May 29, 2018 | Insights
Recent studies on biological and psychological processes are informing how we understand low back pain. How does this new research translate to the clinic?
This blog is part 2 of a three-part series titled “How We Treat Low Back Pain: Emerging Research, Frameworks and Care Models.”
In the last decade, mainstream treatment of low back pain (LBP) has broadened from a sole biomechanical focus to a more holistic approach informed by how pain is processed in the brain.
New evidence-based frameworks have emerged to help guide conversations about pain between providers and patients. We interviewed MedRisk Advisory Board member and a leader in low back pain treatment, Dr. Philip W. McClure, PT, PhD, FAPTA, about this developing shift in the field.
How has our understanding of LBP evolved over the years?
Twenty years ago, patients who presented complaining of pain with no physical evidence were often labeled as looking for secondary gain. It was believed that low back pain was solely caused by excessive mechanical load injuring the tissues – and so the treatment was focused primarily on mechanical methods as well. We have learned a lot over the last decade, and now we understand that pain can be experienced without ongoing tissue damage or harm. We call this phenomenon central sensitization. The nervous system is recognized as an active part of the pain process that can change over time and, therefore, contribute to persistent pain conditions. Rather than a simple mechanical model of tissue overload, we now recognize that pain can also be the result of complex interaction between inflammatory and biochemical processes as well as the psychosocial environment.
How has this informed LBP treatment?
Up until recently, only providers who were really in tune with their patients may have dug deeper than the physical exam to understand contributors to their pain. Now, that process is far closer to mainstream. This is due in part to simple classification schemes that are being embraced by practitioners to help assess patients’ pain early on. The STarT Back Screening Tool is a nice example; it’s been shown to decrease disability from back pain, reduce time off work and reduce costs by making better use of health resources. STarT Back is a simple survey you can run through with patients that helps put them into categories of low, medium or high risk of poor outcome by asking questions about how their low back pain has affected their daily habits as well as how they perceive the severity of their injury. Being able to do this helps a general practitioner say, “This is a high-risk patient; they need more than the usual” versus “This is a low-risk patient, and they are likely to do well.”
How do providers go about discussing this new understanding of pain with patients?
The science of how to most effectively communicate about pain with patients is growing dramatically, but there is still a lot of work to be done to ensure best practice becomes common practice. Essentially, we need to teach LBP patients that, based on what we know about how the brain processes pain, pain does not always equal harm. We need to avoid fear-invoking words and images that are common medical terminology and instead use words that promote the ability to engage in activity and encourage confidence. For some patients, practitioners need to explain that it is safe to keep moving despite the pain and that actual physical activity can make you feel better. But there is an art to saying, “We believe you hurt, and we are going to give you our best care” while also saying “You need to stay active.” The reality is the best care includes staying engaged and staying active. Unfortunately, patients aren’t always getting this message.
What implications does this have for workers’ comp patients?
How an employee’s injury is managed early on may have significant effects on their recovery downstream. A common example is a patient who has injured their back at work. If the company says we only want you back when you’re 100%, then the patient is out of work, gets used to being out work and gains an identity as an injured worker. For some patients, this may lead them to think, “It’s not safe for me to work, so it must not be safe for me to be active” when, as we’ve discussed, this is usually not the case. Companies and patients benefit when employers are able to find modified duty to help keep workers engaged even if they are not at full duty yet. Those involved in work-related social activities have a far better prognosis for durable return to work.
May 3, 2018 | Insights
Exercise therapy and acupuncture are becoming more mainstream treatment options for low back pain. What’s driving this change?
This blog is part 1 of a three-part series titled “How We Treat Low Back Pain: Emerging Research, Frameworks and Care Models.”
In the past, when the term “alternative care” was thrown out in a clinical setting, it meant something wild and non-mainstream. However, the tide is turning in the world of musculoskeletal treatment, and what was once considered “alternative” or “complementary” is in many cases becoming first-line.
Why are options like exercise therapy and acupuncture gaining mainstream adoption as treatment for low back pain (LBP)? In this blog, we examine the forces driving conservative care for LBP and their effects on workers’ comp.
The Downfall of Opioid Treatment
According to a 2015 BMJ article, the rates of opioid prescribing in the United States and Canada are two to three times higher than in most European countries – and more than half of regular opioid users report low back pain. Rates of addiction and overdose-related mortality have risen in tandem with prescription rates, leading the opioid crisis to be named a national public health emergency.
To support a nationwide shift in prescribing habits, a body of research is growing to demonstrate that conservative care (i.e., physical therapy) as first-line treatment for LBP can improve patient outcomes. The evidence is building, but how do we ensure this data filters back down to providers to inform their recommendations for LBP treatment?
Revised Treatment Guidelines
Several factors go into the treatment choices of individual providers; however, practitioners look to evidence-based guidelines as a framework for daily care decisions. Recent research on the efficacy of conservative care treatment, including the role of physical activity, is shaping the revisions of LBP treatment guidelines and recommendations nationwide. The American College of Physicians updated its clinical practice guidelines in February 2017 to promote noninvasive treatment for LBP. The revisions prioritize nonpharmacologic options for the treatment of subacute and acute low back pain as well as chronic LBP. The recommendations for chronic LBP include exercise, multidisciplinary rehabilitation, acupuncture and mindfulness-based stress reduction – further nudging these formerly complementary practices toward the frontline of care.
Likewise, shake-ups are happening among federal- and state-funded insurance plans. Some, like Medicare’s wide-reaching regulation to deny payment for long-term, high-dose narcotics, affect the treatment plans of chronic back pain sufferers, among others. Other regulations are more narrowly focused. For example in Oregon, the state’s Medicaid equivalent, the Oregon Health Plan, reformed its policy after realizing over half of its back patients were receiving narcotics. The new policies, which apply to all back conditions, promote physical therapy, chiropractic and other complementary treatments over painkillers and surgery.
A Word on Workers’ Comp
Is the workers’ comp industry undergoing the same level of reform in its approach to LBP treatment? Signs point to yes. As more studies emerge indicating the efficacy and cost-effectiveness of physical therapy as first treatment, payers and providers are aligning in its favor. In some states, this preference is being baked into workers’ comp policy. In 2017, the Ohio Bureau of Workers’ Compensation (BWC) approved a rule promoting conservative therapy for workers with lower back injuries in lieu of surgery and opioid use. The new policy requires workers to undergo a minimum of 60 days’ comprehensive conservative care, including PT or chiropractic care and rest among other non-surgical treatments, before considering a surgical option. Similarly, Washington State launched a pilot program last year to use acupuncture to treat injured workers with low back pain, with the hope that acupuncture coverage for LBP would extend to other conditions in the future as well.
There is still much work to be done in shifting the mindset of a quick-fix society to embrace a model of LBP treatment that promotes gradual improvement, patient involvement and downstream gains. But given the dangers of opioid prescription, payers, providers and employers seem to agree on one thing: it is, undeniably, time for change.
Apr 6, 2018 | Insights
MedRisk Advisory Board Member Dr. Jane Fedorcyzk responds to new performance measures regarding post-operative PT for carpal tunnel patients.
In December 2017, the American Academy of Orthopaedic Surgeons (AAOS) approved new carpal tunnel syndrome performance measures to be submitted to the U.S. Centers for Medicare & Medicaid Services (CMS) for consideration. The measures, which are based on a previously published AAOS Clinical Practice Guideline (CPG), discourage the routine use of occupational therapy (OT) or physical therapy (PT) after carpal tunnel release (CTR) surgery. In other words, each patient is different. Some patients will recover quickly with a home exercise program and some do better with clinical supervision and direction.
We interviewed MedRisk International Scientific Advisory Board (ISAB) member and hand and upper quarter rehabilitation expert Dr. Jane Fedorcyck, who talked through which patients may benefit from post-operative OT or PT support and what they stand to gain in the process.
The new measure cautions against “routine” use of OT or PT after CTR surgery, but under what circumstances should PT referral be considered?
Often, patients who are experiencing wrist pain have a limited incision carpal tunnel release, where a tiny incision is made at the proximal edge of the palm. The purpose of the surgery is to release a ligament and change the pressure gradient in the carpal tunnel. The surgery isn’t intended to fix the nerve but rather open up the space to allow the blood to flow so it can heal.
But sometimes the incision can cause a new pain experience, or it can improve the pain but issues such as numbness or the inability to move the hand, wrist or arm persist. This is the point at which patients are sometimes referred to a PT and often the first time we see a carpal tunnel patient.
What are the benefits of seeing a physical therapist post-operatively?
If a patient is still experiencing pain after surgery, a PT is going to do a thorough exam to get to the root of the problem. A PT will examine the entire upper limb. A cervical injury could be contributing or occurring at the same time. When there is neurogenic pain in an upper extremity, a PT will clear the cervical spine and brachial plexus and look for associated conditions as well.
But it’s more than the physical exam. A large part of what we do is patient education. Even if it is just that one post-operative visit, we have the opportunity to teach the patient how to do exercises correctly and speed up their recovery. I also teach my patients how to incorporate breathing, so it can act as a distractor against the pain. There is a lot of fear and anxiety in the recovery process, and PTs can help guide patients through that. This kind of education works well in a traditional in-clinic setting and also via telerehab or video conferencing.
How do these new performance measures impact MedRisk’s network of providers?
The guidelines are meant to support clinical decision-making for orthopedic surgeons, which are a source of referrals for OTs and PTs. At MedRisk, we care for these patients after the point of referral.
MedRisk’s evidence-based guidelines are specific to PT and incorporate the latest research, including evidence and recommendations from the American Physical Therapy Association (new updates are expected in 2019), ODG [Official Disability Guidelines], ACOEM [American College of Occupational and Environmental Medicine] and more. We use MedRisk’s guidelines as well as state-mandated guidelines to manage treatment strategies for carpal tunnel patients after they have been referred by the physician for PT.
In our field, treatment strategies are based on available evidence as well as clinical wisdom and the patient’s individual needs. Oftentimes, guidelines are informed by evidence from clinical trials that exclude patients with comorbidities. But real-life patients aren’t like this; they have unique conditions and circumstances. Guidelines must always be considered in the context of the patient to ensure they receive the best care possible.
About Jane Fedorczyk, PT, PhD, CHT, ATC
Jane Fedorczyk is a professor of physical therapy and rehabilitation sciences at the University of South Florida in Tampa, Florida, where she is also the co-coordinator of professional education. A certified hand therapist, she is the Immediate Past President of American Society of Hand Therapists, and active in the American Hand Therapy Foundation and the American Physical Therapy Association.
Dr. Fedorczyk holds a PhD in Physical Therapy and has received several professional honors, including the R. L. Petzoldt Award for Innovation in Hand Therapy.
Mar 7, 2018 | Insights
Practical tips to engage and motivate workers along the road to recovery.
In addition to the physical attributes of an occupational injury, many factors go into an injured worker’s feelings of readiness to return to work. Concerns can range from a fear of getting reinjured and the judgment of teammates to wanting to get back to normal and feeling needed by their employer.
Research indicates that these considerations are amenable to intervention and present opportunities for employers to assist workers on their road to recovery. We interviewed Dr. Jennifer Christian, MD, MPH, a thought leader within the disability benefits and workers’ compensation industries, who offered practical advice on how employers can support workers who have been injured on the job.
1. Humanize the situation.
When a worker gets injured, there is a common phenomenon that occurs: people often focus on the situation instead of the individual. Employees may be conjecturing about the circumstances of the injury. Or a supervisor may not want to bother the injured worker during their recovery. However, to the ailing employee, no contact from people they used to see every day may feel like a form of abandonment.
In order to effectively support injured workers and maintain a welcoming workplace environment, employers must consciously cultivate a positive workers’ compensation culture.
“Remember, this is a human being, and you have a relationship with them,” Dr. Christian said. “It is common courtesy to be sensitive to the worker’s personal experience.”
2. Don’t leave it all to HR.
It’s not uncommon for the Human Resources department to be tasked with managing employee communication throughout the worker’s compensation period. However, research shows that positive supervisor-patient interaction is significantly associated with sustained return to work outcomes. If the employee and his or her supervisor have historically had a positive relationship, then it is completely appropriate – and beneficial – for communications to resume during this critical time.
“We remember who helps us when we are down. Ultimately, employees want to return to employers they trust and who treat them well,” said Dr. Christian.
3. Make meaningful contact.
When reaching out to check in on an injured worker, a supervisor’s or coworker’s sole purpose should be to offer support and compassion. There is a claims adjuster who is responsible for determining the circumstances of the case, and medical details are the business of the worker’s care team. However, there are ways that teammates and managers can support injured employees without knowing all the details. Organizations should consider the value of a training program that educates supervisors on appropriate and meaningful interactions with injured workers.
“It would be appropriate to reach out and say, ‘How are you doing? We miss you.’ Fill them in on updates from your team – both project news and life events from their coworkers. Tell them that you don’t want them to feel like they are missing out,” Dr. Christian said.
4. Offer an “on ramp.”
One of the biggest psychological hurdles for a worker who has been injured on the job is seeing himself or herself as valuable when they are not at 100% function. Often injured workers feel that unless they can do their exact job to the same degree, then they have no place in the workforce.
But modified duty accommodations can allow injured workers to avoid social isolation and motivate their desire to remain a valued member of the team. During this transitional period, the employee can begin to retrain his or her body to take on mission-critical tasks while avoiding re-injury. In fact, research has shown that organizations who offer supervisors more autonomy over decisions of accommodation may help in preventing prolonged work disability.
“It’s the art of saying ‘We need you here; you make a difference’ but not ‘Do you think you can be here by next Friday?’” Dr. Christian said.
5. Give the worker a say.
When making return to work plans, many employers believe the decision lies solely with the employer’s care team. However, the decision of when to resume a job and in what capacity should involve the injured worker, as well.
Recent interpretation of the ADA’s federal disability policy has reinforced the “interactive process” in return to work determinations – that is, the idea that the employee has a right to be involved in the post-injury decision-making process.
For example, if an employee has injured his back on the job at a construction site, he may feel insecure and even a little fearful about returning to his typical work environment. However, if the employee’s supervisor asks him what he thinks he can handle rather than assuming he is not ready or does not want to get back to work, together, they might be able to find a comfortable middle ground.
“They might not be ready to go from sitting on the couch to swinging a sledgehammer, but there’s a good chance they feel comfortable doing something of value,” Dr. Christian said. “Then, work together to increase their load each week. Eventually, they will rebuild capability and confidence. It may be only a matter of weeks before they are back to work full duty.”
About Jennifer Christian, MD, MPH
Dr. Jennifer Christian is co-founder, president and chief medical officer of Webility Corporation, as well as founder and chair of the non-profit 60 Summits Project. She also founded and moderates the Work Fitness and Disability Roundtable, a free, web-based, multidisciplinary e-group devoted to work disability prevention and management with more than 1,000 members. She has both an MD and a Master’s Degree in Public Health and is board-certified in occupational medicine.
Feb 5, 2018 | Insights
New research reveals how PT consultation, as compared with PT participation, affects opioid prescription rates and lower back pain (LBP)-related health care costs.
There is an established body of research indicating that physical therapy as a first-line treatment for uncomplicated lower back pain (LBP) can improve patient outcomes. A University of Utah research team recently dug a little deeper to examine the impact of the PT consultation, which often represents an interaction between patient and provider about the severity of the pain and the prognosis. The study aimed to determine whether “improved outcomes among PT cohorts may represent a combination of patient compliance with the PT recommendation and a patient’s belief about the nature and severity of the LBP.”
Objectives
The study’s focus was on Medicaid patients, who, on average, have worse overall health than the general population and who are 3 times more likely to develop LBP. Researchers looked at differences between Medicaid patients who received a PT consult and those who did not, as well as those who participated in PT and those who did not. A primary objective was to compare the impact of a PT consult and PT participation on opioid prescription rates and LBP-related health care costs over a year.
Findings
Using electronic medical records and claims data, several observations were made regarding the relationship between a patient’s health status and the rate of PT consult. Researchers found the odds of a PT consult increased if patients were prescribed non-steroidal anti-inflammatories or muscle relaxers and decreased if patients were tobacco users or had multiple comorbidities.
Importantly, the study found that the odds of opioid prescription over the year following the index visit reduced not only with PT participation (aOR = 0.47; 95% CI, 0.24 to 0.92) but also with PT consult alone (aOR = 0.65; 95% CI, 0.43 to 1.00), indicating that PT consult itself can positively impact patient outcomes. No differences in LBP-related healthcare costs were noted across the groups during this timeframe.
Thackeray A, Hess R, Dorius J, Brodke D, Fritz J. Relationship of Opioid Prescriptions to Physical Therapy Referral and Participation for Medicaid Patients with New-Onset Low Back Pain. J Am Board Fam Med. 2017;30(6):784-794.
Nov 2, 2017 | Insights
When it comes to advanced imaging and surgical procedures, does the benefit really offset the cost?
Historically, rotator cuff tears and similar injuries had been approached through the lens of a biomedical model, whereby a structural abnormality is identified on a scan and addressed surgically to eliminate pain.
Today, however, we know that abnormalities are not always directly related to shoulder pain and physical therapy is a powerful option for many shoulder injuries. Knowing this, clinicians are now reconsidering the appropriateness and value of advanced imaging and surgical interventions as the first path of treatment for shoulder injuries.
PT Before Scans for Common Shoulder Pain
Shoulder pain has garnered additional attention in the last two decades due to its prevalence among baby boomers. Many consider rotator cuff degeneration to be the equivalent of gray hair and wrinkles.
The fact is, research shows partial or full-thickness tears are present in more than 50% of 70-year-olds and 80% of those over 80 years old. And such shoulder injuries can be present with no symptoms. As such, imaging results can sometimes be misleading because problems identified on the scan are often not necessarily directly correlated with symptoms.
Imaging in the first months following a shoulder injury is now considered unnecessary unless there is significant trauma. Instead, a more thoughtful, physical therapy-based approach is often first course of treatment for non-traumatic shoulder pain and shows promising results.
Surgery and Shots: Looking Beyond the Injury
The medical industry is also changing its perspective toward surgery and injections, recognizing that, like MRI scans, outcomes are not always so black and white. Research shows physical therapy can achieve in the same level of symptom improvement as both corticosteroid steroid injections and surgery for various shoulder issues but with a far smaller financial burden on patients and payers.
When appropriate, aggressive, and timely physical therapy is applied, many patients don’t need surgery at all. Although traumatic and acute tears often require more aggressive operative treatments, research suggests at least 50% of patients with shoulder pain can significantly improve without surgery.
As Dr. Philip W. McClure, PT, PhD, FAPTA said in a recent interview, “…surgery doesn’t always solve pain and there are a lot of people out there with tears that don’t have any pain at all.”
In the interview, McClure references a study by Kuhn, et al, that revealed 75% of patients with atraumatic rotator cuff injuries who participated in an exercise-based physical therapy program were able to avoid surgery. For the patients that followed their PT with surgery, the trial of conservative care did not result in a longer period of disability than it would have with a surgery-first approach.
Conclusion
A shift in shoulder injury treatment is underway. The cost-benefit ratio of surgery is being reevaluated, with the cost of the procedure and subsequent rehabilitation being weighed more thoughtfully. And conservative care treatment plans are becoming more prevalent.
What does the future hold? Many clinicians see physical therapy as first course of treatment becoming the gold standard. If shoulder injury treatment follows the lead of trends in low back pain, then rotator cuff patients can look forward to less invasive rehabilitation and lower medical costs in the years ahead.
Why does exercise show such promise for non-operative rotator cuff rehab and how is the move to conservative care impacting the wider medical community? Read more>>
To learn more about shoulder injury patient education, download the information sheet “I Have a Shoulder Injury. Now What?”.
Milgrom, C, et al. “Rotator-Cuff Changes in Asymptomatic Adults. The Effect of Age, Hand Dominance and Gender.” The Journal of Bone and Joint Surgery. British Volume., U.S. National Library of Medicine, 1 Mar. 1995, www.ncbi.nlm.nih.gov/pubmed/7706351.
“American College of Radiology ACR Appropriateness Criteria.” ACR Appropriateness Criteria, American College of Radiology, 1995, acsearch.acr.org/docs/69433/Narrative/.
Luks, Howard J. “When Should We MRI Shoulder Injuries?” Howard J. Luks, MD, Orthopedic Surgeon, 17 Jan. 2015, www.howardluksmd.com/orthopedic-social-media/mri-rotator-cuff-injuries/.
Rhon, Daniel I., et al. “One-Year Outcome of Subacromial Corticosteroid Injection Compared With Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome: A Pragmatic Randomized Trial.” Annals of Internal Medicine, American College of Physicians, 5 Aug. 2014, annals.org/aim/article/1892614/one-year-outcome-subacromial-corticosteroid-injection-compared-manual-physical-therapy.
Ryosa, Anssi, et al. “Surgery or Conservative Treatment for Rotator Cuff Tear: a Meta-Analysis.” Taylor & Francis, 6 July 2016, www.tandfonline.com/doi/abs/10.1080/09638288.2016.1198431?src=recsys&journalCode=idre20
