By William Rabb

Early physical therapy sessions can mean significantly improved outcomes and lower costs for injured workers with lower-back pain, says a study by the Workers’ Compensation Research Institute that examined almost 26,000 claims.

After controlling for a number of factors, “we conclude that for workers with lower-back pain-only injuries for which physical therapy is indicated, PT within 14 days after injury is likely to be beneficial,” and is associated with lower utilization of medical services and shorter disability duration, the study’s authors wrote.

The WCRI researchers said they believe the report, released Tuesday morning, is the most comprehensive study of the effect of physical therapy timing on the workers’ compensation population. It seeks to help settle questions that have been raised by other reports in recent years on when PT is most effective for back pain. WCRI cautioned that further clinical studies are needed.

The research already has created a buzz in the workers’ compensation world. Dr. Stephen Norwood, editor-in-chief of the Official Disability Guidelines, published by MCG Health, said Tuesday that he had been receiving emails about the study all day.

“On first glance, this looks very compelling,” he said. “If, on further review, we determine that the quality of the study is good, then it would be logical to encourage early use of PT for lower back pain in our guidelines.”

The study said that for many claims, the biggest impact was observed when physical therapy was started four to seven days after the injury. And, when workers wait more than 30 days to start therapy sessions, the costs increased significantly with more magnetic resonance imaging, opioid prescriptions, injections and surgery.

Even attorney involvement and attorney fees were almost double for workers who waited more than 30 days, compared to the those who received physical therapy sessions early on.

The average payment per claim for medical services for those who delayed PT more than 30 days was $5,337, about 28% higher than for workers who started physical therapy in four to seven days. The average number of weeks of temporary disability per claim was almost double that of the early intervention group, the study found.

The report looked only at low-back pain claims, but the authors suggested that similar approaches can be considered for other musculoskeletal injuries. The study also suggested that the findings may encourage claims adjusters, case managers and doctors to pay closer attention to workers who have not received PT within two weeks after an injury.

“The results of our statistical analysis could also assist payers in the development of their predictive models that may help improve medical care and outcomes,” wrote the WCRI researchers, Dongchun Wang, Kathryn Mueller and Randy Lea.

The study could have a lasting impact, said Greg Gilbert, chief reimbursement and government relations officer for Concentra, a nationwide occupational health company.

“This should be the standard of care demanded by the payer and the employer,” he said. “They should expect musculoskeletal injuries, with work restrictions and functional deficits, to receive early active rehabilitation.”

He also hopes that the data will loosen some requirements set by regulators and by insurers that require prior authorization for some physical therapy.

The report could also lend new momentum to physical therapists, who have urged federal and state regulators to adopt permanent rules that would allow the rehab when provided through telemedicine, to be fully reimbursed.

The Texas Division of Workers’ Compensation last month temporarily extended its own rules to reimburse telemedicine physical therapy, occupational therapy and speech therapy services. But the Centers for Medicare and Medicaid Services has said federal law does not allow the therapists to be eligible telehealth providers.

That affects workers’ comp because a number of states, such as Texas, link workers’ compensation reimbursement to what Medicare pays.

The WCRI study notes that lower-back pain has been the leading cause of disability in the United States, costing more than $100 billion a year in medical expenses, lost wages and reduced productivity.

And while more injured workers are receiving physical therapy than ever before, questions have remained about PT’s impact on utilization and outcomes.

Studies have reached different conclusions about PT. Some in the early 2000s suggested that therapy should be delayed for back sprains and strains. More recent reports found at least some connection between delayed therapy and recurrence of back pain and higher medical utilization, the WCRI study explained.

“Robust data on PT visits has been sorely lacking,” MCG’s Norwood said.

A 2019 study found that a large number of physical therapy sessions — more than 15 — is a strong indicator of claims that will have high medical costs. But that study did not examine the timeliness of physical therapy.

The great value of the WCRI report is that it focused exclusively on workers’ compensation claims, said Mary O’Donoghue, chief operations officer for MedRisk. The company manages care for injured workers and has long recommended early PT.

The study’s findings “shows that the whole conservative care movement is really taking hold,” she said.

For many injuries, in years past, the first option was often surgery or opioid-based pain medications, she said. Now, more providers, adjusters and insurers are recognizing the value in physical medicine, O’Donoghue noted.

It’s important now to educate providers and claimants about the benefits of early physical therapy, and the WCRI study should help get the word out, she noted.

Insurers, adjusters and case managers can also make a difference by facilitating how quickly an injured worker is sent to a doctor, and how quickly physical therapy is scheduled once a physician prescribes it, Wang, the WCRI study’s lead author, said in an email Tuesday.

Some treatment guidelines, including ODG and the American College of Occupational and Environmental Medicine’s guides, along with some states’ opioid prescribing guides, have long recommend physical therapy as part of a conservative approach before invasive procedures are chosen.

But recommendations are not the same in all states. The New York Workers’ Compensation Board’s treatment guidelines for low back injuries, for example, were adopted in 2014. They call only for a “maintenance program” of physical therapy or as a prerequisite before disk surgery is recommended. The guidelines do not specify time frames for PT.

The WCRI’s study underscores the growing recognition in occupational medicine that delays in care can result in a “disability mindset” and prolonged recovery, said Phil LeFevre, MCG Health’s managing director.

Norwood said MCG is in the process of forming an internal working group to re-examine its physical therapy, occupational therapy and chiropractic care guidelines. It might take six months, but the effort could produce an overhaul that will reflect the data in the WCRI study and other studies, he said.

The WCRI study is free for members of the Institute and can be purchased by non-members here.


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