May 30, 2019 | Insights
Can physical therapy optimize recovery following knee replacement surgery? A recent study of TKA patients offers new insights.
According to the Agency for Healthcare Research and Quality, more than 600,000 knee replacements are performed each year in the United States. In fact, total knee arthroplasty (TKA) is the most commonly performed inpatient surgical procedure in the United States.
However, some studies have indicated that rehabilitation following knee replacement surgery may not be needed to optimize recovery. Setting out to examine this hypothesis, a team of researchers from the University of Colorado School of Medicine recently conducted a study with the objectives of (1) investigating whether PT utilization is associated with functional improvements for total knee arthroplasty (TKA) patients in home-health-care settings and (2) exploring which factors are related to PT utilization.
The 2018 study, which was published in The Journal of Bone and Joint Surgery, analyzes Medicare home-health-care claims from 2012 for TKA patients who received home-health-care services following surgery. In comparison to low home-health-care utilization, which was defined as ≤5 visits, utilization of 6 to 9 visits was associated with 25% greater improvement in activities of daily living (ADLs) over the home-health-care episode, and improvement increased from there, with 10 to 13 visits seeing 40% greater improvement and ≥14 visits being associated with 50% greater improvement. In addition, patients receiving home-health-care from rural agencies were observed to have lower PT utilization (10.7% fewer visits).
After controlling for medical complexity, baseline function, and home-health-care episode duration, low PT utilization was significantly associated with worse ADL recovery for study patients. Researchers also found that that low users of at-home physical therapy often had less social support and more complex medical conditions and that without adequate post-op care, these patients could require future hospitalization or institutionalization. The bottom line? According to lead researcher Dr. Jason Falvey, the risks of not providing the appropriate level of care post-surgery may result in higher overall healthcare costs in the long term.
More research is needed to develop specific evidence-based treatment strategies for TKA patients, but based on these findings, telerehab, which allows post-surgery treatment to be done in the home, may be a useful tool in promoting patient engagement and utilization for better outcomes after surgery.
Click here to read the article.
Falvey, J. R., Bade, M. J., Forster, J. E., Burke, R. E., Jennings, J. M., Nuccio, E., & Stevens-Lapsley, J. E. (2018). Home-Health-Care Physical Therapy Improves Early Functional Recovery of Medicare Beneficiaries After Total Knee Arthroplasty. JBJS, 100(20), 1728-1734.
May 30, 2019 | Insights
Jill Carnahan, PT, DPT, reflects on how her experience supervising MedRisk’s telerehab team has transformed her perspective on the role of virtual PT visits in injured worker recovery.
When Jill Carnahan, PT, DPT, began working on telerehab cases at MedRisk, she was skeptical. She had previously worked in outpatient orthopedics and women’s health, where therapy was strictly hand-on.
“That’s what’s ingrained in us as therapists – that patients have to be touched to get better,” Carnahan said.
But Carnahan, who now supervises MedRisk’s telerehab staff, kept an open mind as MedRisk launched its telerehab program in June 2017.
As the first managed physical medicine company to offer telerehabilitation for injured workers, the MedRisk clinical staff set out to blaze a new trail in the workers’ compensation industry. Before kicking off the program, they developed proprietary guidelines around how to identify the ideal telerehab patient. Carnahan recognized the company’s concerted effort to screen patients carefully and thoroughly examine the circumstances of each case. The guidelines stipulate that first a patient’s case must be found clinically appropriate for telerehab. Second, the patient must express an interest in participating in the program and have the technology needed.
Once a patient qualifies for telerehab and it is determined when telerehab should begin, Carnahan’s team reaches out to schedule the televisit. These virtual visits are synchronous – meaning patients and providers interact “face-to-face” via webcam. Through the live audio-visual interface, the PT is able to demonstrate appropriate exercises and monitor the patient’s movement on screen. The televisit is also an opportunity for the patient to speak one-on-one with their PT about any roadblocks to recovery and how to overcome them. Following the appointment, stored videos and printable written instructions are available to support patient compliance with their prescribed exercise program.
Convenience, Collaboration & Independence
When asked how her perspective of telerehab has changed since the program launched two years ago, Carnahan says that while she still believes that for many patients, manual therapy will always be an integral component of recovery, she has also seen that telerehab offers substantial benefits to the patient that cannot be replicated in an in-clinic visit.
Naturally, viritual visits are a convenient option for all patients, but for some, they are essential to keeping their treatment plan on track. Patients in rural settings often have to travel a significant distance for an on-site visit. In addition, for those in urban areas who rely on the subway or other public transportation, traveling can become even more complicated when recovering from an injury. Weather and natural disasters can also be complicating factors. MedRisk’s telerehab staff has even extended their hours following natural disasters, such as Hurricane Florence, to ensure workers’ recovery could stay on track. In these instances, travel can be a significant hurdle – one that is mounted through telerehab.
In addition, telerehab allows injured workers with regular on-the-job travel to remain engaged in their recovery as they get back to work. MedRisk’s team of telerehab specialists are licensed in many states, so treatment can continue even as patients cross state lines.
“We’ve seen lots of patients while they are out in the field,” Carnahan said. “Utility workers have logged into their visit from an outdoor location. Truck drivers have called us from the cab (berth) of their trucks. We make it work!”
There is no doubt that mobility and ease of use are attractive features for the telerehab option, but those aren’t the only benefits. According to Carnahan, her transformation from skeptic to telerehab champion is the result of seeing first-hand how powerful these virtual interactions can be.
“The more patients I’ve treated, the more I’ve realized that there is the power of touch and then there is the power of voice,” Carnahan said. “In the clinic, you manually move patients into positions. Sometimes there are distractions. Through the computer, you have to use your words – it’s a back-and-forth process that requires focus, communication and collaboration from both parties. But when the patient gets it on their own, you know they really get it.”
It’s this guidance, Carnahan says, that helps cultivate a spirit of independence and accountability in telerehab patients. For example, Carnahan’s team has sent equipment to patients with cervical injuries so they can be taught via virtual visit to do neck massages themselves at home. Others are shown how to do self-tissue releases and self-joint mobilizations so they can take more ownership of their recovery as they prepare for discharge.
What’s Next
As the MedRisk telerehab program gains traction, Carnhan’s team is growing. The company now offers onsite PTs trained in telerehab to larger employers who want a dedicated therapist available to support their primary and satellite offices. In the months and years ahead, Carnahan expects that, like herself, physical medicine professionals, patients and employers alike will realize the benefits of the program.
“Patients often say to me, ‘Why didn’t I do this sooner?’ I think we are going to be hearing that a lot moving forward,” Carnahan said.
May 1, 2019 | Insights
MedRisk’s ISAB Member Paul Beattie shares how virtual visits and other telehealth capabilities are increasing access to care for patients – including deployed military personnel.
“Force readiness”: it may not be a term that’s often used in civilian life, but it’s certainly a concern shared by employers and the military alike.
“You want to keep your operations in top form. You don’t want to remove people from their jobs unless their health is truly at risk,” said Paul Beattie, PT, PhD, OCS, FAPTA, MedRisk International Scientific Advisory Board (ISAB) Member and faculty in USC’s Doctoral Program in Physical Therapy.
For nearly a decade, Beattie has helped train army, air force and naval chaplains at nearby Fort Jackson to support wounded, injured and emotionally distraught soldiers in the field. The goal: to help soldiers get the care they need while minimizing the need for medical evacuation.
Today, Beattie says this objective is being further bolstered by advances in the military’s telehealth capabilities.
In civilian life, it is not uncommon for people to have primary care physicians who know them well and have even cared for them for years. And when an unexpected issue arises, a referral to a nearby specialist helps connect the patient with the expertise required. According to Beattie, military field sites often rely on just a handful of medical personnel, and physically linking up with healthcare providers, especially for specialty care, has been historically challenging – until now.
The military has dramatically increased access to care through the implementation of telehealth capabilities. Perhaps the most critical telehealth development for the military is the introduction of virtual visits that can now be performed through the military health system website.
Similar to MedRisk’s telerehab program, the military’s Virtual Video Visits, or “V3” appointments, are conducted via a secure video teleconference. This combination of live audio and visual allows medics and physicians who are deployed with soldiers to serve a wider range of patients, without the logistics and costs of in-person visits.
These virtual visits have proven particularly useful in specialty cases that require services like genetic testing, dermatology, nutritional counseling and mental health services, which have been an increasing focus of the military. Similar to injured worker rehabilitation, telehealth can also be a valuable tool in getting back deployed soldiers back on their feet following musculoskeletal injury. Physical therapists are point-of-care in the military, but should a second opinion or specialty care be required, a diagnostic quality image can be captured and sent to a specialist at another military treatment facility (MTF) for interpretation. This often facilitates a faster, complete diagnosis, and the report can be stored and accessed by an authorized user from anywhere in the world.
Beattie cites a groundswell of support to get telehealth functionality implemented in the military. The result has been preventive, acute and life-saving treatment delivered in a more expeditious manner. As for user experience, surveys conducted by the US Army Public Health Command documented high satisfaction among providers, patients and commanders.
With the positive outcomes demonstrated thus far, Beattie expects telehealth will become a pillar of care for the military – and healthcare at large, including workers’ compensation.
“We all have a smartphone on us. The uniform’s even got a pocket for it now,” Beattie said. “I’d say telehealth is here to stay.”
About Paul F. Beattie, PT, PhD, OCS, FAPTA
Paul Beattie is a member of MedRisk’s International Scientific Advisory Board and clinical associate professor at the University of South Carolina Department of Physical Therapy, School of Public Health. A nationally renowned and expert psychometrician specializing in examining, analyzing, and validating patient care questionnaires Dr. Beattie has been instrumental in developing MedRisk’s patient satisfaction instruments as well as consulting on MedRisk’s development of its telerehab program for injured workers.
Dr. Beattie has 30 manuscripts published in peer reviewed journals and more than 100 professional presentations.
Feb 26, 2019 | Insights
A review of 28 published articles has determined which employer interventions are most effective at preventing LBP on the job.
Non-specific low back pain (LBP) continues to pose a significant public health risk in the United States and other industrialized countries, where lifetime prevalence is 60-70% and annual adult incidence is 5%. With 37% of global LBP cases believed to be work-related, recent studies have sought to measure the effectiveness of workplace interventions and prevention strategies, such as education (e.g., back schools), exercise, lumbar supports (e.g., back belts), lifting techniques, and training of employees – however, data have been difficult to sift through, until now.
In 2017, a team of researchers led by Dr. Daniel Sowah at the University of Alberta set out to synthesize this data in a systematic review. They looked at 28 eligible articles published between 1994 and 2016 evaluating the effectiveness of LBP interventions that could be implemented in the workplace. Sowah and his team categorized the interventions as primary or secondary prevention approaches. The outcome measures applied to primary interventions were incidence and prevalence of LBP, and recurrence of LBP was included for secondary prevention. The impact of LBP, disability and cost were also included as outcomes.
The study team found exercise alone or together with education was the only approach that was consistently effective in the prevention of LBP across the body of research, supporting the claim that exercise interventions can help prevent LBP and diminish its related disability and workplace impact, at least in the short term. Notably, education in combination with exercise was found to be more effective than education alone, bolstering the case for a multidimensional approach to LBP prevention in the workplace.
Click here to read the article.
Sowah, D., Boyko, R., Antle, D., Miller, L., Zakhary, M., & Straube, S. (2018). Occupational interventions for the prevention of back pain: Overview of systematic reviews. Journal of safety research, 66, 39-59.
Feb 25, 2019 | Insights
Occupational injury rates and workers’ comp claim frequency continue to decline. Is your total spend for musculoskeletal treatment following suit?
In this two-part series, “Workers’ Comp Costs: Why Physical Therapy is Bigger than You Think,” we explore some of the reasons why, despite positive overall claim trends, the percentage of claims with physical therapy (PT) involvement is on the rise – and why a managed physical medicine program continues to be a necessary component of workers’ comp managed care.
As discussed in part 1 of this series, on-the-job injury rates are declining, but physical medicine claims are steadily climbing, with outpatient physical therapy services listed on 63% of 2017 lost time claims.
Why is physical medicine a part of so many workers’ comp claims? To better understand this trend, let’s take a step back and look at how musculoskeletal injuries affect today’s employees and employers.
The Prevalence of Work-Related Musculoskeletal Injury
According to the Bureau of Labor Statistics (BLS), musculoskeletal disorders alone, including injuries resulting from overexertion such as sprains and strains, made up 31 percent of the total cases for all workers in 2015. While claims rates are falling due in large part to workplace safety programs, the numbers show that accidents are still a risk. And if you’re a growing company with a growing number of employees, that often means assuming higher risk. Falls, slips, and trips accounted for 27 percent of the total occupational injuries and illnesses, and the incidence rate of workers being struck by an object or equipment increased year over year. Professions at a high risk include laborers and freight, stock and material movers; nursing assistants; and heavy and tractor-trailer truck drivers – each accounting for almost 5 percent of the private sector’s musculoskeletal cases in 2015.
Extended Lost Time
The prevalence of musculoskeletal injuries becomes even more concerning when you consider that musculoskeletal disorder cases typically have more days away from work than the average nonfatal workplace injury or illness. In fact, according to BLS data, in 2017, the median number of days away from work for musculoskeletal injuries was 13 compared with 9 for all other workplace injuries. Unless well-coordinated, recuperation for patients with musculoskeletal injuries can be unnecessarily complicated and drawn out. One way to counteract these effects is for employers to ensure injured workers are matched with the right physical therapist as quickly as possible and feel supported during the scheduling process so treatment can begin promptly. Physical therapy as a first-line of treatment has been shown to be a cost-effective contributor to positive patient outcomes.
Conclusion
Workplace safety programs are a big part of keeping workers’ comp claims in check, but for the injuries that cannot be prevented, employers must set their workers up for success. A managed physical medicine program is a must-have for employers as the increase in claims with physical medicine involvement continues to climb. Ensure your company has the necessary partners and resources in place so that no matter how much your company grows or healthcare policies change, your injured workers can rely on a supported and streamlined road to recovery.
Feb 1, 2019 | Insights
Occupational injury rates and workers’ comp claim frequency continue to decline. Is your total spend for musculoskeletal treatment following suit?
In this two-part series, “Workers’ Comp Costs: Why Physical Therapy is Bigger than You Think,” we explore some of the reasons why, despite positive overall claim trends, the percentage of claims with physical therapy (PT) involvement is on the rise – and why a managed physical medicine program continues to be a necessary component of workers’ comp managed care.
For almost a decade the news of fewer occupational injury rates and the declining frequency of workers’ compensation claims have been making headlines. Experts credit the downward trend to a wide range of contributing factors, including advances in safety, automation, better management and more.
However, some employers may be surprised that their workers’ comp costs, especially those related to musculoskeletal treatment, are not necessarily mimicking this descending slope.
While injury rates and frequency have been declining, data from the Workers’ Compensation Research Institute (WCRI) show that the percent of claims with physical medicine involvement has been increasing. In 2011, 56 percent of lost time claims included outpatient physical medicine services (i.e., physical therapy, occupational therapy or chiropractic care). By 2017, the 18-state median was up to 63 percent with some states like California and New Jersey even higher at 72 and 71 percent, respectively.
This consistent, year-over-year increase can be attributed in part to a better understanding of the value physical medicine brings to the workers’ compensation community and the benefit it plays in supporting return to work goals. Physical medicine not only helps address musculoskeletal issues; it also promotes patient participation in recovery and self-management, improves patient compliance with treatment strategies and reduces the risk of re-injury.
Today, mounting evidence shows that early physical therapy also reduces the risk of opioid addiction and can reduce downstream healthcare costs, suggesting that this trend of increased PT involvement will continue and even escalate. With multiple visits to coordinate, continued authorization requests to manage and a variety of return-to-work treatment strategies to implement, employers must ensure they are equipped to effectively manage physical medicine today and in years to come.
Click here to learn more about one managed care program and the trends impacting physical medicine in workers’ compensation.
And stay tuned for part 2 of this series, where we’ll look more closely at the nature and effect of musculoskeletal injuries in the workplace – and physical medicine’s role in getting workers back on their feet.
