By Mary O’Donoghue, Chief Clinical and Product Officer, MedRisk
Shoulder pain is one the most common musculoskeletal problems in workers’ compensation, second only to low back pain. In fact, it is even more prevalent in some industries. Like low back pain, shoulder pain has been shown to respond well to conservative care, especially physically therapy.
Strenuous work, including heavy lifting over a long period of time, carrying, pulling, or pushing can cause shoulder pain and problems. The type of repetitive overhead arm motion that warehouse workers, flight attendants and construction workers perform also contributes to shoulder issues.
Symptoms include pain at rest and when lifting and lowering the arm or with specific movements. Some patients feel weakness when lifting or rotating the shoulder or experience a crackling sensation when moving the shoulder in certain positions. Limited range of motion and/or pain associated with internal and external rotation and forward flexion can indicate a partial thickness tear of the rotator cuff. Another symptom is painful abduction, which is the movement away from the median plane of the body. Full-thickness tears are indicated by weakness of external rotation and abduction.
Until recently, surgery was the common approach to rotator cuff tears and similar shoulder injuries. Now, guided by research, clinicians are adopting more conservative methods. This usually involves a combination of physical therapy and temporarily modifying activity, such as avoiding heavy lifting or sustained overhead use of the arms.
Research shows physical therapy improves symptoms of various shoulder issues as well as surgery does at a greatly reduced financial burden for payers and with less risk of complications for patients. Six weeks after beginning an exercise-based physical therapy program, less than 10 percent of patients with atraumatic rotator cuff injuries needed surgery, according to a large study conducted by the MOON Shoulder Group. Two years later, only two percent of the remaining patients had opted for surgical repairs. A Kuhn et. al. study showed that 75 percent of patients with atraumatic rotator cuff injuries who participated in an exercise-based physical therapy program were able to avoid surgery. Additionally, the disability periods of those who did have surgery after physical therapy did not have longer periods of disabilities than occurred with a surgery-first approach.
Surgery usually requires physical therapy before and after the procedure. Rotator cuff surgery typically involves six or more weeks of sling immobilization, followed by six to 12 weeks (approximately 24 sessions) of rehabilitation. Returning to full duty usually takes about six months. Unfortunately, repair failure is common. The MOON study said that re-tear rates ranged 25 to 90 percent despite the lengthy rehabilitation time.
Exercise seems to produce the best outcomes for shoulder injuries, although the medical community does not fully understand how and why it works. It could be that exercises strengthen the muscles around the shoulder to compensate for deficiencies in the injured or degenerative rotator cuff and preserve functionality.
As with low back pain, patient education and getting patients involved in their own treatment decisions improve outcomes. A recent study by the American Association of Orthopedic Surgeons shows that surgical patients who were engaged in treatment decision making were 34 percent more satisfied with their pain management plans and 36 percent more satisfied with treatment results.
Key points to convey in the educational process are how very common shoulder pain and injuries are and that full recovery can be expected in most cases. Patients should be aware of clinical evidence that supports the benefits of a timely and aggressive physical therapy program before considering surgery and that MRI images can be misleading. Problems identified on the image may have been present prior to symptoms and may not be the cause of the pain.
Patients also need to understand how their attitudes toward treatment affect their results. A study published in the Journal of Shoulder and Elbow Surgery showed that a patient’s decision to undergo surgery was influenced more by low expectations about the effectiveness of physical therapy than by their symptoms or anatomic features of the rotator cuff tear.
Whether it’s shoulders or low back pain, conservative care and patient education are critical to a successful managed care program. They improve the quality of care, encourage compliance with treatment and help remove fear and catastrophizing and other psychosocial barriers to recovery.
About Mary O’Donoghue
Mary O’Donoghue is responsible for MedRisk’s new product and business line development as well as strategic leadership of all clinical programs and research. A dynamic industry expert, Ms. O’Donoghue joined MedRisk with over 30 years of experience in the managed care, group health, disability and workers’ compensation industries having held senior leadership positions in strategic planning, operations management and product development with top carriers, third party administrators and managed care organizations. A Registered Nurse by trade, Mary O’Donoghue brings a strong clinical background and extensive industry experience to the MedRisk team.
Based in King of Prussia, Pa., MedRisk is the leader in physical rehabilitation solutions for the workers’ compensation industry. The company’s programs deliver savings and operational efficiencies that are significantly greater than traditional programs. MedRisk, which has successfully completed a SSAE 16 Type II examination, ensures high quality care and delivers outstanding customer service. To that end, all customer service professionals, healthcare advocates and physical therapists are based in the U.S. Customers include insurance carriers, self-insured employers, third-party administrators, state funds, and case management companies. For more information, visit www.medrisknet.com or call