Early opioid prescription and risk of long-term opioid use among US workers with back and shoulder injuries: a retrospective cohort study.

The number of prescription opioid overdose deaths has increased dramatically in recent years and many prescribers are unsure how to balance treatment of pain with secondary prevention. Guidelines recommend low-severity injury patients not receive opioids early in the course of their care, but evidence supporting this guideline is limited. Data from 123 096 workers' compensation claims with back and shoulder injuries were analysed to evaluate this guideline. Back and shoulder injury claimants with early opioid use (≤1 month after injury) had 33% lower (95% CI 24% to 41% lower) odds and 29% higher (95% CI 6% to 58% higher) odds, respectively, of long-term opioid use (>3 months) than claimants with late opioid use, after adjusting for key covariates. Stratified analyses indicate that early opioid use does not appear to increase the risk of long-term use except in cases where no diagnosis or only the diagnosis of unspecified shoulder pain is given prior to prescription.

Effects of neuromuscular electrical stimulation on cytokines in peripheral blood for healthy participants: a prospective, single-blinded Study.

INTRODUCTION: The effect of exercise on cytokines may improve muscle strength. Neuromuscular electrical stimulation (NMES) is a muscle-preserving therapy that benefits patients unable to participate in active exercise. How NMES alters cytokines is unclear. The aim of this study was to study the effects of 1 NMES session on cytokines associated with protein metabolism during exercise. METHODS: We evaluated the effects of NMES on IL-1, IL-6, IL-10 and TNF-α levels in peripheral blood. Participants received NMES to bilateral lower extremity muscles (quadriceps, tibialis anterior, gastrocnemius) for 30 min. Blood samples immediately pre- and post-NMES were drawn at 15-min intervals to 2-h follow-up, and the mean values of pre-NMES levels were compared to peak and trough post-NMES levels. For cytokines with significant changes, we conducted a repeated-measures linear regression analysis. We also measured post-NMES lactate and creatine kinase levels. RESULTS: We enrolled nine eligible participants. There was a significant increase in peak IL-6 from the mean pre-NMES value [0·65 (0·89) to 1·04 (0·89) pg ml-1 , P = 0·001] and a significant decrease in trough IL-1 [0·08 (0·07) to 0·02 (0·02) pg ml-1 , P = 0·041] and TNF-α [2·42 (0·54) to 2·16 (0·59) pg ml-1 , P = 0·021]. In repeated-measures regression analysis, we identified significantly higher mean IL-6 values throughout the full 120 min post-NMES period, and a significantly higher mean IL-1 value at 30 min post-NMES. There were no significant differences in peak IL-10, trough IL-6, lactate, or creatine kinase values. CONCLUSIONS: In nine healthy humans, 30 min of NMES was temporally associated with changes in cytokines similar to the effects of active exercise and may mediate NMES' observed effects on reducing muscle weakness.

Evaluating Clinical Practice Guidelines Based on Their Association with Return to Work in Administrative Claims Data.

OBJECTIVE: To examine the association between non-adherence to clinical practice guidelines (CPGs) and time to return to work (RTW) for patients with workplace injuries. DATA SOURCES/STUDY SETTING: Secondary analysis of medical billing and disability data for 148,199 for shoulder and back injuries from a workers' compensation insurer. STUDY DESIGN: Cox proportional hazard regression is used to estimate the association between time to RTW and receipt of guideline-discordant care. We test the robustness of our findings to an omitted confounding variable. DATA COLLECTION: Collected by the insurer from the time an injury was reported, through recovery or last follow-up. PRINCIPAL FINDINGS: Receiving guideline-discordant care was associated with slower RTW for only some guidelines. Early receipt of care, and getting less than the recommended amount of care, were correlated with faster RTW. Excessive physical therapy, bracing, and injections were associated with slower RTW. CONCLUSIONS: There is not a consistent relationship between performance on CPGs and RTW. The association between performance on CPG and RTW is difficult to measure in observational data, because analysts cannot control for omitted variables that affect a patient's treatment and outcomes. CPGs supported by observational studies or randomized trials may have a more certain relationship to health outcomes.

Neuromuscular electrical stimulation for intensive care unit-acquired weakness: protocol and methodological implications for a randomized, sham-controlled, phase II trial.

BACKGROUND: As the population ages and critical care advances, a growing number of survivors of critical illness will be at risk for intensive care unit (ICU)-acquired weakness. Bed rest, which is common in the ICU, causes adverse effects, including muscle weakness. Consequently, patients need ICU-based interventions focused on the muscular system. Although emerging evidence supports the benefits of early rehabilitation during mechanical ventilation, additional therapies may be beneficial. Neuromuscular electrical stimulation (NMES), which can provide some muscular activity even very early during critical illness, is a promising modality for patients in the ICU. OBJECTIVE: The objectives of this article are to discuss the implications of bed rest for patients with critical illness, summarize recent studies of early rehabilitation and NMES in the ICU, and describe a protocol for a randomized, phase II pilot study of NMES in patients receiving mechanical ventilation. DESIGN: The study was a randomized, sham-controlled, concealed, phase II pilot study with caregivers and outcome assessors blinded to the treatment allocation. SETTING: The study setting will be a medical ICU. PARTICIPANTS: The study participants will be patients who are receiving mechanical ventilation for 1 day or more, who are expected to stay in the ICU for an additional 2 days or more, and who meet no exclusion criteria. INTERVENTION: The intervention will be NMES (versus a sham [control] intervention) applied to the quadriceps, tibialis anterior, and gastrocnemius muscles for 60 minutes per day. MEASUREMENTS: Lower-extremity muscle strength at hospital discharge will be the primary outcome measure. LIMITATIONS: Muscle strength is a surrogate measure, not a patient-centered outcome. The assessments will not include laboratory, genetic, or histological measures aimed at a mechanistic understanding of NMES. The optimal duration or dose of NMES is unclear. CONCLUSIONS: If NMES is beneficial, the results of the study will help advance research aimed at reducing the burden of muscular weakness and physical disability in survivors of critical illness.