Aug 24, 2017 | Insights
Rotator cuff and other shoulder injuries are among the most common occupational musculoskeletal problems. Why is this region so susceptible to injury, and what can employers do about it?
Low back pain may be the first injury that comes to mind when considering top work-related musculoskeletal ailments, but shoulder injuries are a close second — sometimes outpacing low back pain in some industries. Shoulder pain affects 18-26% of the general population and is one of the most common regional pain syndromes. It is also among the most common musculoskeletal problems in workers, making it difficult for patients to carry out daily tasks both at home and in the workplace. Financial burden is also a common side effect. Not only can healthcare fees be quite costly, but injury can result in time away from work, impaired work performance and even early retirement or disability.
Anatomy of a Shoulder Injury
Why is the shoulder particularly susceptible to injury? Often mistaken as a simple ball and socket joint, the shoulder is actually quite complex, has a wide range of motion and can handle impressive physical demands. However, because it consists of four articulations and a constellation of bones, muscles and ligaments in and around the joint capsule, it is vulnerable to a spectrum of articular and peri-articular pathologies. Pain can also be referred to the shoulder region while the true culprit lies elsewhere. The most common source of referred pain to the shoulder is the neck, but some viscera such as the heart, liver, or gall bladder can produce shoulder pain as well.
Risk Factors
For most shoulder pain, the true cause is unknown. There is no widely accepted classification system for reporting shoulder problems; however, recent studies have pinpointed some factors associated with shoulder pain. Perhaps the most widely studied of these is age. As we grow older, our tendons degenerate and osteoarthrosis of the joints can develop. A high body mass index has also been found to be a risk factor of incident shoulder pain.
In the workplace, physically strenuous work that loads the shoulder, include lifting, carrying, pulling or pushing, may cause pain. Working with hands above shoulder level is another strong predictor of incident shoulder pain. Some studies have also shown poor job control and work with high psychological demands to be related to shoulder pain. Mental stress is being investigated as a causal factor, but further research is needed.
Employer-Led Prevention
The good news is that, however common, shoulder injuries can be mitigated in the workplace. Employers should conduct regular worksite evaluations. When hazards are detected, they should be corrected through engineering controls such as workstation reconfiguration or tool redesign. Physical job demands should be matched to worker size and fitness level. Employee training programs should emphasize the importance of proper posture, lifting techniques, and overall fitness. Administrative controls such as adjusting procedures, rotating shifts or reconsidering break schedules may also be effective. Talk with your employees about concerns they may have, and work together to create a culture of injury awareness and prevention.
Linaker, C., & Walker-Bone, K. (2015). SHOULDER DISORDERS AND OCCUPATION. Best Practice & Research. Clinical Rheumatology, 29(3), 405–423. http://doi.org/10.1016/j.berh.2015.04.001
Shanahan, E. M., & Sladek, R. (2011). Shoulder pain at the workplace. Best Practice & Research Clinical Rheumatology, 25(1), 59-68.
Teunis, T., Lubberts, B., Reilly, B. T., & Ring, D. (2014). A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. Journal of shoulder and elbow surgery, 23(12), 1913-1921.
The Texas Department of Insurance, Division of Workers’ Compensation (TDI, DWC). Shoulder Injury Prevention FactSheet. HS05-033C (9-07). http://www.tdi.texas.gov/pubs/videoresource/fspreventingsho.pdf
Van Eerd, D., Beaton, D., Cole, D., Lucas, J., Hogg-Johnson, S., & Bombardier, C. (2003 epidemiology, 56(10), 925-936.). Classification systems for upper-limb musculoskeletal disorders in workers:: A review of the literature. Journal of clinical epidemiology, 56(10), 925-936.
Aug 2, 2017 | Insights
As virtual PT services make their way into workers’ comp, which patients stand to benefit most?
There’s no doubt telemedicine is a key element of next generation health services. Seventy-four percent of group health consumers say they would use telehealth options. Before strategizing how to attract and convert patients to use telehealth services, however, the baseline needs of the patient must first be considered.
Research shows that telerehabilitation is effective and comparable to conventional in-clinic care, yet telerehabilitation hasn’t yet entered the mainstream when it comes to the workers’ comp industry. During this transitional phase, as telerehabilitation gains steam as an accepted complement to traditional, in-clinic care, it is imperative that payers work with managed care organizations who focus on identifying the patients who can benefit most from virtual PT services.
As a part of this process, both the requirements for a successful telemedicine engagement and the motivators that will drive patients to see telerehab as a viable healthcare alternative need to be defined.
Prerequisites for Telerehab Success
Not every case can be appropriately treated through virtual services. Even if an injury is found to be appropriate for telerehabilitation, the patient must also have the technology required to remotely connect with their provider. For this reason, a managed care organization need to offer a data-driven screening program to identify ideal telerehab candidates and take into account the following:
Injury/Treatment Plan: Is telerehab clinically appropriate – and if so, when? The severity, nature of the injury and any complicating factors will be the first consideration of any screening program. Some treatment plans will not translate well to telepractice, such as monitored patient with unusual or heavy work demands; s/he may need specialized equipment or in-person supervision. In other instances, in-clinic PT sessions can be supplemented with valuable remote offerings including online education, virtual home exercise supervision and online discharge planning appointments, to create a hybrid treatment plan.
Technology Access: At a minimum, telerehab patients will need a computer, smartphone or other device that is compatible with the HIPAA secure telehealth software. The device must be connected to the internet, either through a dependable wireless or wired connection, or a mobile network. Most telerehab treatment plans necessitate the use of a microphone and camera, which are built-in to most computers and mobile devices but can be purchased as external hardware if needed. Speeds of 15Mbps download and 5Mbps upload are best to ensure a smooth video streaming experience.
Reasons Patients Say ‘Yes’ to Telehealth
Although many patients may meet the requirements outlined above, not all will be interested in using telerehabilitation services. There are many reasons that patients might feel motivated to engage with their provider in a virtual fashion. Here are some of the more common drivers of enthusiastic telerehab adopters:
Location: Healthcare services in rural areas have taken a hit in recent years. According to the National Rural Health Association, 75 rural hospitals have closed and 673 more are in danger of closing. The shortage of clinicians working in remote areas and absence of specialty services like physical therapy often means increased travel times for rural patients. Telerehab services offer these patients a fast and convenient option to get the care they need. In a 2012 report by the Institute of Medicine for the National Academies, it was found that telehealth increases quality of care and reduces costs in rural communities.
Demographic: While interest in technology cannot be dictated strictly by age, conventional wisdom would tell us that telehealth may find more traction among younger patients. After all, research has shown that millennials are 5 times more likely to adopt technology than any other age group. And in a recent survey, 71% of millennial patients indicated they would like to engage with their provider via a mobile app. While younger patients may be more eager to adopt telerehab, older patients should not be excluded from such services. Although little research has been done within virtual PT for workers’ comp, high patient satisfaction among older adults has been reported for telerehab services in home health applications after stroke, fall, etc.
Lifestyle: For some patients, the appeal of telehealth really boils down to convenience. In the workers’ comp arena, convenience may have added weight for frequent business travelers who find it difficult to establish a consistent schedule at a physical “home base” provider or others who have family obligations that make it more difficult to travel to appointments. A survey conducted by the American Telemedicine Association found convenience to be the top motivator for active healthcare users interested in complementing or replacing their in-person care with telehealth services.
Conclusion
Be it the severity of injury, a complex treatment plan or a lack of technology, there will always be instances when telehealth is not a suitable solution. However, in many cases, it represents a more direct route to recovery. As the practice of telerehabilitation becomes more prevalent, buy-in from injured workers and their employers will only increase. Now is the time for payers to establish a standard of care and a foundation of interest as we anticipate increased user growth, advancing technologies and expanded clinical capabilities in the years to come.
Aug 2, 2017 | Insights
Simple precautions employers can take to protect their workforce from harmful UV rays.
There is a common misconception that sunburn is something you can feel as it happens; however, solar ultraviolet radiation (UVR) can damage skin without detection. More than 100 million Americans will experience sunburn this year, and thanks to a depleted ozone layer, exposure to UVR has increased, making sunburn, and its symptoms, more intense.
How can employers help workers protect themselves from sunburn – and a heightened risk of skin cancer? Here are three tips for keeping your worksite sun-safe no matter the season.
1. Share sun protection strategies.
Although sunburn prevention measures are no secret, they are not always practiced 100% of the time. It is encouraging that in 2010, 70% of adults reported that they usually or always practice at least one of the three sun-protective behaviors described below. However, given the extended hours that many workers can spend at an outdoor worksite, it is important to remind employees of these proven strategies to block out UV rays.
- Dress the part. A quick test to tell if you’re wearing sun-protective garb: place your hand between a single layer of fabric and a light source. If you can see your hand, the clothing does not offer optimal protection. A wide-brim hat also helps protect the head, forehead, ears, eyes, nose and scalp, and UV-absorbent sunglasses can block 99-100% of UVA and UVB radiation.
- Apply sunscreen. Sunscreen 15 SPF and above should block 93 percent of UV rays. Tell employees to follow product directions to ensure continuous protection.
- Limit exposure and seek shade when appropriate. UV rays are most intense between 10 a.m. and 4 p.m. An easy sun intensity test: if your shadow is shorter than you, the sun’s rays are at their strongest.
2. Modify working conditions as needed.
In addition to encouraging good habits among your employees, there are many ways to modify your work conditions to protect your workforce from overexposure. UV rays are strongest during mid-day, near the equator, during summer months and at very high altitudes. Bearing this in mind, it’s sometimes useful to train workers to use the UV Index Scale, a rating system established by the World Health Organization. The Index incorporates effects of the position of the sun in the sky, forecast cloud cover and ozone amounts into its level-based scoring system, which is used to warn people of increased risk. At level 3 or higher, the amount of solar UV radiation is strong enough to damage skin. Therefore, many workplaces have their employees adjust their schedules when levels are “very high” or “extreme.” In addition, employers should schedule breaks for workers to seek out workplace-provided shade, such as tents, shelters and cooling stations, and to reapply sunscreen. Schedules that minimize outdoor tasks during mid-day and rotate workers to reduce UV exposure are also recommended.
3. Incorporate sun safety into policies and training programs.
Making strides toward sun safety is much easier when it is integrated into your company culture and policy. Here are a few ways to get started.
- Skin protection is an oft-overlooked aspect to overall wellness, so be sure to incorporate it into your workplace wellness program, perhaps in the same unit as avoiding heat illness.
- Teach employees about the signs and symptoms of UV exposure, such as red, warm and tender skin, blistering, headache, nausea fatigue – but also warn them that symptoms may not start for about 4 hours after sun exposure.
- Encourage outdoor workers to model sun-safe behaviors and to discuss the importance of sun protection with coworkers and customers alike.
The effects of sunburn may not be immediately apparent. Symptoms may be delayed and signs may not be readily visible. But don’t underestimate the impact it can have on employee health and workplace operations. By adapting your work policies to be more sun-conscious – and simultaneously encouraging workers to keep their skin health top of mind – the risks of UV exposure can be effectively mitigated.
Jun 8, 2017 | Insights
Guideline-adherent physical therapy has been shown to reduce utilization and cost – but are standard guidelines enough to address the unique needs of each injured worker?
In 1994, at the time of MedRisk’s founding, there was a gap to be filled in managed care. Historically, there had been a heavy focus on unit cost, which was relevant in the case of hospitalizations and outpatient procedures. But in the workers’ comp industry, physical therapy, which carried a comparatively low unit cost, had fallen under the radar and become an overlooked driver of rising medical costs.
Carriers and TPAs had no way to effectively manage the utilization of physical therapy, occupational therapy or chiropractic services. Multiple visits and requests for continued treatment were uncontrolled, without clinical treatment guidelines in place and administrative resources to manage the process. Consequently, the quality of physical rehabilitation suffered and return-to-work results were less than optimal.
There had to be a better way – but to truly improve patient outcomes, it wouldn’t be as simple as enforcing visit caps to decrease costs. The industry turned to evidence-based treatment guidelines, and over recent years, various states have adopted treatment guidelines to help control visits. But is it enough? While the cost savings from early guideline-adherent physical therapy is substantial, individual patients have unique needs and personal circumstances that go beyond clinical diagnoses. To truly improve outcomes and the quality of care, the industry’s next step is to drill down and tailor rehabilitation to the needs of each injured worker, throughout the entire continuum of care.
MedRisk’s Platinum Grade Program for Physical Medicine Management takes an evidence-based, patient-centric approach to managing rehabilitation through the following programs.
Patient-Provider Matching
Individualized service begins at the time of referral when MedRisk’s patient advocates are tasked with finding an appropriate provider for a patient. Key performance indicators (KPIs) on provider outcomes by injury type, age, gender and patient satisfaction are captured and incorporated into MedRisk’s dynamic scheduling algorithms to match the patient with the best provider for his or her unique needs. By matching a patient with a provider who is not only nearby but also well-versed in the patient’s injury type with a proven track record of return to work, the patient is set up for success.
Patient Education
For workers injured on the job, it is often their first experience with the complex world of workers’ compensation – and it may even be their first experience with a serious injury. Studies show that patients who know what to expect before and after surgery are 23% more likely to follow post-surgical instructions (e.g., PT) with 31% fewer reported post-surgical problems. In addition, pre-operative physical therapy (education) has been shown to reduce postoperative care by up to 29%, saving on average more than $1,000 per patient [1]. By proactively scheduling post-operative physical therapy and educating patients on what to expect in advance of an initial evaluation or functional capacity evaluation, MedRisk helps set expectations and reduces fear and anger – two proven psychosocial barriers to recovery.
Evidence-Based Guidelines
There is no such thing as a one-size-fits-all rulebook for utilization. A healthy 25-year-old does not face the same challenges as a 60-year-old diabetic smoker when recovering from a knee injury. While a framework is needed to ensure consistency and quality, a degree of flexibility is also necessary to account for these variations.
MedRisk’s proprietary evidence-based guidelines are unique to physical medicine and go beyond simple recommendations for the appropriate one-size-fits-all number of visits. Developed over the course of five years, MedRisk guidelines address timing, choice and sequence of modality and take into account the chronicity, severity and complexity of the injury. Managed by the company’s International Scientific Advisory Board, the guidelines are continuously refreshed to incorporate new research in the field.
Conclusion
Over the course of the last 20 years, MedRisk has reduced managed physical medicine patients’ visits by 41 percent compared with unmanaged cases. This is a collective statistic, but it was not achieved by approaching the patient population as an indistinguishable group. Instead, improved patient outcomes have been affected one by one, at the individual level, throughout every step of recovery.
Jun 6, 2017 | Insights
Employers need to be prepared to guard against the risk factors of heat-related illness when an extraordinarily hot day strikes – summer or not.
Under Occupational Safety and Health Administration (OSHA) law, employees must provide workplaces free of known safety hazards, which includes protecting their workforce against extreme heat. However, mercury rising isn’t the only—or the best—indication that your workers are at risk for health-related illness.
The heat index is a single value that factors in both temperature and humidity and is a better reflection of how hot it feels on a given day. The higher the heat index, the less able our bodies are to evaporate sweat and cool the skin. Before heat index levels have the chance the rise, take these four steps to ensure you and your employees are prepared to beat the heat.
1. Formulate a heat illness prevention plan.
The actions required by your company will vary depending on the level of risk on a given day. One way to frame out your heat illness prevention plan is to base it on the National Oceanic and Atmospheric Administration’s system, which uses the heat index to delineate four risk levels:
| Risk Level | Heat Index | Protective Measures |
| Lower (Caution) | Less than 91°F | Implement precautions and heighten awareness |
| Moderate | 91°F to 103°F | 97164 Re-evaluation |
| High | 103°F to 115°F | Additional precautions to protect workers |
| Very High to Extreme | Greater than 115°F | Triggers even more aggressive protective measures |
Source: Adapted from OSHA.gov
2. Prep your workforce.
For low-level days, OSHA recommends providing water and provisions located at convenient rest areas, and advising workers to wear sunscreen. As the heat index increases, you may want to consider reevaluating your work/break schedule to allow for more frequent periods of shaded rest. At extreme temperatures, psychological monitoring may be called for and certain work activities may need to be rescheduled. Click here for OSHA’s complete list of recommendations by risk level.
It might seem like overkill to remind workers to drink water on a hot day, but the daily grind can be a serious distraction and it’s easy to forget to hydrate. Drive home this point in new worker training, and establish a system for reminding workers on exceptionally hot days. In addition, make sure your employees know how to recognize signs of heat-related illness, when to report them, and where to go if they need immediate medical assistance.
3. Monitor conditions day-by-day.
Just because you have your plan on paper and your employees trained, doesn’t mean it’s time to sit back and run on autopilot. Employers should track worksite weather daily to assess heat-related risk and take appropriate action. Begin each day with a mandatory check of the current and predicted heat index from the National Weather Service or consider downloading OSHA’s Heat Smartphone App to check the conditions of your worksite as well as risk level and corresponding recommendations.
4. Stick with the plan – but adapt when needed.
The plan established in step 1 will serve as a guide for general implementation, but be aware of additional risk factors that require extra vigilance. Any worker exerting exceptional energy, working in direct sunlight or using bulky protective equipment or non-breathable clothing may be at higher risk of heat-related illness. Be particularly watchful of workers who may not have established a tolerance to hot conditions, such as new employees, temporary workers or those returning after a break of week or more. Allow these employees to gradually increase their workload and take more frequent breaks to acclimatize to hot conditions.
We can’t always accurately predict when a hot day might strike. Use the steps above to formulate a plan that allows you to take action to protect your employees’ health – and your operation – at a moment’s notice.
May 9, 2017 | Insights
Learn more about the primary approaches driving today’s telerehabilitation services and how they can serve the workers’ compensation market.
In recent years, we have seen a growing body of research supporting the positive impact telemedicine can bring to patient care. As a result, telehealth has picked up steam among group health payers, with a growing number of patients interested in trying a remote care option in lieu of an in-person visit. However, telemedicine is only just now generating interest in the workers’ compensation arena. The obvious benefits for injury triage, case management and physician follow-up is clear – but the value of telemedicine for a traditionally hands-on service like physical therapy has not yet been recognized fully. Below we explore three models of telemedicine technology, how they’re being used in PT and the benefits of each.
Live Video (Synchronous)
Often referred to as “real-time,” synchronous telehealth tools facilitate live, two-way interactions between patients, caregivers and providers using audiovisual technologies. This type of telemedical care is often employed as an alternative to an on-site clinical visit for the purposes of consultation and diagnosis. In addition to reducing transportation costs and bolstering access to care in remote areas or during off hours, these convenient virtual visits have been shown to improve patient satisfaction and potentially improve care outcomes. This type of technology may be used by physical therapists to perform an at-work environmental assessment, conduct a goal setting session or dispense patient education. It may also be possible to administer functional training, movement facilitation, a guided assessment or a therapeutic exercise through the use of live video.
Store-and-Forward (Asynchronous)
As the name indicates, store-and-forward telemedicine involves the secure transmission of pre-recorded materials. A wave of tech start-ups and apps has been developed to generate educational tools for patients. Orca Health, an educational app company, provides tools that PTs can use to explain common injuries of the shoulder, knee and spine in layman’s terms through the use of interactive anatomical 3-D models, videos and images. Orca’s videos demonstrating stretches and strengthening techniques are also a valuable resource for patients to safely and accurately execute therapeutic exercises away from the clinic.
But store-and-forward applications don’t just benefit patients; they also strengthen communication between providers by facilitating the transmission of documented patient history including videos, digital images, lab results and health records. Asynchronous platforms designed for this purpose provide the means to exchange protected health information in a secure manner. This technology is often employed when a physical therapist needs to evaluate a case or render a service outside of a live interaction. Clinical store-and-forward applications have become quite common, enabling faster diagnoses and better treatment strategies, especially in settings where specialists may not be readily available. Inexpensive and easy to use, asynchronous telemedicine services can also lower wait times by optimizing the use of health care providers’ time.
Remote Patient Monitoring (RPM)
RPM technologies allow an individual’s personal health and medical data to be collected and transmitted to a provider. Often used to aid chronic disease management – such as diabetes, heart conditions or high blood pressure – these platforms allow providers to track a patient’s vital signs while they are at home or in a care facility. In many cases, the RPM data is transmitted automatically, generating a report for the provider or a team of health monitoring professionals who flag unusual findings for clinical review. By providing practitioners the means to monitor for early warning signs and quickly intervene, RPM, or telemonitoring, can help patients adhere to their treatment plan and potentially reduce life-threatening complications.
The latest RPM technology for telerehabilitation includes The Vera System, a new innovation from Reflexion Health, which guides patients through exercises and, using cutting-edge motion-tracking technology, tracks their movements to ensure they are doing them correctly. The physical therapist receives the performance data, and the patient receives real-time feedback and tips as they perform the exercises. Duke University plans to research the effectiveness of the system in its in-progress 2017 study.
A Look to the Future
Although different in their approaches, all three models of telemedicine can deliver significant value for physical rehabilitation. It is only a matter of time before telerehabilitation becomes integrated into treatment strategies for patient-centered organizations. In a world where people use apps to track everything from fitness and eating habits to nightly sleeping patterns, it is easy to imagine a healthcare system where the link between technology and physical medicine is strengthened: where, through the latest technologies, patients can reach their healthcare provider quickly and easily, and where injured workers are guaranteed the therapeutic support they need when and where they need it most.
