May 24, 2017

Michael Weinper: The Goldilocks Syndrome: How Much PT is Just Right for an Injured Worker?

By Michael Weinper, PT, DPT, MPH, President, PTPN

Michael WeinperIf Goldilocks were to go in search of the “just right” fit for managing a workers’ compensation claim, one of the first options she would try on for size would be physical therapy. With most injuries involving musculoskeletal problems, and back pain being one of the most common claims, PT is often used as part of the care plan for recovery.

“Right sizing” is important not only for an effective plan of care, but also for managing costs effectively. Physical therapy costs can be one of the top medical expenses in the early stages of a workers’ compensation claim and can account for up to 50% of workers’ compensation costs in the first 90 to 120 days of a claim1.

So, seeking the right balance of quality care, a fast return to work, and prudent cost management, our workers’ compensation Goldilocks will be asking questions like:

  • How much PT is too much?
  • How little PT is not enough?
  • Is it better to take a “wait and see” approach after a musculoskeletal injury, or to treat it with aggressive, early treatment as if it were a sport injury?

A possible – and incorrect – assumption may be that it is wise to avoid the use of physical therapy and instead take a wait-and-see approach, or to try medications first. However, recent research shows that there is more value in appropriately aggressive physical therapy interventions at the start of the claim, and provides important guidance for making the best decisions for using PT.

The Evidence: Early Intervention is Best
A study reported in the journal Spine describes the impact of early versus delayed use of physical therapy on patient outcomes. In this study, a national database of employer-sponsored health plans was analyzed for patients treated with physical therapy for lower back pain. The analysis found that early physical therapy was associated with reduced risk of subsequent health care treatments and costs, as compared with delayed physical therapy2.

With early physical therapy, there was a decreased risk of advanced imaging, additional physician visits, surgery, injections, and opioid medication. Not only were these complications avoided, but total costs went down. The average cost per case for treating lower back pain was $2,736.23 lower for patients receiving early physical therapy.

Another study, taken from data from the Centers for Medicare and Medicaid Services and also published in Spine, looked at more than 400,000 patients treated for acute low back pain who received physical therapy in the acute phase (less than four weeks) versus in the chronic phase (more than three months). Findings show the prompt use of physical therapy resulted in less subsequent medical services. Researchers suggested that early physical therapy may promote a greater sense of self-reliance in managing low back pain and confidence in positive outcomes, as well as preventing patients’ dependency on additional health care services and medications3.

These two studies confirm that for workers’ compensation injuries, an early and aggressive (but appropriate to the case) use of PT services is likely to lead to a faster recovery, to decrease the likelihood of surgery and to avoid unnecessary costs of more invasive treatment.

Avoid the Costs of Complications
When surgery and other procedures are not needed, the employer not only saves directly on these medical expenses, but also saves the cost of complications – and the adverse health outcomes – that can result from them.

Every surgery has the potential for unforeseen complications that can lead to further treatment, more costs, additional time off work and even a long-term disability. Moreover, with surgeries, the likelihood of a hospital-acquired infection must be considered as an undesirable outcome as well. Treatment by outpatient PT can help avoid all of these potential costly health risks.

Pull the Plug on Drugs
The “just right” approach to physical therapy may also be a prescription to avoid another major costly pitfall in the treatment of a workers’ compensation patient: the growing epidemic of opioid use, stemming from efforts to control and manage pain.

The Federal Centers for Disease Control and Prevention has strongly urged doctors to prescribe opioids more judiciously, pointing to the growing number of overdose deaths. A 2006 study of workers’ compensation cases showed that 32 injured workers who were prescribed opioids for pain had died of overdoses involving these drugs, and the strength of the average daily dose prescribed to patients had shot up by more than 50 percent. Furthermore, doctors were not monitoring these patients, they were simply increasing dosages. Overall, the physicians were not focused on treating the underlying condition4.

Another study found that of 8,443 workers’ compensation claimants with new onset, disabling lower back pain, 21 percent received at least one early opioid prescription. Those who received significant dosages of opioids were disabled 69 days longer than those who received no early opioids. The risk for surgery was three times greater and the risk of receiving late opioids was six time greater. The study concluded that the use of opioids for the management of acute lower back pain may be counterproductive to recovery5.

There are many aspects to the thorny problem of opioid abuse, among them the lack of awareness of many treating physicians of the appropriate use of opioids, prescription fraud and the subjective nature of pain. However, the fact is that in many cases, narcotics are initially prescribed to alleviate pain from ailments for which physical therapy may be an alternative. Rather than treat the symptom (pain), physical therapy gets to the root cause: the injury and imbalance in the body that can lead to recovery and a potentially pain-free life.

These research findings all point to the early use of physical therapy as a strategy that will improve outcomes and save costs. Reliance on PT rather than potentially dangerous prescription drugs can also offer a better chance for long-term pain relief without the risks of addiction, health complications and the potential for an overdose from strong narcotics that are now too often used for pain management.

The moral of the “Goldilocks” story is that too much caution in the use of physical therapy can result in a slower recovery, additional medical intervention, overall higher costs and longer time off work. On a practical level, the next question that arises is how can the workers’ compensation care manager, treating physician and/or adjuster make the best choices when determining a course of treatment in physical therapy?

Part 2 of the “Goldilocks Syndrome” will identify the practical guidelines to get the “Just right” remedy for physical therapy.

About Michael Weinper
Michael Weinper, PT, DPT, MPH, is president and founder of PTPN, the nation’s premier network of independently owned physical therapy offices, and is a nationally recognized leader in the physical therapy profession. He is also the owner of Progressive Physical Therapy, an independent outpatient physical therapy practice with four locations in Southern California.

About PTPN
PTPNPTPN is the nation’s premier specialty network of rehabilitation therapists in independent practice. It has led the rehabilitation industry in pioneering national contracting and quality assurance programs since 1985. The network has nearly 1,000 provider offices (including physical, occupational and speech therapists) in 23 states. PTPN contracts with most major managed care organizations in the nation, including insurers, workers’ compensation companies, PPOs, HMOs, medical groups, and IPAs. All members of PTPN must be independent practitioners who own their own practices. For more information on PTPN, contact Stephen Moore at 818-737-0246 or smoore@ptpn.com, or visit ptpn.com.

Notes
1Harrison, S. (2013). Monitoring Physical Therapy Treatment Can Curb Workers Comp Costs. Business Insurance. Retrieved from http://www.businessinsurance.com/article/20130811/NEWS08/308119998#full_story

2Fritz, J., Childs, J., Wainner, R. & Flynn, T. (2012, December 1). Primary Care Referral of Patients with Low Back Pain to Physical Therapy: Impact on Future Health Care Utilization and Costs. Spine, 37, 2114-2119.

3Gellhorn, A., Chan, L., Martin, B. & Friedly, J. (2012). Management Patterns in Acute Low Back Pain: the Role of Physical Therapy [Abstract]. Spine, 37(9), 775-782.

4Meier, B. (2012, April 8). Tightening the Lid on Pain Prescriptions. The New York Times.

5Webster, B., Verma, S., & Gatchel, R. (2007). “Relationship Between Early Opioid Prescribing for Acute Occupational Low Back Pain and Disability Duration, Medical Costs, Subsequent Surgery and Late Opioid Use [Abstract], Spine, 32(19), 2127-2132.

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