Oct 5, 2021 | Insights
Communication is the heart of the relationship between a physical therapist and patient. Here are four guidelines to help improve patient conversations—and create superior outcomes.
After an initial evaluation, PTs will typically prescribe exercises and provide low back pain (LBP) patients with information about their diagnosis, prognosis and plan of care.
A positive interaction between the patient and physical therapist during this evaluation has been linked with reduced pain and disability, as well as a higher satisfaction with treatment. In fact, studies have shown that the initial evaluation process may produce small but significant therapeutic effects related to pain, fear-avoidance and functional measure of mobility and sensitivity.
But this is only true if the therapist successfully delivers the advice and the patient receives and retains the intended message.
Unfortunately, there are cases in literature that show inconsistencies between a PT’s self-assessment and a patient’s perception. This is not just a communication breakdown but a risk to the patient’s overall care.
For example, patients with spinal problems need to understand that back pain is generally benign and activity is key to recovery. If they do not perceive this message, they have a higher risk of disability and lower treatment satisfaction 6 months after treatment.
In a study published in Wiley Physiotherapy Research International, all patients remembered the PT’s first piece of advice, with diminishing retention for the second and third pieces of advice. Simultaneously, PTs underestimated success of message delivery in the first and second items of advice and overestimated success for the third.
While the disconnect may have been marginal in this study, there were a number of factors at play that enhanced the patient-therapist interaction. Based on this research, here’s what can be done to ensure PTs successfully communicate and patients actually listen.
How to Make Sure Patients Listen: Four Guidelines
#1. Use Shared Decision Making
Shared decision making is a consultation process in which a clinician and patient work together to make a health decision. It involves discussing options, benefits and harms and considering patient values, preferences and circumstances.
Taking a collaborative approach of the clinical evaluation and involving patients throughout the diagnostic process helps ensure that the patient understands what the provider recommends—thus bolstering retention of advice and exercises.
#2. Prescribe Simple Exercises
It’s one thing to retain a provider’s advice for managing LBP. It’s another to actually follow it.
Patients are more likely to participate in exercise programs that consider their preferences, circumstances and past exercise experiences. With that said, patient adherence improves when providers prescribe:
- A limited number of exercises
- Simple yet effective exercises
- Exercises that are easy to include in daily life
#3. Address Patient Concerns
A patient’s worries, fear-avoidance, individual beliefs and experiences with LBP can negatively impact their prognosis and overall treatment outcomes.
For example, a patient may be influenced by a family member’s experience with similar pain.
It’s important to have a dialogue about these concerns and then develop specific and reasonable management strategies that addresses a patient’s worries.
#4. Identify & Address Patient Expectations
Finally, patients come into physical therapy with a set of expectations.
For the most part, patients expect specific, tailored exercises. They also expect investigations that lead to a diagnosis and an explanation of what actually caused it.
Opening a dialogue about these expectations—and addressing them—will further improve communication and patient outcomes.
Conclusion
Patient-therapist communication is critical and it all starts at the initial evaluation. As the industry continues to prioritize patient-centric care, it’s important to engage the patient from the beginning to ensure that they hear and understand the diagnosis and treatment.
Because when patients remember what PTs tell them, they are more likely to adhere to exercises and see improvements with their LBP.
MedRisk’s patient-centric approach to managed physical medicine starts with its PT Consult service: a consultation between an on-staff PT and the patient in advance of treatment. PT Consult prepares patients for what PT is like and the physical benefits it brings, such as strength, pain relief, mobility and recovery. There is a screening for any psychosocial factors that could impact recovery and the consultation helps set the patient’s expectations for therapy and what the recovery journey may look like, establishing a positive mindset as they get ready to start with their MedRisk provider.
Supp, G, Schoch, W, Baumstark, MW, May, S. Do patients with low back pain remember physiotherapists’ advice? A mixed-methods study on patient-therapist communication. Physiother Res Int. 2020; 25:e1868.
https://doi.org/10.1002/pri.1868
Sep 9, 2021 | Insights
For patients with a new episode of neck pain, initially consulting with a nonpharmacological provider (physical therapist or chiropractor) may decrease opioid exposure.
Neck pain is an immense physical, social and economic burden, regarded as a major public health problem. In fact, half of all individuals will experience a clinically important episode of neck pain at some point in their life, and 80% of those people eventually seek care. Despite this prevalence, there has been no consensus on the type of provider a patient should see first for care—a key indicator of downstream healthcare utilization. On top of that, there are the ever-present dangers of opioid addiction, which has been identified as a public health epidemic.
To address these problems, a study published in the Mayo Clinic Proceedings: Innovations, Quality & Outcomes journal aimed to determine the connection between the type of provider initially consulted and 1-year, downstream healthcare utilization to inform future care recommendations.
In the study, Horn et al investigated a retrospective cohort of 1,702 patients with a new episode of neck pain over a 1-year period. The researchers then separated those patients into groups based on who they consulted first: primary care provider (PCP), physical therapist (PT), chiropractor (DC), or a specialist.
The study found that the practitioner consulted at the index visit for neck pain can have an impact on downstream healthcare utilization. More importantly, the researchers found that, when compared to an initial neck pain consultation with a PCP, an initial consultation with a nonpharmacological provider (DC or PT) is associated with a decrease in opioid use 30 days and 1 year after initial consultation.
These findings are consistent with recent guidelines, which favor nonpharmacological interventions. In light of the opioid addiction epidemic, stronger alignment of PTs and DCs as front-line providers by healthcare systems may be needed.
MedRisk’s PTConsult services support this goal by proactively identifying and solving for issues through a telephone consultation and screening process. PTConsult takes or recommends the best course of action to eliminate obstacles to recovery and reduce total claim cost and healthcare utilization.
To read the full article, click here.
Horn ME, George SZ, and Fritz JM – Influence of Initial Provider on Health Care Utilization in Patients Seeking Care for Neck Pain
Mayo Clin Proc Innov Qual Outcomes. 2017 Dec; 1(3): 226–233.
Sep 3, 2021 | Insights
Physical therapists can empower patients with chronic musculoskeletal disorders by supporting effective self-management.
Persistent musculoskeletal disorders—including spine-related neck and back problems—are painful to patients and costly for workers’ compensation payers and society as a whole. Among occupationally active adults, musculoskeletal disorders are the main causes of disability. Often work related, they can lead to lost time and reduced productivity.
Biomechanical and psychosocial risk factors often influence musculoskeletal disorders. That’s why, as an article published in the Journal of Orthopaedic & Sports Physical Therapy argues, a person-centered approach focusing on self-management strategies is so essential to helping patients restore and maintain function.
In the paper, Barlow et al outline the physical therapist’s (PT) role in supporting effective self-management. The authors define self-management as “the ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition.”
As experts in musculoskeletal disorders, PTs are ideally positioned to provide self-management support that focuses on teaching skills that patients can use to manage these conditions on their own. In this approach, PTs help patients understand their conditions and the biomechanics of them while promoting behavioral changes and active lifestyles.
PTs help patients develop a patient-preferred approach to physical therapy exercises to improve function and strength, reduce pain, and increase well-being. The goal is for the patients to develop their own strategies to reducing their symptoms. Techniques may involve exercise, pain management, cognitive behavioral therapy, shared decision-making, acceptance, problem-solving and/or mindfulness, and other techniques. It’s all very individualized.
With self-management, PTs provide support as the patients set goals, recognize barriers to achieving them and learn how to measure the effectiveness of their own self-management. This provider-patient partnership is an essential component of this approach.
As the leading provider of managed physical medicine for the workers’ compensation industry, MedRisk stays abreast of industry trends such as this. By so doing, we continue providing our carriers, TPAs and employers access to the best national network of credentialed PTs in the workers’ compensation industry.
To read the full article, click here.
Promoting the Use of Self-management Strategies for People with Persistent Musculoskeletal Disorders: The Role of Physical Therapists
Nathan Hutting, Vernerian Johnston, J. Bart Steal, and Yvonne F. Hearkens
Journal of Orthopaedic & Sports Physical Therapy 2019 49:4, 212-215
Aug 4, 2021 | Insights
Adherence to established clinical practice guidelines could reduce high downstream healthcare utilization.
Musculoskeletal pain as a whole is a common and costly health condition. Up to 84% of the general population will report at least one episode of low back pain (LBP) at some point in their life. This high rate of LBP treatment also has high downstream costs. An article published in PLOS One systematically reviews a collection of peer reviewed studies to evaluate the influence of physical therapy guideline adherence on healthcare utilization and costs for LBP patients.
Hanney et al conducted an electronic search across various peer-reviewed journals to assess current evidence on how guideline adherence affects LBP costs. The authors identified seven primary factors for healthcare utilization and costs:
- Number and duration of PT visits
- Prescription medication use
- Physician office visits
- Emergency department care
- Advanced imaging
- Surgical procedures
- Injection procedures
With some exceptions, the review showed that those participating in an adherent PT treatment program experience lower healthcare utilization. This includes fewer and shorter PT visits, fewer medications, fewer visits to the physicians or emergency department and less use of advanced imaging, surgical, and injection procedures.
While further research is needed to provide firm evidence on the impact of guideline adherence among patients with LBP, this preliminary evidence is a great step towards optimized effectiveness and efficiency in value-based healthcare systems.
That’s why MedRisk invested in the development and on-going maintenance of physical medicine specific evidence-based treatment guidelines. These guidelines take into consideration chronicity (the age of the injury), complexity (multiple body parts and/or comorbidities), severity and surgery. They also address the best treatment choice, timing, and sequence of interventions. Their specificity make them a valuable supplement to ODG, ACOEM, and state-specific guidelines. MedRisk’s proprietary guidelines, developed and maintained by our International Scientific Advisory Board, allow us to proactively identify cases that may be trending off track and support clinical decision-making—ultimately eliminating unnecessary downstream utilization and costs.
To read the full article, click here.
Hanney WJ, Masaracchio M, Liu X, Kolber MJ. The Influence of Physical Therapy Guideline Adherence on Healthcare Utilization and Costs among Patients with Low Back Pain: A Systematic Review of the Literature. PLoS One. 2016 Jun 10;11(6):e0156799. doi: 10.1371/journal.pone.0156799. PMID: 27285608; PMCID: PMC4902217.
Jun 3, 2021 | Insights
Psychosocial factors—including fear of movement and anxiety about the future—are an expected and normal part of LBP experiences.
Low back pain (LBP) interventions are often categorized as “physical” or
“psychological,” creating a potential barrier to recovery in some patients who may be inhibited by these psychosocial factors. An article published in the British Journal of Sports Medicine challenges this separation, stating that understanding and addressing psychosocial factors in clinical practice can help better optimize patient management.
In the research, O’Keeffe et al investigated how psychosocial factors do not always indicate mental health disorders and are not distinct from biological factors. Reductions in pain and disability after treatment are, to some degree, facilitated by changes in non-physical factors, like self-efficacy. For example, exposure to a specific movement that the patient fears paired with an empowering narrative from the provider can reduce the associated fear or anxiety.
The study also argued that psychosocial factors do not only appear in persistent pain presentations. In fact, the authors, who included Steven Z. George, PT, PhD, FAPTA, a member of MedRisk’s International Scientific Advisory Board (ISAB), said that psychosocial factors are an expected and normal part of LBP experiences, acute or chronic.
Psychosocial factors may be just as important to consider as “other factors” when a patient “fails” during “normal” treatment. Exploring and addressing these factors at the front end will ultimately drive more successful patient outcomes. This research supports MedRisk’s PTConsult, a service that makes adjusters aware of any psychosocial factors and provides patient education on the importance of physical therapy, treatment expectations and any perceived barriers to recovery (including anxiety).
To read the full article, click here.
O’Keeffe M, George SZ, O’Sullivan PB, et al Psychosocial factors in low back pain: letting go of our misconceptions can help management. British Journal of Sports Medicine 2019;53:793-794.
Jun 3, 2021 | Insights
How can MedRisk services help streamline treatment for neck injury patients? Manager of Clinical Services Suzanne Sadusky, PT, DPT, shares the important role her team plays in injured worker recovery.
This blog is part 3 of a 3-part series titled “Neck Injuries in Workers’ Comp: Managing Pain and Controlling Cost.”
Neck injury can be a complex treatment area for physical medicine clinicians. From headaches to nerve pain, the symptoms of neck injury can be wide-ranging, which can increase the cost of diagnosis and treatment if not managed appropriately.
MedRisk aims to simplify the pathway to recovery for injured workers, including those being treated for neck injury. We sat down with Suzanne Sadusky, PT, DPT, MedRisk’s Manager of Clinical Services, to discuss the journey of a neck injury referral and how MedRisk supports streamlined, cost-effective treatment every step of the way.
1. Pre-Treatment Services
As soon as a referral is made, MedRisk gets to work in matching the patient with an appropriate provider based on specialty, location, and availability – within an average of 4 hours. This helps patients be seen for an initial evaluation within 2.6 days of referral. First, the patient may consult with one of MedRisk’s on-staff physical therapists prior to treatment. During this dialogue, the PT can identify things that could impact recovery, such as prior surgeries, existing ailments, and psychosocial factors such as depression or anxiety. Notes from the consult are delivered to stakeholders in a comprehensive report, which allows these insights to be considered in developing an optimal treatment plan. In addition, the PT uses the consultation to educate the patient on the treatment process, set expectations for recovery and encourage patient participation and compliance.
“We try to alleviate any anxiety about starting therapy and answer their questions,” Sadusky said. “We are not the treating therapist and we are not the insurance carrier. We are a third party, which puts us in a unique position.”
2. Clinical Oversight
As the first company to introduce evidence-based guidelines for managed physical medicine, MedRisk is committed to keeping treatment guidelines up to date. The company’s proprietary guidelines, which are categorized by body part, are assigned to every case that opens at MedRisk, and they help set expectations for the number of visits and the amount of time that is expected for recovery. The guidelines were developed by and are maintained by MedRisk’s International Scientific Advisory Board (ISAB), an elite panel of world-renowned specialists in physical medicine and workers’ compensation who oversee all clinical aspects of MedRisk’s medical management programs. The group meets regularly to review current scientific literature and new treatment protocols and vet MedRisk’s guidelines, which are specific to physical therapy and workers’ compensation.
“The guidelines go a long way in keeping treatment on track. However, there will always be instances when patients do not progress as expected,” Sadusky said. In these cases, Sadusky’s team is called upon to do a clinical review. During this process, the team reviews the case documentation and reaches out to the treating therapist to discuss whether additional therapy is necessary. With these insights in hand, MedRisk is then able to provide recommendations to adjusters on how to optimize treatment moving forward.
3. Telerehabilitation
Telerehabilitation has become a more standard component of treatment throughout the pandemic, and according to Sadusky, the benefits will hold up well into the future.
“During COVID, it often wasn’t always safe or possible to be in the clinic, and it really showed how telerehab can support continuity of care,” she said. The option of receiving PT services from home can help patients avoid gaps in treatment, maintain steady progress, and control their symptoms in the expected timeframe. In the case of neck injury, patients may receive equipment, including TheraBands, an exercise ball, and weights, with instruction for self-management and advanced strength exercises through a virtual PT appointment. This allows patients to avoid common pitfalls that could have derailed in-person treatment, extended the duration of the claim, and potentially delayed return to work.
Conclusion
What presents as neck pain can often be more complex than meets the eye, as the injury can sometimes involve the shoulder or spine. When treating a clinically complex injury, it’s important that treatment plans are both patient-centered and streamlined. Through MedRisk’s managed physical medicine services – communication with patients and stakeholders, clinical oversight, and telerehabilitation – a more predictable and cost-effective path to recovery can be achieved.
About Suzanne Sadusky, PT, DPT
Suzanne is a licensed physical therapist. She has worked at MedRisk for over 6 years and is currently the Manager of MedRisk’s Clinical Services team. Her team is responsible for performing clinical reviews and providing documented recommendations based on use of appropriate clinical guidelines. Suzanne holds a Doctor of Physical Therapy degree from Boston University and a Bachelor’s in Health Studies degree also from Boston University. Prior to joining MedRisk, Suzanne worked in a variety of settings as a physical therapist. These include outpatient orthopedics and workers’ compensation, acute care, and acute inpatient rehabilitation, as well as independent living and skilled nursing facilities. She has also been involved in facilitating online learning through Boston University’s transitional DPT program.
