Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.
OptumLabs, Eden Prairie, Minnesota.
JAMA Netw Open. 2021 Oct 1;4(10):e2131271. doi: 10.1001/jamanetworkopen.2021.31271.
Many individuals who undergo total knee replacement (TKR) become long-term opioid users after TKR. Associations of physical therapy (PT) interventions before or after TKR with long-term use of opioids are not known.
To evaluate associations of PT interventions before and after TKR with long-term opioid use after TKR.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the OptumLabs Data Warehouse on 67 322 individuals aged 40 years or older who underwent TKR from January 1, 2001, to December 31, 2016, stratified by history of opioid use. The analyses for the study included data from January 1, 1999, to December 31, 2018.
Any PT interventions within 90 days before or after TKR, post-TKR PT dose as number of sessions (ie, 1-5, 6-12, and ≥13 sessions), post-TKR PT timing as number of days to initiation of care (ie, <30 days, 31-60 days, or 61-90 days after TKR), and post-TKR PT type (ie, active vs passive).
The association of pre- and post-TKR PT with risk of long-term opioid use occurring more than 90 days after TKR was assessed using logistic regression while adjusting for confounders, including age, sex, race and ethnicity (Asian, Black, Hispanic, or White), obesity, type of insurance, geographical location, and physical and mental health comorbidities.
A total of 38 408 opioid-naive individuals (21 336 women [55.6%]; mean [SD] age, 66.2 [9.2] years) and 28 914 opioid-experienced individuals (18 426 women [63.7%]; mean [SD] age, 64.4 [9.3] years) were included. Receipt of any PT before TKR was associated with lower odds of long-term opioid use in the opioid-naive (adjusted odds ratio [aOR], 0.75 [95% CI, 0.60-0.95]) and opioid-experienced (aOR, 0.75 [95% CI, 0.70-0.80]) cohorts. Receipt of any post-TKR PT was associated with lower odds of long-term use of opioids in the opioid-experienced cohort (aOR, 0.75 [95% CI, 0.70-0.79]). Compared with 1 to 5 sessions of PT after TKR, 6 to 12 sessions (aOR, 0.82 [95% CI, 0.75-0.90]) and 13 or more sessions (aOR, 0.71 [95% CI, 0.65-0.77) were associated with lower odds in the opioid-experienced cohort. Compared with initiation of PT within 30 days after TKR, initiation 31 to 60 days or 61 to 90 days after TKR were associated with greater odds in the opioid-naive (31-60 days: aOR, 1.45 [95% CI, 1.19-1.77]; 61-90 days: aOR, 2.15 [95% CI, 1.43-3.22]) and opioid-experienced (31-60 days: aOR, 1.10 [95% CI, 1.02-1.18]; 61-90 days: aOR, 1.32 [95% CI, 1.12-1.55]) cohorts. Compared with passive PT, active PT was not associated with long-term opioid use in the opioid-naive (aOR, 1.00 [95% CI, 0.81-1.24]) or opioid-experienced (aOR, 0.99 [95% CI, 0.92-1.07]) cohorts.
This cohort study suggests that receipt of PT intervention before and after TKR, receipt of 6 or more sessions of PT care after TKR, and initiation of PT care within 30 days after TKR were associated with lower odds of long-term opioid use. These findings suggest that PT may help reduce the risk of long-term opioid use after TKR.
重要性：许多接受全膝关节置换术（TKR）的患者在 TKR 后成为长期阿片类药物使用者。TKR 前后物理治疗（PT）干预与长期使用阿片类药物的相关性尚不清楚。
目的：评估 TKR 前后 PT 干预与 TKR 后长期使用阿片类药物的相关性。
设计、地点和参与者：这项队列研究使用了 OptumLabs 数据仓库中 67322 名年龄在 40 岁或以上、2001 年 1 月 1 日至 2016 年 12 月 31 日期间接受 TKR 的患者的数据，这些患者按阿片类药物使用史进行分层。研究的分析包括了 1999 年 1 月 1 日至 2018 年 12 月 31 日的数据。
暴露因素：TKR 前后 90 天内的任何 PT 干预、TKR 后 PT 剂量（即 1-5、6-12 和≥13 次治疗）、TKR 后 PT 启动时间（即 TKR 后<30、31-60 和 61-90 天）和 TKR 后 PT 类型（即主动与被动）。
主要结果和措施：使用逻辑回归评估 TKR 前后 PT 与 TKR 后 90 天以上长期阿片类药物使用风险的相关性，同时调整混杂因素，包括年龄、性别、种族和民族（亚洲人、黑人、西班牙裔或白人）、肥胖、保险类型、地理位置以及身体和心理健康合并症。
结果：共纳入 38408 名阿片类药物初治患者（21336 名女性[55.6%]；平均[SD]年龄 66.2[9.2]岁）和 28914 名阿片类药物经验患者（18426 名女性[63.7%]；平均[SD]年龄 64.4[9.3]岁）。在阿片类药物初治患者中，接受任何 TKR 前 PT 与较低的长期阿片类药物使用风险相关（调整后的优势比[OR]，0.75[95%置信区间[CI]，0.60-0.95]）和阿片类药物经验患者（调整后的 OR，0.75[95% CI，0.70-0.80]）。在阿片类药物经验患者中，接受任何 TKR 后 PT 与较低的长期使用阿片类药物风险相关（调整后的 OR，0.75[95% CI，0.70-0.79]）。与 TKR 后 1-5 次 PT 相比，TKR 后 6-12 次（调整后的 OR，0.82[95% CI，0.75-0.90]）和 13 次或更多次（调整后的 OR，0.71[95% CI，0.65-0.77]）与阿片类药物经验患者中较低的长期使用阿片类药物风险相关。与 TKR 后 30 天内开始 PT 相比，TKR 后 31-60 天或 61-90 天开始 PT 与阿片类药物初治患者（31-60 天：调整后的 OR，1.45[95% CI，1.19-1.77]；61-90 天：调整后的 OR，2.15[95% CI，1.43-3.22]）和阿片类药物经验患者（31-60 天：调整后的 OR，1.10[95% CI，1.02-1.18]；61-90 天：调整后的 OR，1.32[95% CI，1.12-1.55]）的长期使用阿片类药物风险更高。与被动 PT 相比，阿片类药物初治（调整后的 OR，1.00[95% CI，0.81-1.24]）或阿片类药物经验（调整后的 OR，0.99[95% CI，0.92-1.07]）患者的主动 PT 与长期使用阿片类药物无关。
结论和相关性：这项队列研究表明，TKR 前后接受 PT 干预、TKR 后接受 6 次或更多次 PT 治疗以及 TKR 后 30 天内开始 PT 治疗与长期阿片类药物使用的可能性降低相关。这些发现表明，PT 可能有助于降低 TKR 后长期使用阿片类药物的风险。
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