Ideal care involves a partnership between the medical providers and the injured worker with the appropriate support from the claims professional. The medical providers must prescribe and provide the essential treatments and exercises to maximize recovery. The injured worker must properly follow the prescribed treatments to achieve full recovery. The claims administration should make sure that the approval and payment processes encourage quality care. This process requires accurate assessment of the injury, structured education and tutoring of the patient, and assessments of progress to ensure necessary performance by the injured worker at home.
Home exercises are the key to recovery. In-office physical therapy sessions are usually limited to a maximum of two or three sessions per week. If the injured worker does not perform his or her home exercises throughout the rest of the week, recovery will likely be substantially delayed.
If physical therapy is not prescribed, the injured worker may still be asked to work on the recovery at home. For example, the treating physician may prescribe home exercises to the injured worker, but the doctor’s only follow-up with that injured worker may be at the next doctor’s visit, which could be weeks later. In this scenario, there is no established method to ensure quality care or exercise compliance. These are scenarios when a remote monitoring solution can be crucial to ensure adherence and obtain optimum outcomes.
Obstacles to obtaining optimum physical therapy outcomes are when:
- The injured worker is mis-matched with a physical therapist who does not have the expertise needed for treating the body part injured, or when the personality of the injured worker and the physical therapist does not match.
- The injured worker does not follow the “Homework” exercise program.
- The physical therapy exercises are not the optimum treatment due to misdiagnosis or unknown underlying conditions which hinder recovery.
- There are logistics problems or gaps in medical care.
- There are communication problems between the medical providers and the injured worker.
- The physical therapy schedule does not support or facilitate light or modified duties.
- The injured worker does not have the aligned recovery goals or the correct attitude needed to achieve a full recovery.
- Intervening when the injured worker is not recovering
Best practices to achieve optimum Physical Therapy outcomes require:
Matching the right physical therapist with the injured worker.
To achieve optimum physical therapy outcomes, the qualifications and skills of the physical therapy provider should be matched with the specific injury needs of the injured worker. Matching determinants should include consideration of the provider’s expertise of treating the specific injured body part as well as the provider’s training, language skills and personality. Specific recommendations by the treating physician should be considered when matching the physical therapy provider to the injured worker.
The ability to communicate in the language of the injured worker is a key to success. Translation services can help, but fluency by the physical therapist is preferred. The larger the number of physical therapy provider options, the greater the chances for proper matching. Rural or remote workers have fewer options available. In this situation, remote or telemed options are beneficial.
The injured worker does all of the prescribed “Homework”
To maximize physical therapy outcomes the injured worker must adhere to the prescribed recovery treatment plan as prescribed by their treating physician or physical therapist, first by attending all of the scheduled in-office appointments, and secondly by doing the proper “Homework” as prescribed by the physical therapist.
A few years ago, in an effort to reduce “physical medicine expense”, the workers’ compensation industry transitioned the physical therapy process from doing a high number of sessions at the physical therapist’s office to a system that combined in-office care and educating the injured worker to do much of the therapy work at home. In theory, the outcomes from home therapy were imagined to be the same. The practical results are that many times injured workers do not achieve optimum physical therapy outcomes because they do not:
- Do their prescribed “Homework”, which is their home exercise programs.
- Understand the importance of their prescribed exercises or how to do them at home.
- Have an accurate diagnosis or are receiving the wrong treatment.
- Put full effort into their recovery due to outside motivating factors.
In the worst case, these failures result in increased medical costs, longer temporary disability periods, additional surgeries and increased permanent disability ratings.
An injured worker has the responsibility to attend treatment sessions and to do their homework. Unfortunately, many research studies confirm that adherence with home exercise programs has been shown to be very poor. Using a remote monitoring application, such as the Recupe mobile app, can improve this adherence. If injured workers do not attend therapy sessions or do not do their homework, they will likely have a longer episode of care with increased costs and reduced optimum outcomes.
Ensuring that the treatment and diagnoses are correct
Misdiagnosis results in the wrong treatment and delays a full recovery. An early indication of misdiagnosis or inappropriate treatment is if an infection is evident when pain is increasing, or the recovery is not progressing. If not properly addressed, the misdiagnosis could result in compensatory behaviors and creation of further injuries. One of the causes of misdiagnosis is when the injured worker and the medical providers do not share the same language. For instance, if the injured worker is diligently doing all the prescribed physical therapy yet is not recovering on a timely basis.
Logistics works correctly – Coordinating the medical care between the doctor and the physical therapist, as well as communication with all stakeholders
Logistics issues include the following:
- Problems with timely scheduling of the initial physical therapy appointment for the initial evaluation.
- A gap in care after a surgery. If physical therapy has not been prescribed but the injured worker is asked by the treating physician to work on recovery at home.
- If the physical therapist is not initially available due to scheduling issues.
- When there are delays in the approval for physical therapy by the payer (either at the onset of physical therapy or if the injured worker needs additional sessions).
- When the formal physical therapy sessions have ended but the injured worker still needs to continue at-home care to fully recover.
- When there are problems with the availability of the injured worker. This may be due to problems with scheduling times for the physical therapy sessions when the injured worker has other medical appointments or limited availability due to work hours (or has other
family responsibilities) and is not available during normal physical therapy business hours.
- If there are problems with transportation logistics. The injured worker does not have a convenient method to get to and from the physical therapy sessions, i.e., the distance to the therapist’s office is excessive due to living in physically remote locations.
Transportation to medical appointments can present a challenge, especially if the injured worker does not have transportation or has lost their ability to drive due to their injury. Though the workers’ compensation system is supposed to provide transportation reimbursement or actual transportation, claim administrators are not always aware of the transportation challenges which the injured worker is experiencing. Transportation challenges also require schedule flexibility. At-home exercises and Remote Therapy through mobile apps are a practical solution – the recovery exercises can be done anywhere.
Avoid gaps in the Physical Therapy care
To attend in-office physical therapy, there must be availability for appointments at accessible times and locations. When there are many physical therapy clinics with available appointment times and within a close geographic area of the injured worker’s home or work, scheduling is usually not a problem. If the employer or claims administrator is contracted to only a single-site physical therapy provider, scheduling and attending physical therapy sessions can be a significant challenge.
If treatment requests are denied the explanation should be founded on evidence-based medicine guidelines and easily understood by the injured worker as well as by the physician and the physical therapist. If the denial for treatment is based on a denial of compensability for the workers’ compensation claim, the explanation should be promptly conveyed to all parties, so no treatment is provided inappropriately.
Standardized home exercise programs can also be pre-approved by healthcare professionals and given to injured workers during any time gaps between medical examinations and the first physical therapy visit – or even in cases where physical therapy is not prescribed. Remote therapy mobile apps allow push notifications that can be sent to encourage activity, with times and sessions all customized to the injured worker.
During the recovery, injured workers may be on modified duty or have other work responsibilities. Physical therapy clinics that are only open during specific business hours (nine to five) may not have sufficient (or the necessary) times or hours to serve the injured worker’s needs. A solution to this problem is a home therapy care program that is prescribed and remotely supervised by the medical provider or physical therapist.
One of the biggest gaps in care is caused by delays in physical therapy approvals from the claim administrator. This is of particular importance when there is a request for additional or supplemental physical therapy visits. It is important for the claim administrator to make sure that all requests for treatment are immediately reviewed and appropriately approved. One challenge in approving additional care is the question of the effectiveness of the initial physical therapy sessions. Independent verification of the progress (both in pain reduction and range of motion) is an effective tool to facilitate prompt approval of additional care.
Avoiding Communication barriers
Communication barriers include the following:
- When the injured worker and the medical provider do not speak the same language.
- When the injured worker is in pain just after the injury or surgery and the medical provider or physical therapist is explaining what to do for the home exercises and the injured worker is not able to concentrate or does not fully comprehend what is being said.
- When the injured worker does not understand the medical terminology which is being used to explain the injury or treatment.
For optimum physical therapy results injured workers must be able to properly communicate with their physical therapists. This is a challenge when the two do not share the same language. In these cases, there must be appropriate translation services available. Some therapy clinics use Google Translate, while other clinics may offer a telephone translation which consists of a translator on a speaker phone translating the conversation. In-practice, having someone in the office who understands the unique medical technology and vernacular of physical therapy and also speaks the injured worker’s language is the best solution. Communicating with the injured worker in the injured worker’s native language is important for Mobile Apps as well as for remotely supervised home exercises.
Communication with the injured worker from the doctor and the physical therapist should explain the injury, set clear goals for recovery, and explain the treatment. Communication about physical therapy appointments should include the name of the physical therapist, the location of the physical therapy facility as well as the date and time of the appointments. Ideally, the appointment process should be viewable to all healthcare providers so there are no conflicts between doctor appointments and therapy appointments.
The referral to the physical therapist should include an accurate description of the injury, a description of the medical treatment, the reason for the referral and use a physical job description from the claims administrator or employer, to help set the specific treatment goals for recovery (timelines for recovery, optimum range of motion and level of pain). These recovery goals should be agreed upon with the injured worker.
The optimum recovery experience is when the medical provider, and the physical therapist and the entire treatment team share data and reports on a timely basis. One communication barrier can be if the treating doctor and the physical therapist are not using compatible medical record systems. Also, the physical therapist should keep the entire treatment team and claims administrator informed of all scheduled appointments, any missed appointments, if there are any identified obstacles (physical, or psycho-social) that may delay recovery, the injured worker’s progress, and if there are any substantial physical changes.
Electronic modes of communication between the treating team can increase success because direct communication can be difficult as the schedules in the physical therapist offices are often packed.
For home exercises, communication from a mobile app can facilitate compliance and success. For example, it should provide the medical provider and the physical therapist with up-to-date injured worker information, such as adherence to treatment protocols, pain, and range of motion. This will allow the entire treatment team and claims administrator access real-time data to analyze the injured worker’s recovery and compliance.
After the final physical therapy session, the therapist should provide a discharge report to the medical provider and the claims administrator outlining the treatment performed as well as the appropriate measurements (pain levels, as well as range of motion, on injured and uninjured parts of the body), any discernible atrophy, strength of grip, and ability to perform physical job-specific requirements as outlined in the physical job description.
Quality communication with injured workers may also include using technology that is easily used and understood by the injured worker. Cell phone ownership is a reasonable assumption and the communication process with injured workers can involve emails, texting, or voice reminders for appointments. The communication technology should be HIPAA compliant and be in the language which the injured worker understands and routinely uses to communicate.
The employee goes back to work through light or modified duties
Performing light or modified duties safely is one of the best ways to facilitate a faster and full recovery. The existence of light jobs or modified duties should be shared with the entire medical treatment team, as well as if the injured worker is performing light or modified duties. Once an injured worker is on modified duty, the employer should work diligently with the injured worker and front-line supervisors to ensure compliance with any job restrictions. The injured worker should be fully informed on self-care and follow-up care or activity limitations prescribed by the medical provider and physical therapist.
Most physical therapists are not provided with an accurate copy of the physical requirements of the injured worker’s job duties. Setting goals for recovery with specific job activities always improves outcomes. The first step in achieving proper recovery goals is to get a copy of the physical job description. It is important for the physical therapist to understand what tasks will be required of the injured worker as return to work and physical activity goals are set. In addition to achieving function and reducing pain, an injured worker’s goals must also be focused on returning to the job safely.
The system aligns recovery goals with the injured workers’ attitude
The first physical therapy session is the most important session. This is where the recovery expectations are set, deficits are diagnosed, and the treatment plan is outlined. Home exercises are key to recovery. Non-compliance with the home exercises results in recovery delays. Unfortunately, non-compliance is quite common, with one study measuring noncompliance with home exercises at 70%.* Remote supervision of home exercises is the optimum solution for this problem.
Prior to or during the first session, the physical therapist should communicate directly with the injured worker the expectations of how long sessions will take and what to expect during the sessions. At the first session, the therapist should spend time getting to know the injured worker to determine if there are any comorbidities or psychosocial obstacles to achieving recovery. The physical therapist should communicate a careful, thorough and realistic explanation of the treatment which has been prescribed, set an expectation of recovery (timelines and levels of recovery), and provide detailed descriptions of why the injured worker is performing both passive and active actions to maximize recovery. The physical therapist should also provide an explanation of why participating in physical therapy should not result in re-injury.
At every session, the physical therapist should set an expectation on how much effort the injured worker will have to exert and how much pain may be expected (both during and after the session). This is because the injured worker may experience “good pain” which is a necessary part of recovery. At the end of each session, the Physical Therapist should make sure that the injured worker understands the exact nature and extent of any physical therapy homework that needs to be performed.
At the last physical therapy session, the therapist should also make sure that the injured worker is fully aware of the extent of recovery and, if needed, how much homework may still be needed to fully recover to achieve full range of motion or reduce pain. The physical therapist should also provide insight concerning physical activities to avoid reinjury and protect the injured worker from aggravating the injury.
Much of the success for recovery involves the injured worker’s expectations and engagement in their treatment and recovery. It is incumbent on the employer, the medical providers, and the claims administrators to set clearly understood expectations for recovery and return to work.
Although Physical Therapy is extremely useful, it is not the only panacea. If there is little or no benefit after a series of sessions, then further evaluation is required. Plethy’s Recupe mobile app is an excellent option that helps solve most of these listed problems by offering exercises that were prescribed by the treating physician or physical therapist that can be performed at an injured worker’s convenience.
Intervene when the injured worker is not recovering
Unfortunately, even with the best care, further treatment interventions are sometimes still required. Diagnoses may be more complex, requiring reassessments and treatment plan modifications. The key to all these interventions is that they must be timely. Injured workers will adapt to injuries in ways that may lead them to further injuries. These mal-adaptations can lead to instances where injuries appear to jump to new body parts. To prevent damage from these mal-adaptations, improper care must be quickly identified. Early identification of developing concerns needing timely intervention is possible when there is readily available supporting data.
In addition to regular re-evaluations, remote monitoring of home exercises with a sensor, such as with the Recupe app, provides the data that may reveal these mal-adaptations. Properly intervening to correct care will result in improved outcomes and decreased costs.
Actions to improve Physical Therapy outcomes
- Understand your diagnosis and how physical therapy and prescribed home exercises will help you recover.
- Set your goals for recovery and returning to full work duties safely.
- Engage in your treatment by accomplishing all of the prescribed “homework.”
- Let your medical provider and your physical therapist know if you are not recovering as expected.
- Make sure you understand any information and instructions that you receive.
- Let your claims administrator know if there are any logistics issues preventing you from participating in your care.
- Make sure that the approvals for treatment are processed timely and communicated to all stakeholders.
- Provide a copy of the job description to the medical provider and the physical therapist to help them focus on recovery goals.
- Manage all potential logistics issues which prevent the injured worker from getting treatment on a timely basis.
- Monitor the injured worker’s prescribed home therapy compliance to determine if the injured worker is on the right path to recovery.
- Use available tools such as accessing real-time data to analyze the injured worker’s compliance and recovery progress.
- Make sure the treatment expertise is aligned with the injury and body part to ensure proper treatment of the specific injury.
- Determine if any single at-home exercise is causing pain which would hinder the exercise.
- Give consideration to suggesting alternatives if the personality of the injured worker and you are not a healthy match, or if language barriers are a barrier to proper care.
- Discuss the diagnosis and explain the treatment plan to the injured worker.
- Set expectations for pain, experience, recovery and return to work.
- Be clear on how the patient should perform the at-home physical therapy homework exercises.
- Monitor the injured worker’s home therapy compliance using realtime data.
- If the injured worker is not making projected progress according to the care plan you prescribed, check-in with the injured worker to ensure the plan is understood or seek understanding if there are obstacles to participation.
- Communicate with the claims administrator and the medical provider if the injured worker is not achieving the anticipated recovery from their injury.
- Provide the injured worker and the physical therapist with an accurate diagnosis and describe the expected treatment necessary to recover.
- Set the expectation for recovery and return to work.
- Obtain and review the injured worker’s job description and set the expectation of the patient to work towards a return-to-work recovery.
- Work with the employer on providing appropriate light and or modified duties.
- Prescribe physical therapy pre-surgery as well as post-surgery to maximize recovery from surgical interventions.
- Closely monitor the recovery progress and intervene promptly if the injured worker is not achieving the expected recovery progress.
The lead author is an employee of Plethy.
Supporting medical references:
- Reeve, J., Stiller, K., Nicol, K., McPherson, K. M., Birch, P., Gordon, I. R., & Denehy, L.
(2010). A postoperative shoulder exercise program improves function and decreases pain following open thoracotomy: a randomized trial. Journal of physiotherapy, 56(4), 245-252.
- Hernández, A. M. R., Alarcón, T., Menéndez-Colino, R., Maestre, I. M., González-Montalvo,
J. I., & Puime, Á. O. (2020). Factors affecting exercise program adherence in patients with acute hip fracture and impact on one-year survival. Brazilian Journal of Physical Therapy,
- McLean, S. M., Burton, M., Bradley, L., & Littlewood, C. (2010). Interventions for enhancing adherence with physiotherapy: a systematic review. Manual therapy, 15(6), 514-521.
- Nicolson, P. J., Hinman, R. S., Wrigley, T. V., Stratford, P. W., & Bennell, K. L. (2018). Self-reported home exercise adherence: a validity and reliability study using concealed
accelerometers. Journal of orthopedics & sports physical therapy, 48(12), 943-950.
- Essery, R., Geraghty, A. W. A., Kirby, S. & Yardley, L. Predictors of adherence to home-based physical therapies: a systematic review. https://doi.org/10.3109/09638288.2016.1153160 39, 519–534 (2016).
- Moyer, R., Ikert, K., Long, K. & Marsh, J. The Value of Preoperative Exercise and Education for Patients Undergoing Total Hip and Knee Arthroplasty: A Systematic Review and
Meta-Analysis. JBJS Rev. 5, E2 (2017).
- Chen, H., Li, S., Ruan, T., Liu, L. & Fang, L. Is it necessary to perform prehabilitation exercise for patients undergoing total knee arthroplasty: meta-analysis of randomized controlled trials. Phys. Sportsmed. 46, 36–43 (2018).
- McDonald, S., Page, M. J., Beringer, K., Wasiak, J. & Sprowson, A. Preoperative education for hip or knee replacement. Cochrane Database Syst. Rev. 2014, (2014).
- Edwards, P. K., Mears, S. C. & Lowry Barnes, C. Preoperative Education for Hip and Knee Replacement: Never Stop Learning. Curr. Rev. Musculoskelet. Med. 10, 356–364 (2017).
- Matassi, F., Duerinckx, J., Vandenneucker, H., & Bellemans, J. (2014). Range of motion after total knee arthroplasty: the effect of a preoperative home exercise program. Knee Surgery, Sports Traumatology, Arthroscopy, 22(3), 703-709.
- Calatayud, J., Casaña, J., Ezzatvar, Y., Jakobsen, M. D., Sundstrup, E., & Andersen, L. L. (2017). High-intensity preoperative training improves physical and functional recovery in the early postoperative periods after total knee arthroplasty: a randomized controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy 25(9), 2864-2872.
- Chiang, C. Y., Chen, K. H., Liu, K. C., Hsu, S. J. P., & Chan, C. T. (2017). Data collection and analysis using wearable sensors for monitoring knee range of motion after total knee
arthroplasty. Sensors, 17(2), 418.
- Fleischman, A. N., Crizer, M. P., Tarabichi, M., Smith, S., Rothman, R. H., Lonner, J. H., & Chen, A. F. (2019). 2018 John N. Insall Award: Recovery of knee flexion with unsupervised home exercise is not inferior to outpatient physical therapy after TKA: a randomized trial. Clinical Orthopaedics and Related Research, 477(1), 60.