Feb 5, 2020 | Insights
Dr. Steven George explains how PTs can treat those who have had musculoskeletal pain during COVID-19
Chronic pain is not a new problem in the United States. It is one of the most common reasons for seeking medical care and has been linked to anxiety and depression, poor health and reduced quality of life and, as seen in the news, a dependence on opioid prescriptions.
However, this is the first time in recent history that those managing pain are doing so through a pandemic. As mounting research points to the effectiveness of conservative care, physical therapy has asserted a central role in both preventing and managing long-term musculoskeletal pain. How can physical therapists best support patients during a time when postponed treatment puts musculoskeletal patients at a higher risk of delayed recovery and chronic pain?
To learn more, we sat down with MedRisk International Scientific Advisory Board (ISAB) member Steven Z. George, PT, PhD, FAPTA, from Duke University’s School of Medicine. He is the Laszlo Ormandy Distinguished Professor in Orthopaedic Surgery and also serves as Director of Musculoskeletal and Surgical Sciences for the Duke Clinical Research Institute and Vice Chair of Research for the Department of Orthopaedic Surgery.
The Psychosocial Factors of Pain
Helping injured workers manage musculoskeletal pain is a primary focus for physical therapists, but according to Dr. George, effective treatment often encompasses more than addressing physical symptoms. An emerging topic of PT research is how beliefs and emotions impact the pain experience.
Especially in the case of an on-the-job injury, psychosocial factors, which include pain-related fears, perceived injustice, and fear of reinjury, can prevent a patient from being active in their rehabilitation. This can then significantly impact recovery. According to Dr. George, pain catastrophizing (another psychosocial factor), which is associated with pessimism and helplessness, can lead to poor outcomes in musculoskeletal injury. Depression and anxiety, whether specific to the injury or a general trait, can also affect potential for recovery.
“We have 25 years of literature where researchers were looking for one particular factor that posed the most risk to recovery – a ‘ring to the rule them all,’” he added. “But what we have found is there’s not just one, and it’s not even just about the number of factors that are elevated. They compound. So, this needs to be considered as a cumulative risk model.”
This research is supported by the use of screening tools, such as the STarT Back Screening Tool, the Optimal Screening for Prediction of Referral and Outcome tools, or the Örebro Musculoskeletal Pain Questionnaire (ÖMPQ) MedRisk uses to assess for psychosocial factors, in a rehabilitation patient.
It is not uncommon for patients to exhibit 1 or 2 psychosocial factors, but when this number increases, there is a higher risk of delayed recovery. Although it’s too early to say, it’s reasonable to expect to see more of these boxes being checked by workers’ comp patients in 2020 and 2021.
“Everyone talks about the second wave of COVID-19, but we are also concerned about the second wave of pain management. As treatment resumes, it may be harder to change negative beliefs and fears related to work injury. And when you think about catastrophizing, this pandemic is also a ‘hand that’s been dealt’ to us all,” Dr. George said.
As hospitals have postponed surgeries and PT treatment has been delayed, many patients have not had the same level of access to nonpharmacologic pain management options, such as PT, during the pandemic. These factors, combined with the psychological impact of such a profound event, will likely equate to a different experience of pain – and likewise, a different course of treatment – for these patients moving forward.
Psychologically Informed Physical Therapy
How should PTs adapt their approach to delivering treatment as the country continues to fight coronavirus? The answer includes implementing safety precautions, like masks and disinfecting, to mitigate the spread of the virus – and more. Many clinicians are embracing the principles of psychologically informed practice, as it bridges the gap between standard PT practice, based on biomedical tenets, and a more cognitive-behavioral approach, derived from principles of mental health treatment. (Click here to learn more about related research from MedRisk ISAB member Dr. Chris Main.) The main goal is to identify psychosocial signs, or “yellow flags,” that may affect treatment outcomes.
Using screening tools like those mentioned above, PTs then adapt standard treatments to incorporate, for example, deep breathing exercises, mental imagery and progressive muscle relaxation, to ease the pain associated distress and improve outcomes.
One way to prompt a discussion about the patient’s pain experience is through motivational interviewing, a counseling technique that helps patients resolve ambivalent feelings and insecurities and find internal motivations to change their behavior. In taking this personalized approach, PTs can also open the door to exploring the relationship between fear and movement. A behavioral approach to exercise is one of the hallmarks of psychologically informed practice.
“If a patient stops an exercise and says it hurts, the PT needs to understand whether they are stopping because they are experiencing injury or because they are experiencing pain,” Dr. George said. “Not all pain is bad; successful rehab involves working through some of the pain. That’s how the system adapts.”
Psychologically informed physical therapy encourages PTs to incorporate “gentle pushback” to lead patients to a place where they see the value of stretching themselves to do 10 minutes of exercise while bearing some discomfort, rather than stopping at 5. This approach is all predicated on the assumption that the exercises being prescribed by the PT are not harmful.
These types of conversations during therapy also encourage patients to take an active part in their recovery, which Dr. George believes is particularly important to treating today’s PT patients. Self-management is a part of all treatment guidelines, but as the use of telerehabilitation rises, PTs must reassure patients that their participation is part of a team-based approach.
“You don’t want the patient to take it as ‘It’s all on you. It’s more ‘We are going to work on finding techniques that work for you, together,” he said.
Conclusion
During these uncertain times, patients may start treatment later than planned or in a different method than expected (i.e., telerehabilitation). However, PT remains one of the most valuable methods for preventing or managing long-term musculoskeletal pain.
Conservative care, particularly immediately after injury, has been shown to be effective and to have a protective effect against opioid use, but even patients who may have been given a short-term pharmacologic treatment can see beneficial effects through physical therapy. The entire care team, including the patient, needs to be involved in developing a long-term treatment plan of which physical therapy may be a part.
No matter the patient’s circumstances, clinicians should assume that the pandemic has had an impact on their recovery and, like so many aspects of pandemic life, treatment will require adaption to be most effective.
“Whether the patient’s injury is physically affected by COVID-19 or not, we should be sensitive to just how stressful it must have been to be in pain during this time,” Dr. George said. “Let the patient state that simple fact without the PT feeling like it needs to be fixed. Be open to recognizing [the pandemic] as something that has made this recovery much, much harder and allow that to be a part of treatment.”
Feb 4, 2020 | Insights
How has MedRisk’s telerehab program increased access and engagement for injured workers? Director of Clinical Services Brian Peers, DPT, shares his insights.
From DIY home improvement videos to virtual mental health services, online platforms have changed the way we get professional help when we need it. It should, therefore, be no surprise that technology has infiltrated the world of rehabilitation. However, MedRisk’s Telerehabilitation Program isn’t just about jumping on the bandwagon of a popular fad – the idea was born out of the needs of the injured worker.
For more than 25 years, MedRisk has been the liaison among patients, providers and payers. Now, for the first time, MedRisk is leveraging HIPAA-compliant, secure videoconferencing technology to help busy and clinically eligible patients take advantage of the convenience that a virtual rehabilitation program can provide.
How has the telerehabilitation program changed the return-to-work journey for MedRisk-referred patients? We sat down with MedRisk’s Director of Clinical Services Brian Peers, DPT, to get a closer look.
Traditional Vs. Telerehab
Traditionally, recovery from a worker’s comp injury has involved several trips to a brick-and-mortar PT clinic prior to discharge; however, MedRisk’s virtual tools and therapeutic methodology now make it possible for some or all of injured worker treatment to be completed virtually, from just about anywhere.
In order for patients to be eligible to participate in the telerehab program, they must meet MedRisk’s three-pronged enrollment criteria. According to Peers, they must be “ready,” meaning they have the technology and skills needed to access and utilize the online platform. They must also be “willing” – that is, they must express an interest in participating. And, finally, they must be deemed “able” to take part in the program, based on a clinical assessment of the type and severity of their injury as well as the nature of their treatment plan.
Increasing Patient Engagement
There are some injuries for which in-person physical therapy will always be necessary; however, as the program’s track record shows, for many patients, treatment does not need to be on-site in order to be engaging and effective.
Perhaps the biggest advantage for telerehab patients is the undivided attention they receive from a dedicated PT in their sessions. With telerehab, there are no other patients in the room; therapy is one-on-one. This enhanced level of support allows therapists to ensure compliance throughout the duration of treatment and help engage and encourage patients as they regain their strength. The platform also offers a virtual “open door” to a physical therapist should any questions or concerns arise.
“When you go to your primary care doctor, you typically have an exam, and then maybe your doctor asks, ‘Is there anything else I can help you with?’ This is the most impactful part of the experience because you can say ‘Well, my neighbor told me…’ or ‘What would happen if …?” Likewise, for the injured worker, we are finding the most valuable benefit of telerehab, in addition to the technical instruction, is that one-on-one time with their therapist. With telerehab, patients have that ‘facetime’ for the whole visit,” Peers said.
In addition to live video conferencing, patients benefit from customized exercise assignments, a video library and resources available within the platform’s online portal throughout guided therapy and in between appointments. They can log their exercises, view notes from a recent session, schedule a virtual “face-to-face” visit, and communicate with their MedRisk provider through secure messaging.
“Initially, a patient may be very dependent on the therapist; however, as treatment progresses, it’s about making sure the patient has a clear understanding of their condition and how to independently manage it. Telerehab allows us to engage with the patient during this period when recovery becomes a more active process.”
Program Outcomes
Feedback from the program’s first two years has been overwhelmingly positive. It has a 95% satisfaction rate, with patients citing “convenience” and “1:1 time with the therapist” as top benefits of the program. A blended model of in-clinic care and telerehab shows 20-35% savings compared to comparable claims, and patients have seen up to a 36% decrease in duration of care over standard treatment.
In fact, the program has generated such interest that MedRisk now offers large employers the option of staffing large facilities with a MedRisk PT trained in delivering care via live video-conferencing. This onsite PT is trained in the employer safety protocols so they can deliver in-person therapy at the company’s home office as well as deliver consistent care to employees at smaller satellite offices via the telerehabilitation platform.
“It’s been gratifying to witness the success of the program,” Peer said. “We are hearing from patients, ‘I wish I had done this sooner.’ I think it’s fair to say it’s working, and it’s working better than any of us had ever expected.”
Nov 1, 2019 | Insights
Research has shown that fear, anxiety and other psychosocial factors can be barriers to recovery in injured workers. How should PTs go about factoring these concerns into their treatment plans? MedRisk Advisory Board member Chris J. Main, PhD, weighs in.
MedRisk ISAB member Chris J. Main, PhD, has had an interest in musculoskeletal pain and disability for more than 40 years, but becoming an authority on the subject was not a deliberate plan. According to Main, his expertise in the bio-psychosocial approach to pain management is a culmination of experience in a diverse range of settings.
Main initially began working in orthopaedic surgery in Glasgow, UK, before gaining experience at a tertiary pain clinic in Manchester, UK. Over the course of this time, he recognized the bearing that fear, catastrophizing, and other psychosocial factors can have on the rehabilitation process. At the same time, he saw no formalized clinical framework for proactively addressing the issue.
“Some pain management techniques that were developed originally in the rehabilitation of chronic pain disability are being used as a means of secondary prevention. However, adoption is in its early stages,” Main said.
He is hoping some traction can be gained through his research at Keele University, where he has been working to link psychosocial screening for chronicity with target treatment. The goal is to provide a standard protocol for PTs and other clinicians to identify psychosocial barriers to recovery so they can address them early, ideally preventing chronicity, which often includes delayed return to work (RTW) in the case of injured workers.
Such an approach was studied by Main and fellow researchers from around the globe, who evaluated the effect of a psychosocial intervention protocol on Australian workers with soft tissue injuries. In the intervention group, workers were screened within 1-3 weeks of injury using the Örebro Musculoskeletal Pain Screening Questionnaire, short version (ÖMPSQ-SF) – the same questionnaire that is utilized by MedRisk staffers during PT consult prior to treatment. Those identified as being at high risk of delayed RTW were offered psychological assessment and a comprehensive protocol to address the identified RTW obstacles. Similarly identified injured workers in the control group were managed under usual (stepped) care arrangements.
At 2-year follow-up, the mean lost workdays for the intervention group was less than half than that of the control group. In addition, their claims’ costs were 30% lower, as was the growth trajectory of their costs after 11 months.
“Our findings supported our hypothesis that brief psychological risk factor screening, combined with a protocol for active collaboration between key stakeholders to address identified psychological and workplace risk factors for delayed return to work, can achieve better return on investment than usual (stepped) care,” Main said.
According to Main, outcomes like this are garnering attention from the physical medicine community; however, opportunities for training have remained limited. Recognizing this need, Main is assisting colleagues at Duke University in developing a new training program that uses psychologically informed practice (PiP) as a general framework and emphasizes the nature of communication with the patient as a key component. He sees opportunity for this approach to be harnessed in workers’ compensation as well.
“I believe it has the potential to significantly change the outcome of interventions with tangible benefits to payers and providers as well as injured workers,” he said.
Oct 4, 2019 | Insights
Chief Clinical and Product Officer Mary O’Donoghue shares why a consultation with an on-staff physical therapist prior to treatment is a critical component of MedRisk’s Platinum Grade Program for Managed Physical Medicine.
It’s a well-known fact that physical therapy as first-line treatment can improve patient outcomes, but what about a consultation with a physical therapist? Can a simple conversation between patient and provider in advance of treatment affect outcomes?
Research says yes. A 2018 study from the University of Utah found that a discussion between patient and provider about the severity of pain and prognosis can reduce the chance of opioid prescription by up to 65%. And according to MedRisk Chief Clinical and Product Officer Mary O’Donoghue, the benefits don’t stop there. In this article, we take a closer look at what physical therapy (PT) consultation entails at MedRisk and three ways this important touchpoint can benefit injured workers.
1. Educate the Patient
Patients directed to the MedRisk network for physical rehabilitation receive a clinical phone consultation with one of MedRisk’s on-staff physical therapists prior to scheduling and before the start of treatment. One of the objectives of the call is to educate the injured worker on why physical therapy is valuable, what to expect and the importance of active engagement and compliance with the treatment plan. Individualized coaching is also provided for the specific diagnosis, such as low back pain or shoulder injury, to reassure patients that in most cases, conservative care (including PT) will relieve.
Altogether, the consultation is intended to support a reduction in appointment no-shows and cancellations, better compliance with at-home exercise, a lower rate of opioid prescription and a decrease in medical costs.
“We’re finding with the level of patient engagement that can be cultivated during these calls,” O’Donoghue said.
2. Address Psychosocial Factors
According to O’Donoghue patient education can mitigate the fear and anxiety that often comes with a work-related injury. But the PT consult goes a step further to address catastrophic thinking and other negative factors that may also be at play following an occupational injury.
MedRisk’s physical therapists use the opportunity to help allay worry and set expectations.
“The patient may have a run-of-the-mill diagnosis, but if during the consultation the patient indicates that she is afraid of re-injury then it might be an opportunity to apply additional resources to the case, such as a nurse case manager to potentially avoid delayed recovery down the road,” O’Donoghue said.
3. Introduce Telerehabilitation
During the consultation, MedRisk physical therapists have an opportunity to better understand a patient’s unique needs. For instance, do they travel for work? How far are they from the closest clinic? If the patient is identified as clinically eligible for telerehabilitation, it is discussed as an option during the consultation.
MedRisk’s telerehabilitation program takes a blended approach to treatment consisting of telerehabilitation, traditional clinic delivery and fluidity between these two service delivery options. Using advanced HIPAA-compliant technology, a US-based MedRisk clinician can connect instantly with the patient for face-to-face evaluations and coaching. Treatment may also be supported by MedRisk’s dynamic library of instructional videos and “store-and-forward” materials to facilitate patient education and improve satisfaction. Remote patient monitoring for guided home exercises is also available to capture and summarize clinical data on performance, progress and compliance to maximize care management.
“Sometimes it’s the people you least expect who are eager to try it. One of our first telerehab patients back in 2017 was 62 years old,” O’Donoghue said. “Many travel for work, and we ask them if there’s a hotel room or conference room available to them. As long as the injured worker has a private, appropriate place to participate in therapy and they are comfortable with the technology available, we can be successful in delivering PT.”
Conclusion
When a worker gets injured on the job, they may not know much about the road ahead of them, especially if it is their first injury. Connecting with a physical therapist before visiting the clinic can help patients gain a sense of understanding and control in what can initially seem like a hopeless situation.
“You just never know how a patient is feeling. If they are disengaged or have already made up their mind that are not going to get better, treatment will be an uphill battle. This could end up being the most important appointment they have,” O’Donoghue said.
Jul 29, 2019 | Insights
A 2019 systemic review of high-quality clinical practice guidelines has yielded a set of 11 key recommendations for best-practice musculoskeletal treatment – all of which have been historically supported by the MedRisk Platinum Grade Program for Physical Medicine.
In a recent article published in the British Journal of Sports Medicine, a multidisciplinary research team identified 11 clinical practice guideline (CPG) recommendations for treating adult musculoskeletal pain. The recommendations are the product of a systemic review of 44 CPGs addressing spinal pain, hip/knee pain and shoulder pain. The authors contend that practice aligned with these guidelines results in “better outcomes and lower costs;” however, there can be barriers to integrating the recommendations into daily practice, including a lack of guidance for implementation.
As a leading physical medicine managed care organization, MedRisk works to close these “evidence-to-practice gaps” by supporting our expert providers with patient-centered services, education and our own evidence-based guidelines focused on rehabilitating the injured worker.
In this article, we take a closer look at the study authors’ 11 recommendations and how they are addressed by the MedRisk Platinum Grade Program for Managed Physical Medicine.
Patient-Centered Services
Fittingly, the first recommendation from the study authors is “Care should always be patient-centered.” The dedicated physical therapists (PTs) in our provider network live this principle every day in the treatment they provide, and MedRisk helps facilitate patient-centered care as soon as a case hits our desk. Our representatives use a dynamic scheduling algorithm to match patients with a provider who is equipped to meet their treatment needs and who can see them as soon as possible.
Many providers routinely conduct an assessment that includes a physical examination (Recommendation 5) and screening for “red flag” conditions (Recommendation 2) at the start of treatment. But even before the initial evaluation, MedRisk’s on-staff PTs first conduct a phone consultation. The conversation helps identify psychosocial factors like anxiety and catastrophic thinking (Recommendation 3) that may be a roadblock to recovery. After this initial interaction, the MedRisk PT can help facilitate better understanding and communications about the patient’s unique case in advance of the physical evaluation and treatment.
This phone consultation is also used as an opportunity to educate patients about their condition and treatment (Recommendation 7). Patients learn about next steps in their rehabilitation and the important role they play as an active participant in the recovery process. When applicable, this can include a discussion of why exercise and physical activity is often a key component of treatment, as discussed in Recommendation 8. Should the patient be identified as an ideal candidate, a MedRisk PT will also present the option of the MedRisk Telerehabilitation Program, which can support the patient’s transition to independence and help ensure compliance with exercises prescribed during treatment.
MedRisk’s Evidence-Based Treatment Guidelines
Recommendation 11 from the study authors states that “treatment should facilitate return to work” and encourage patients to remain active and engaged throughout their recovery. MedRisk supports successful return to work with the only evidence-based guidelines in the industry specific to physical medicine and the injured worker. These proprietary guidelines are continuously updated to incorporate new research in the field, including developments related to therapies, comorbidities, psychosocial factors and barriers to recovery. For example, the study authors’ ninth recommendation is “Manual therapy should be used only as an adjunct treatment,” and manual therapy and the application of other modalities are detailed in the MedRisk guidelines.
Throughout treatment, MedRisk takes an active role in monitoring progress and facilitating communication between providers and case manager/adjusters so that as patients are benchmarked against “validated outcome measures” (Recommendation 6), all parties can ensure the injured worker is on track with their current treatment plan.
Knowledge Sharing
Research in the field of physical medicine continues to yield new approaches and emerging therapies. MedRisk keeps a pulse on these developments and disseminates content regularly to our provider network. In recent years, growing evidence has led the industry to promote nonsurgical care as first-line treatment (Recommendation 10). This finding has been promoted in MedRisk study spotlights and newsletter articles. Likewise, the study authors advise against the use of radiological imaging except when a serious pathology is suspected (Recommendation 4) – which is an approach we have also promoted to our provider network.
MedRisk aims to share leading-edge research and to incorporate the latest evidence-based findings into our operations. The fact that our programs and services align with these 11 core recommendations suggests that our Platinum Grade Program for Managed Physical Medicine delivers what constitutes high-quality musculoskeletal care.
To learn more about this study and related recommendations, click here.
