Feb 6, 2017 | Insights
Arthroscopic partial meniscectomy is a procedure used to treat as many as 300 in 100,000 US patients annually.
While a heavily relied upon intervention, knee arthroscopy has been associated with short-lived and sometimes inconsequential benefit but additional harms. In fact, only 1 in 5 previously conducted randomized controlled trials found that partial meniscectomy resulted in greater pain relief compared with non-surgical treatment one year post surgery.
Now, new research out of Norway is positing that exercise therapy and knee arthroscopy may be similarly effective for pain relief and other patient-reported outcomes in a younger, more active population with a lower body mass index than previously studied. The results indicate that clinicians and middle-aged patients with meniscal tear and no definitive radiographic evidence of osteoarthritis should consider exercise therapy as a viable treatment option.
Read more: Exercise therapy versus arthroscopic partial meniscectomy for meniscal tear in middle aged patients: randomized controlled trial with two year follow-up
Sep 8, 2016 | Insights
Successful recovery from a musculoskeletal injury is reliant upon accurate diagnosis and appropriate treatment; however, these two areas of expertise are typically handled in two separate camps: radiology and physical medicine. Could patients benefit from bridging the gap between these two disciplines? MedRisk advisory board member Matthew Walsworth, MD, PT, weighs in.
The most recent addition to MedRisk’s International Scientific Advisory Board is a rare breed in the world of musculoskeletal medicine. Dr. Matthew Walsworth obtained a master’s degree in physical therapy from Baylor and went on to serve for 6 years as a physical therapist in the U.S. Army. He spent his days treating back and neck injuries, but, according to Walsworth, his role encompassed more than that.
“In the military, physical therapists are given a bit more autonomy as a point of direct care,” said Walsworth, referencing the enduring legislative and payer-imposed restrictions on PT as a direct point of access.
When Walsworth chose to leave the army and resume his life as a civilian, he decided to pursue a degree in medicine, in order to continue that direct care function. He had a hunch that his studies would lead him to a career in radiology, and he was right – although the realities of the position were at odds with his previous clinical experience.
“I enjoyed the diagnostic part of the job but soon realized that imaging often meant sitting in a dark room a good portion of the day. I missed that close interaction with patients,” Walsworth said.
This realization led Walsworth to pursue a fellowship in interventional radiology at UCLA, and, today, he splits his time between diagnosis and treatment as an interventional and diagnostic radiologist at the West Los Angeles Veterans Affairs Medical Center.
When asked how his physical therapy background informs his radiology practice, Walsworth says it’s all about perspective.
“I am able to look at things a bit more functionally,” he said. “The imaging and the function don’t always correlate. I treat a lot of patients with peripheral artery disease who suffer from pain in their legs due to poor blood flow. I can make confident decisions about when to choose lifestyle modifications and when to opt for a given treatment because I have seen the results of both first hand.”
Walworth’s multidisciplinary approach embodies the goal of MedRisk’s international scientific advisory board. Made up of an elite panel of world-renowned specialists in physical medicine and electrodiagnostics, ISAB is charged with maintaining evidence-based clinical guidelines for all of MedRisk programs – and filling the gaps between diagnostic imaging and physical medicine with proactive oversight and innovative integrated solutions.
As for physical medicine at large, what does the future have in store?
“I’m hopeful,” says Walsworth. “As physical therapy grows as a field, there may be opportunity for PTs to become more autonomous, and for PTs and radiologists to collaborate and communicate more. Integration would be hugely beneficial to not only us as clinicians, but also to our patients.”
Aug 4, 2016 | Insights
Workers in the manufacturing industry have the highest incidence rate of Carpal Tunnel Syndrome (CTS) out of any other industry, racking up 1.9 injuries per every 10,000 workers.
CTS is a significant contributor to higher-than-average physical therapy costs for 35- to 44-year-old workers in manufacturing driven mostly by parts assembly workers. As one of the most common injuries requiring physical therapy for this age group, CTS is third only to shoulder pain and lumbago injuries and affects twice as many female manufacturing employees as male.
However, new research from Spain suggests physical therapy may be just as effective as surgery in alleviating pain and restoring function. This research is leading those in the industry to posit a higher reliance on non-surgical physical therapy, which may equate to a decrease in surgical costs.
Read more: 2016 Trends Report: Manufacturing
Jun 1, 2016 | Insights
Many states currently restrict the ability of patients to see a physical therapist as their first point of care. What are the risks—and what are the benefits—to PT as direct point of access?
Access is a big issue for savvy consumers selecting a plan in today’s healthcare marketplace. The ability to see specialists and non-physician healthcare professionals without a referral can be the deciding factor when comparing insurers or choosing between an HMO and PPO.
However, in some states, direct access to physical therapy treatment remains a legislative issue.
According to the Health Care Cost Institute, current state laws restricting direct access to physical therapy include:
- Requiring a physician referral prior to seeing a physical therapist
- Time limits on how long a patient can be seen by a physical therapist before requiring a physician visit
- Education and/or credential thresholds for physical therapists to see patients directly
These restrictions have implications for patients, physical therapists nationwide and the healthcare system at large.
Disempowering the Physical Therapist
Those opposing direct access to PT have contended that physical therapists lack the education needed to recognize infections, fractures and other serious medical conditions. They state that because physical therapists do not order diagnostic tests and make medical diagnoses, they require medical oversight.
Physical therapy is a highly regulated profession across all 50 states, requiring both formal education and clinical training to analyze a patient’s condition and assess his or her PT needs. Physical therapists are trained to recognize when it is appropriate to safely and effectively treat a patient – and when signs and symptoms indicate that the patient should be referred to another healthcare professional.
Much like physicians, physical therapists look for warning signs in the physical exam and patient history that would prompt further testing, as outlined in the Guide to Physical Therapist Practice. When there is concern of a serious nature, the problem would be deemed outside the PT’s scope of practice, and a referral to a physician would be in order.
Impacting Utilization Rates
In turning this argument on its head, one may surmise that because physical therapists do not have the same medical privileges as physicians, seeing a PT first may result in lower utilization of unnecessary medical services. And they would be right.
According to a study by Frogner et al that compared patients suffering from low back pain (LBP) who first saw a physical therapist versus another provider, several positive utilization outcomes were associated with seeing a physical therapist first, including:
- Significantly lower costs across almost all settings (with a few exceptions)
- Significantly lower probability of having an emergency department (ED) visit
- Lower imaging rates
Notably, patients with LBP who first saw a physical therapist also had a lower probability of opioid prescription, which is a likely outcome for patients who visit an emergency department with persistent back pain. It should not be surprising that concurrent with an increase in back pain-related opioid prescriptions, EDs have seen an uptick in drug overdoses. Research shows that opioids do not significantly improve health outcomes, but are associated with an increase in mortality risk.
Expanding Access, Addressing Cost
Overutilization of medical services not only has implications at the patient level; it further clogs a strained healthcare system struggling to control costs and improve access to critical medical care.
Healthcare costs related to LBP, for example, continue to outpace non-LBP expenditures, amounting to $90.6 billion in direct costs and $19.8 billion in indirect costs. As we reform our national healthcare system and face a shortage of primary care physicians, states must look for new ways to offer healthcare access to their citizens while controlling cost. One way is to expand access to non-physician healthcare professionals, such as physical therapists.
In the Frogner et al study, it was found that patients who had PT first saw significantly lower care cost totals compared with those who had PT later or no PT (controlling for patient characteristics and distance between patient and provider). Although there was not a significant difference in pharmacy costs, patients who had PT first accrued lower physician and outpatient costs overall. These patients were also less likely to use imaging services, which, when used prematurely, has been found to lead to higher costs without significant health benefits.
Research continues to be done to support the efficacy and benefits of direct PT care. Over recent years, limitations found in state laws have eroded; however, many unnecessary barriers to direct PT care still remain.
By amending outstanding legislative restrictions, we can empower physical therapists to exercise the extent of their training, provide patients with less expensive and more timely care, and offer an additional entry point to an overburdened national healthcare system.
Bibliography
American Physical Therapy Association (APTA) (2016, April 15). Direct Access at the State Level. Retrieved from www.apta.org/StateIssues/DirectAccess/
Direct Access: Where’s the Risk?
Frogner, B. K., Harwood, K., Pines, J. M., Andrilla, H., & Schwartz, M. (2016). Does Unrestricted Direct Access to Physical Therapy Reduce Utilization and Health Spending?
Apr 26, 2016 | Insights
Advanced imaging is a popular – and expensive – first course of action for patients with lower back pain – but does it always pay off?
Approximately 80 percent of adults experience some form of lower back pain (LBP) in their lifetime. It’s so common, in fact, that it is discussed at 1 in every 17 primary care visits. Such prevalence has prompted an unprecedented focus on the diagnosis and management of LBP patients. Yet despite our increased understanding of back pain, LBP-related costs have increased, with the United States spending more than $86 billion on direct LBP-related costs in 2005, and $1500-$2000 per individual in direct costs.
Conservative Care as First Treatment
A 2015 study published in Health Services Research (Fritz et al) sought to investigate the high cost of advanced imaging for patients with uncomplicated LBP. In particular, the research team compared the healthcare utilization and LBP-related charges of patients who received advanced imaging versus the more conservative physical therapy as the first management strategy.
In a study of 841 people who required additional care following a primary care appointment for uncomplicated LBP, Fritz and colleagues found that those who were first sent for MRIs were more likely to receive a surgical or injection intervention, require specialty care or visit an emergency department. In addition, these individuals saw LBP-related charges averaging $6,193. That’s $4,793 more than those who were first administered physical therapy.
The Psychology of Advanced Imaging
Research suggests that advanced imaging is a more costly first step and, in the absence of specific symptoms, may not deliver significant clinical benefit during this early stage of treatment (Chou 2009). So why do MRIs continue to be so common, especially given their high price tag? In the discussion section of her study, Fritz explains that the reasons often have more to do with psychological matters than lumbar concerns.
- Patient expectations: When a patient sees a primary care physician for LBP, he or she is typically looking for a diagnosis and a curative, or at least pain-relieving treatment. Many patients believe that back pain is a sign that the spine has become abnormally positioned and must be corrected or risk becoming unsound or unreliable on a daily basis. This often leads them to push for advanced imaging – and to view denial of such services as an unfavorable response. Consumer research suggests that offering an alternative to replace the broken expectation is important in these instances. Physical therapy, which is viewed as a credible form of treatment, is often an ideal and agreeable alternative.
- Labeling: Identifying and labeling the source of pain through advanced imaging can provide patients with a sense of satisfaction, but this can also lead to heightened concern – and even catastrophic thinking, a known psycho-social barrier to recovery. As an alternative, conservative clinical care (e.g., physical therapy) may be a way to avoid the negative consequences of labeling and deter additional care-seeking while, at the same time, yielding clinical outcomes similar to those who first undergo lumbar imaging (Chou 2009).
- Specialty care vs. self-care: The care-seeking prompted by advanced imaging can often lead patients down a road of specialists and procedures, rather than encouraging them to actively participate in the management of their condition. A major component of physical therapy is engaging patients in their treatment and educating them about their pain – including the fact that most uncomplicated back pain subsides over time. This approach often motivates patients to contribute to the management of their back pain away from the clinic. Additionally, it has been suggested that the self-management strategies learned in physical therapy may play an important role in long-term care and help patients avoid recurrent cases.
The study by Fritz et al reaffirms a growing body of research suggesting that while advanced imaging can be extremely valuable in certain contexts, it may not be a necessary course of treatment in the initial management of uncomplicated LBP. For the right patients, physical therapy will often prove to be an ideal alternative as the less invasive and less costly option. But perhaps even more valuable, by collaborating with a physical therapist in their own care, patients may find that the road to recovery is one they can largely walk on their own.
Bibliography
Chou, R., Fu, R., Carrino, J. A., & Deyo, R. A. (2009). Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet, 373(9662), 463-472.
Escolar-Reina, P., Medina-Mirapeix, F., Gascón-Cánovas, J. J., Montilla-Herrador, J., Valera-Garrido, J. F., & Collins, S. M. (2009). Self-management of chronic neck and low back pain and relevance of information provided during clinical encounters: an observational study. Archives of physical medicine and rehabilitation, 90(10), 1734-1739.
Fritz, J. M., Brennan, G. P., & Hunter, S. J. (2015). Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: associations with future health care utilization and charges. Health services research, 50(6), 1927-1940.
Murphy, D. R., & Hurwitz, E. L. (2011). Application of a diagnosis-based clinical decision guide in patients with neck pain. Chiropractic & manual therapies, 19(1),
Optum (2014). Conservative back treatment maximizes quality and affordability. Retrieved from www.optum.com/content/dam/optum/resources/whitePapers/ConservativeArticle_112211.pdf
Zusman, M. (2013). Belief reinforcement: one reason why costs for low back pain have not decreased. Journal of Multidisciplinary Healthcare, 6, 197–204. http://doi.org/10.2147/JMDH.S44117
