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Achieving Value-Based Physical Therapy

If you help manage the health care of employees, there are three words you may have come to know that leave you feeling anxious … chronic, repetitive, stress. Many musculoskeletal diagnoses may be related to chronic repetitive stress, such as tennis elbow, plantar fasciitis, anterior knee pain, trochanteric bursitis, temporomandibular joint dysfunction; and two very common diagnoses, often related to work, include carpal tunnel syndrome and rotator cuff strain. As with any physical injury, ailment or disease, the rehabilitation process can be simple and, at other times, very complex.

When you think of chronic repetitive stress, do you visualize an overtreated musculoskeletal problem, costly for the employer, draining for the patient, and enduring for you? Have you ever seen a physical therapy referral requesting continuation at three times per week for six to eight weeks, following an excessive number of visits without evidence of progress? Have you ever wondered if physical therapy would ever end? Or why the patient would continue in the absence of progress? Do you find yourself feeling as though you have no authority to improve the situation, simply because it is directed by a medical doctor? If so, you will be pleased to know that this type of physical therapy is not to be considered standard care. This article brings hope for better results.

While health care providers and consumers become more focused around outcomes, the million dollar question is, “How can one determine, in advance, the most economical and effective pathway of rehabilitation for chronic-repetitive-stress injuries?” In other words, “How can one ensure value-based physical therapy?” As you begin to understand and apply the following physical therapy guidelines within your management of chronic-repetitive-stress injuries, you should be able to contribute more effectively toward value-based health care. And you will have a better understanding of how to address any lack of quality you may have tolerated in the past.

Five Elements of Patient Management

My professional training as a physical therapist involves performing a thorough examination followed by evaluation using professional skills to identify a physical therapy diagnosis and prognosis. A plan of care is established, which includes the interventions necessary to achieve the outlined goals. The American Physical Therapy Association identifies examination, evaluation, diagnosis, prognosis and interventions as “the five elements of patient management.” Consider this to be a foundation around which you may align your expectations to achieve physical therapy outcomes that are measurable, sustainable and functional. Patients and their advocates, like you, are beginning to contribute more assertively to achieve improved health care outcomes. In part, this is related to the rising cost of health care and diminishing outcomes. These five elements may be used as a guide toward achieving positive physical therapy outcomes as well as to help identify when physical therapy may not be appropriate.

The physical therapy examination should include a history of the patient’s health care, a review of systems, and particular tests and measures. Two important outcomes of a thorough examination include: 1) To allow evaluation/determination of a physical therapy diagnosis and prognosis; and 2) To establish a measurable baseline of impairments (i.e., decreased range of motion) and functional limitations (i.e., inability to open a jar). A plan of care is then established. This includes precise physical therapy interventions that impact the patient’s impairments and functional limitations. Examples of interventions include manual therapy to mobilize joints and other tissues; therapeutic exercise to improve range of motion, strength, independent management, etc.; neuromuscular re-education to improve coordination, control, posture, etc.; aquatic therapy to normalize function with the assistance of buoyancy; and taping/bracing to improve stability and control.

The physical therapist should always have a rationale to support the utilization of each skilled intervention. Consider the rationale to be the science that supports the physical therapist’s choice of intervention. Think of each intervention as a mini-experiment in which there is a hypothesis followed by a controlled approach resulting in a measurable outcome. Comparison between the expected outcomes and the actual outcomes involves the professional evaluation process.

If care continues in the absence of constant evaluation, then it could be considered “non-skilled.” Non-skilled care is appropriately performed as a home exercise program. The home exercise program may be performed independently or with the assistance of other caregivers. Examples of caregivers include family, friends, coaches and personal trainers. It is important for the physical therapist to identify skilled versus non-skilled care, and to allocate resources accordingly, so care is cost-effective and efficient. Such conscientious utilization practices help to uphold the integrity, professionalism and value of the physical therapy profession.

Ideally, the patient will progress steadily toward the anticipated goals and expected outcomes. Since rehabilitation does not always follow a steady pathway, constant evaluation is imperative. Re-examination and plan modification is necessary at particular points of the rehabilitation process. Discharge occurs when the patient achieves the anticipated goals and expected outcomes. Discontinuation occurs when the patient is unable to progress, is no longer demonstrating progress, or chooses to discontinue.

Application of the five elements promotes outcome-based physical therapy of high value. A referral from a physician with a medical diagnosis of carpal tunnel syndrome, for instance, does not imply a particular treatment plan. It is the physical therapist’s professional responsibility to perform an appropriate examination, establish a diagnosis/prognosis, provide care accordingly, and coordinate with all members of the health care team.

Identifying Cause: A Dynamic Look

For carpal tunnel syndrome, the diagnostic process may include differentiating between: cervical spine nerve root involvement; versus peripheral nerve entrapment at the shoulder or elbow; versus entrapment of the median nerve within the carpal tunnel. Multiple impairments are typical, which may include postural dysfunction, decreased range of motion throughout the cervicothoracic spine or elbow/wrist, strength deficits, poor neuromuscular control, scar tissue, decreased flexibility, joint dysfunction, muscle imbalance, and decreased endurance. Rotator cuff strain would likely include many of the same types of impairments but would involve different tissues. For example, consider the impairment of muscle imbalance for carpal tunnel syndrome versus rotator cuff strain. Typical muscle imbalances between forearm extensors and flexors should be considered for carpal tunnel syndrome; comparatively, typical muscle imbalances between the anterior and posterior shoulder girdle musculature should be considered for rotator cuff strain.

In the case of chronic repetitive stress injuries, such as carpal tunnel syndrome and rotator cuff strain, impaired posture and/or inappropriate ergonomics are often the root cause. If so, the physical therapy diagnosis should be stated accordingly, indicating the postural influence. Think of posture as dynamic rather than static. Imagine a “snapshot” of a body segment at any given moment. Consider other body segments beyond the painful or limited segment. There is constant movement despite the first-appearance of a static position; hence posture being dynamic rather than static.

Dynamic posture involves a multitude of snapshots. Physical therapists analyze functional movement patterns, simply described as “posture,” to identify optimal versus suboptimal loading of the musculoskeletal system. Analysis of posture should not be oversimplified, nor should it be documented in a generic way (i.e., only as forward-flexed versus upright). It is the physical therapist’s professional responsibility to thoroughly document the interrelationship between all impairments and their relationship to functional limitations. It is essential to identify more than only impaired strength and range of motion and consider the influence of posture and other impairments.

Insufficient physical therapy would identify a limited number of the impairments necessary and may not include a physical therapy diagnosis at all. One or more of the five elements may be incomplete or lacking entirely. Co-morbidities such as degenerative conditions, obesity, generalized de-conditioning and stress-related diseases confound the treatment of chronic repetitive stress injuries. The physical therapy plan of care should take these co-morbidities into consideration. Coordination and collaboration with other health care professionals becomes increasingly important when multiple co-morbidities affect the patient’s prognosis. A patient-centered model of care demands all health care providers to focus on patient outcomes and leave power/control aside. Coordination and collaboration is a mutual responsibility of all health care professionals.

A Shift to Wellness

Have you envisioned an improved model of care? Do you favor a complementary- or alternative-medicine approach? Do you feel uneasy about the possibility of changing our health care model, including current insurance models? Regardless of your position regarding the future of our health care system, you might agree that “wellness” is becoming more than a buzzword. Our culture is moving into value-based health care, which demands greater outcomes from providers and greater patient accountability. It is a triangular approach toward health care, one that integrates wellness programming into worker’s compensation management and personal health care management.

This triangular approach allows access into a proactive model of health care. For example, if a person seeks care for an injury, work-related or not, treatment would be directed toward long-term lifestyle management and prevention, known as “wellness.” This constant wellness mentality would create a strong shift toward patient accountability and ownership of one’s health care, regardless of third-party liability. This would reduce the perception of entitlement and shift toward self-responsibility. Similarly, if a person were not injured and were actively managing their health through a wellness program, then worker’s compensation and personal health care utilization/costs would likely be lower. Employers could then allocate some of the savings to support more aggressive wellness programming, further empowering providers, patients and employers toward improved health and health care.

As you contemplate your role within an evolving health care system, remember it is reasonable for any member of a patient’s health care team, like case managers, to discuss the physical therapy plan of care with the provider. Identify the five elements. Although a patient may have a physical need, and even a referral from a physician, standards of physical therapy as outlined by the American Physical Therapy Association must be met. As you consider that million-dollar question of how to ensure value-based physical therapy throughout rehabilitation of chronic-repetitive-stress injuries, you should now have a clearer understanding of the physical therapy process.

Matt Knutson, PT, President of Therapy Advances Inc., provides utilization review/management and patient advocacy services to complement the case manager’s role related to musculoskeletal dysfunction. His strategies lower health care costs and promote greater provider/patient accountability. ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it )