TABLE I Cohort Characteristics
Pre-TKA Opioid Use
Overall (N = 156) Yes (N = 36) No (N = 120) P Value
Age* (yr) 65.7 ± 8.21 67.5 ± 8.2 65.2 ± 8.2 0.13
Female† 97 (62.2%) 23 (23.7%) 74 (76.3%) 0.81
BMI* (kg/m2) 31.1 ± 6.06 31.0 31.1 0.84
Graduated from college†‡ 0.40
No 61 (39.6%) 16 (26.2%) 45 (73.8%)
Yes 93 (60.4%) 19 (20.4%) 74 (79.6%)
Comorbidities* 0.81 ± 0.98 0.81 0.81 0.90
Baseline WOMAC score*§
Pain 43.9 ± 13.55 46.9 ± 15.7 43.0 ± 12.8 0.12
Function 43.7 ± 14.16 49.0 ± 14.1 42.1 ± 13.8 0.009
Pain Catastrophizing Scale score* 11.8 ± 8.55 15.5 ± 10.3 10.7 ± 7.7 0.006
Type of insurance† 0.91
Private 129 (82.7%) 30 (23.3%) 99 (76.7%)
Medicaid/Medicare/other 27 (17.3%) 6 (22.2%) 21 (77.8%)
*The values are given as the mean and standard deviation. †The values are given as the number of patients with the percentage in parentheses.
The percentages in the “Yes” and “No” groups are based on the numbers in the “Overall” group. ‡Data missing for one patient in each group.
§The WOMAC score was transformed to a 0 to 100-point scale (100 indicating the worst score).
TABLE II Opioid Utilization
No. (%) of Patients
Opioid Use Preoperative Postoperative
Codeine 0 (0%) 0 (0%)
Hydrocodone 14 (9.0%) 52 (33.3%)
Hydromorphone 1 (0.6%) 20 (12.8%)
Morphine 0 (0%) 3 (1.9%)
Oxycodone 14 (9.0%) 150 (96.2%)
Tramadol 20 (12.8%) 30 (19.2%)
Other 0 (0%) 0 (0%)
Multiple opioid prescriptions 14 (9.0%) 146 (93.6%)
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4. most common opioids used preoperatively in this sample were
oxycodone, hydrocodone, and tramadol. Fourteen (9.0%) of
the patients used >1 type of opioid. The proportions of subjects
using each preoperative opioid identified within the medical
records are shown in Table II.
Postoperatively, 150 (96.2%) of the patients had at least
1 opioid prescription listed in their medical record, with 146
(93.6%) having prescriptions for multiple opioids. Oxycodone
was the most frequently prescribed opioid (150; 96.2%), fol-
lowed by hydrocodone (52; 33.3%) (Table II).
Demographic characteristics (age, sex, and education
level) were similar between patients with a documented history
of pre-TKA opioid utilization and those who had not used
opioids preoperatively. The unadjusted mean baseline WOMAC
pain score was worse for those who had used opioids before TKA
(46.9 points compared with 43.0 points for those who had not),
but the difference was not significant (p = 0.12), and those who
had used opioids before TKA had significantly worse functional
limitations (49.0 compared with 42.1 points, p = 0.009) (Table I).
Multivariate analysis showed that, after adjusting for
baseline WOMAC pain and comorbidity scores, pain cata-
strophizing was the only factor independently associated with
pre-TKA opioid use. Those who had used opioids before TKA
had mean a Pain Catastrophizing Scale score of 15.5 points
compared with 10.7 points for those who had not (p = 0.006).
Every unit increase in the Pain Catastrophizing Scale score was
associated with a 4.7% increase in the adjusted odds of using
opioids prior to TKA. After we adjusted for the propensity
score, the baseline WOMAC score became more balanced be-
tween those who had used and those who had not used opioids
before TKA (Table III).
Relationship Between Pre-TKA Opioid Use and Outcomes
After adjustment for the propensity score and baseline WOMAC
pain score, patients who had not used opioids before TKA had a
mean 6-month WOMAC pain score of 10.5 points (95% con-
fidence interval [CI] = 8.3 to 12.8) compared with 17.1 points
(95% CI = 12.8 to 21.4) for those who had used opioids prior to
TKA (Table III). Multivariate analyses adjusted for the propen-
sity score and baseline pain score showed that the opioid group
had a mean 6-month WOMAC pain-score reduction of 27.0
points (95% CI = 22.7 to 31.3) compared with 33.6 points (95%
CI = 31.4 to 35.9) for the non-opioid-use group; the difference
between the groups was 6.6 points (p = 0.008) (Table III).
Sensitivity analyses using an inverse probability of opioid
use weighting method showed similar results, with the reduc-
tion in the WOMAC pain score being 5.7 points less for the
opioid users than for those who had not used opioids prior to
TKA (p = 0.0430). Adding pre-TKA functional limitations to
the model did not qualitatively change the results.
Comparison with Other Published Studies
Table IV summarizes the findings of published studies com-
paring outcomes of common orthopaedic procedures between
opioid users and non-users. After analyzing Knee Society scores
2 to 7 years following TKA, Zywiel et al. reported a 14.1%
TABLE IV Comparison Between Current Study and Other Published Evidence on Reduction in Pain Benefits in Opioid Users Compared with
Non-Users
Study Joint Time Frame Scale
Reduction in Benefits
in Opioid Users (%) P Value
Radcliff et al.
22
Spine 4 yr ODI 0.8 0.790
Morris et al.
15
Shoulder 2-9 yr ASES score 14.5 0.005
Zywiel et al.
16
Knee 2-7 yr Knee Society objective score 14.1 <0.001
Pivec et al.
10
Hip 58 mo Harris hip score 7.7 0.002
Nguyen et al.
17
Hip and knee 6-12 mo WOMAC 21.4 <0.01
Present study Knee 6 mo WOMAC 8.9 <0.001
TABLE III Adjusted Baseline and 6-Month WOMAC Pain Scores, and Change Over 6 Months, Stratified by Pre-TKA Opioid Use*
Pre-TKA Opioid Use
Yes No Difference Between Groups
Time Point Mean 95% CI Mean 95% CI Mean 95% CI
Baseline 44.6 40.3-48.9 43.7 41.4-46.0 1.0 24.0-5.9
6 months 17.1 12.8-21.4 10.5 8.3-12.8 6.6 1.7-11.5
Change 27.0 22.7-31.3 33.6 31.4-35.9 6.6 1.7-11.5
*Model adjusted for propensity score.
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5. reduction in pain relief (p < 0.001) between the opioid users
and non-users16
. Pivec et al. reported that, at 58 months after
total hip arthroplasty (THA), opioid users had a 7.7% reduc-
tion in pain relief, as shown by Harris hip scores (p = 0.002),
compared with non-users10
. Nguyen et al. reported that pre-
operative opioid use resulted in a significant (p < 0.01) re-
duction of 21.4% in pain relief at 6 to 12 months following
TKA or THA17
. In a study with a 2 to 9-year follow-up, Morris
et al. reported a significant, 14.5% reduction in pain relief,
according to the ASES score, for those who had used opioids
prior to reverse shoulder arthroplasty (p = 0.005)15
. Notably,
Radcliff et al. did not report a significant difference in the ODI
at 4 years after lumbar discectomy between those who had and
those who had not used opioids prior to surgery22
(Table IV).
Discussion
The use of opioids for chronic non-cancer-related pain has
increased drastically within the past decade23
. This trend
has been observed for knee osteoarthritis, with nearly half of
Medicare beneficiaries with this condition receiving at least
1 opioid prescription in 20096
. As the majority of eligible patients
with knee osteoarthritis eventually undergo TKA1
, understand-
ing the postoperative effect of pre-TKA opioid use is imperative
to the creation of appropriate treatment guidelines. Using data
collected from medical records, we found that patients who had
used opioids prior to TKA experienced less pain relief 6 months
postoperatively than patients who had not used opioids prior
to TKA.
The results that we present support and expand on pre-
viously published findings regarding the influence of pre-TKA
opioid use (Table IV). Zywiel and colleagues reported that pa-
tients using opioids prior to TKA had significantly higher rates of
revision for residual pain or stiffness (8 of 49 knees) than those
who had not used opioids (0 revisions)16
. Furthermore, their
opioid-treated patients had significantly lower Knee Society
scores at the time of final follow-up, suggesting worse clinical
outcomes, than their non-opioid-using counterparts. Pivec et al.
reported similar results regarding the effect of preoperative opi-
oid use on the clinical outcomes of THA, with their patients who
used narcotics prior to surgery having worse Harris hip scores
than those with no history of opioid use10
. Nguyen et al. included
an intervention group in their study on the effects of preoperative
opioid use on TJA outcomes. They showed that, while the opioid-
dependent group had significantly worse follow-up WOMAC
scores than patients with no preoperative opioid use, those who
reduced their opioid consumption by at least 50% prior to sur-
gery did not have different outcomes compared with those
without a history of opioid use17
. The analyses in these papers,
however, were often limited by small sample sizes, lack of ad-
justment for additional comorbidities, and a lack of randomi-
zation into the treatment groups.
Our current study, which showed results consistent with
those in the prior literature and expanded the evidence that
pre-TKA opioid use is associated with less pain relief following
the surgery, had several methodologic benefits. We adjusted for
baseline WOMAC pain scores and comorbidities as well as for
the propensity score for using opioids before TKA to provide
a more comprehensive adjustment for potential confounding
by indications and to isolate the independent effect of pre-TKA
opioid use on pain relief. Overall, the 6-month change in the
WOMAC pain score was associated with the baseline pain score
and opioid use. Preoperatively, there was a small but not sig-
nificant difference in the WOMAC pain scores between the
groups, whereas the pain scores at 6 months were significantly
worse for those who had used opioids preoperatively (p = 0.008).
This difference indicates that preoperative opioid use may have
affected the pain reduction achieved with the TKA.
Our data showed that pre-TKA opioid use was associated
with pain catastrophizing but not with baseline pain. Fur-
thermore, pre-TKA opioid use, but not pain catastrophizing,
was independently associated with worse post-TKA pain. Our
study suggests that pain catastrophizing may play an important
role in decisions by physicians and patients to use opioids,
which then places them at risk for poorer outcomes.
Of the drugs that we considered to be opioids, tramadol was
the most frequently used prior to TKA. Tramadol is a centrally
acting analgesic unique for its multiple mechanisms of pain relief,
given its behavior as an opiate agonist and as a reuptake inhibitorof
both norepinephrine and serotonin. We chose to classify tramadol
as an opioid because it is structurally analogous to other opioids.
There are important limitations to our analyses. As
evidence of opioid utilization was obtained from the medical
record and patients were not interviewed for verification, we
are unable to definitively state that opioid prescription resulted in
utilization of the entire prescribed dosage. It is possible that pa-
tients received a prescription and failed to obtain the analgesic or
took less than the dispensed amount. This could lead to an un-
derestimation or overestimation of the effects of opioids on pain
relief provided by TKA. Conversely, as preoperative opioid pre-
scriptions were identified from a single medical record, it is pos-
sible that patients received additional opioid prescriptions from
outside sources. Additionally, without verification interviews we
were unable to fully characterize postoperative opioid use, which
could have affected pain reporting during follow-up visits. Our
cohort consisted of patients enrolled in the AViKA study, a ran-
domized controlled trial of care navigation following TKA, which
could have contributed to selection bias. We followed patients for
only 6 months following TKA. It is possible that those who used
opioids before TKA could have eventually, over a longer period of
time, obtained the same degree of pain relief obtained by the
patients who had not used opioids preoperatively. Since we did
not have an objective way to assess individual pain tolerance
in general, we could not rule out the possibility that differences
in the reported severity of the painwere affected by differences in
pain tolerance. We also did not have data on pain in other joints
or the spine prior to TKA, which may have had an impact on
post-TKA pain. Finally, patients were enrolled from a single,
tertiary, academic medical center, potentially limiting the gen-
eralizability of our results.
In conclusion, the data that we presented support prior
reports of worse TKA clinical outcomes in persons who used
opioids preoperatively16
. Specifically, our data showed that
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6. preoperative opioid use may contribute to decreased pain relief
in the early postoperative period.
As individuals with osteoarthritis spend an average of
13 years between trials of nonoperative therapies and elective
TKA1
, our results should be viewed as a warning that opioid
use may be problematic during this period due to their neg-
ative effects on subsequent TKA outcomes. Furthermore,
considering that the U.S. spends over $1.5 billion5
annually on
prescription opioids for patients with knee osteoarthritis, and
nearly $30 billion24
on illicit use, reducing use of opioids may
decrease their deleterious effects. Clinicians and policy makers
may consider limiting the use of opioids prior to TKA to optimize
post-TKA pain relief. n
Savannah R. Smith, BA1
Jennifer Bido, BA2
Jamie E. Collins, PhD1,2
Heidi Yang, MS, MPH1
Jeffrey N. Katz, MD, MSc1,2,3
Elena Losina, PhD1,2,4
1Orthopaedic and Arthritis Center for Outcomes Research (S.R.S., J.E.C.,
H.Y., J.N.K., and E.L.) and Policy, Innovation eValuation in Orthopedic
Treatments (PIVOT) Research Center (J.E.C., J.N.K., and E.L.),
Department of Orthopaedic Surgery, and Division of Rheumatology,
Immunology, and Allergy (J.N.K.), Brigham and Women’s Hospital,
Boston, Massachusetts
2Harvard Medical School, Boston, Massachusetts
3Departments of Epidemiology and Environmental Health, Harvard T.H.
Chan School of Public Health, Boston, Massachusetts
4Department of Biostatistics, Boston University School of Public Health,
Boston, Massachusetts
E-mail address for E. Losina: elosina@partners.org
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