Prolonged, delayed, and non-evidence-based PT all worsen outcomes

Posted on: August 16 2019

Yesterday’s Business Insurance newsletter features a study of Texas workers’ compensation claims handled by a large insurance carrier.  It shows the association of prolonged physical therapy (PT) with worse claims outcomes. In particular, cases with >15 PT visits were significantly more expensive in terms of both medical costs, lost work time, and indemnity costs (wage replacement plus impairment awards) than cases with a smaller number of visits. This was true for both non-surgical and surgical claims. 

To read the full article in Business Insurance visit this link: Research links physical therapy and time off costs

The study was reported in this month’s Journal of Occupational & Environmental Medicine [Citation Below]. In the study, nonsurgical claims with 15 or more PT visits had average indemnity costs of $19,013 — nearly $10,000 more than the next costliest category of those with 10 to 14 visits.   Average medical costs for >15 visit claims were $18,494 — $10,000 greater than the 10-to-14 visit claims. Surgical claims with > PT visits had an average combined indemnity and medical cost of $71,014. This was $31,627 more than that of claims with 10 to 14 visits.

An earlier (and huge) study by US Army physical therapists showed that delay in referral for PT, the use of non-evidence based PT techniques (passive modalities and prolonged treatment) were both associated with poorer outcomes in low back pain. NOTE: This is NOT an argument for everyone to get PT;  in fact, only 16% were ever referred, and of those only half had more than one visit.) This study DOES have a lot of credibility because military PTs have no economic motivation to prolong care. However, within the therapist group, philosophies of care apparently vary as does adherence to evidence-based techniques. The patients who received prompt AND evidence-based treatment had the best outcomes. Interestingly however, prompt access to PT was MORE IMPORTANT than evidence-based treatment. Those who received treatment quickly (even if it was not evidence-based) had BETTER OUTCOMES than those who were referred late and got evidence-based PT. [Citation Below] 

For (rare) major injuries or complex surgeries in which prolonged recovery is expected, extensive rehabilitation may be necessary and appropriate for optimal recovery of function.  However, the take home message of this study is that prolonged INEFFECTIVE, UNNECESSARY treatment – often due to HALF-HEARTED participation by the patient or weak adherence to the home exercise program  — doesn’t produce good outcomes. 

Here are some ways to anticipate, recognize, prevent, and rein in excessive PT.   

1. Make sure workers are educated (and understand) the difference between hurt and harm, and how to tell which is which. Both the physician and the PT need to deliver this message: Over-protection of an injured body part can delay recovery; PT and exercises may cause discomfort while it is actually helping you recover. We all need to learn to tell the difference between our body complaining about working hard, and our body really warning us that tissues are on the verge of being damaged (e.g., torn or broken). 

2. Be clear what functional losses are causing problems now at home and at work, and aim the therapy at restoring those things.  

3. Require that the level of function be evaluated and documented at least weekly  – using specific questions, objective measures, and preferably a chart or graph that displays progress over time. “50% better” isn’t good enough, particularly if that is the report every time! A table or some other visual display of progress makes plateaus in recovery much easier/quicker to notice. 

4. Plateaus are probably an indicator that therapy is not working and either the therapeutic strategy or the therapist needs to be changed. Prolonged plateaus may be a sign that “maximum medical improvement” has occurred. 

5. Be careful not to inadvertently add chronic and pre-existing conditions to a temporary one by extending treatment to additional body areas without explicit evaluation and authorization.

 

Citations:

The Relationship of the Amount of Physical Therapy to Time Lost From Work and Costs in the Workers’ Compensation System  Leung, Nina; Tao, Xuguang Grant; Bernacki, Edward J.  Journal of Occupational and Environmental Medicine.61(8):635-640, August 2019.

Implications of early and guideline adherent physical therapy for low back pain on utilization and costs.  John D Childs1*, Julie M Fritz2, Samuel S Wu3, Timothy W Flynn4, Robert S Wainner4, Eric K Robertson5,  Forest S Kim6 and Steven Z George7.   BMJ Health Services Rsch (2015) 15:150 (Open Access)  DOI 10.1186/s12913-015-0830-3

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