Utilization and Payments of Office-Based Physical Rehabilitation Services Among Individuals With Commercial Insurance in New York State

Manual therapy and exercise for adhesive capsulitis: a systematic review with meta-analysis

BACKGROUND

Adhesive capsulitis (AC) affects approximately 1% of the general population. Current research lacks clear guidance on the dosage of manual therapy and exercise interventions.

OBJECTIVE

The purpose of this systematic review was to assess the effectiveness of manual therapy and exercise in the management of AC, with a secondary aim of describing the available literature present on the dosage of interventions.

METHODS

Eligible studies were randomized clinical/quasi-experimental trials with complete data analysis and no limits on date of publication, published in English, recruited participants >18 years of age with primary adhesive capsulitis, that had at least two groups with one group receiving manual therapy (MT) alone, exercise alone, or MT and exercise, that included at least one outcome measure of pain, disability, or external rotation range of motion, and that had dosage of visits clearly defined. An electronic search was conducted using PubMed, Embase, Cochrane, Pedro, and clinicaltrials.gov. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias 2 Tool. The Grading of Recommendations Assessment, Development, and Evaluation was used to provide an overall assessment of the quality of evidence. Meta-analyses were conducted when possible, and dosage was discussed in narrative form.

RESULTS

Sixteen studies were included. All meta-analyses revealed non-significant effects of pain, disability, and external rotation range of motion at short- and long-term follow-up, with an overall level of evidence ranging from very low to low.

CONCLUSION

Non-significant findings with low-to-very-low-quality of evidence were found across meta-analyses, preventing seamless transition of research evidence to clinical practice. Lack of consistency in study designs, manual therapy techniques, dosing parameters, and duration of care impedes the ability to make strong recommendations regarding optimal dosage of physical therapy for individuals with AC.

Outcomes of direct access telehealth physical therapy for patients with musculoskeletal pain: a single cohort observational retrospective study

BACKGROUND

Telehealth direct access physical therapy is becoming more prevalent in the management of outpatient musculoskeletal pain. This innovative model affords more opportunity to reach potential patients who otherwise would not be able to access services due to geographical isolation, travel barriers, and timely access to quality care.

OBJECTIVE

The purpose of the study was to investigate if pain, function, and ability to perform jobs improved after direct access telehealth physical therapy in patients with musculoskeletal pain.

METHODS

A single cohort retrospective design was implemented to offer telehealth physical therapy to patients with musculoskeletal pain from March to November 2021. Eligible patients were at least 18 years old, located in California, and had a history of peripartum pelvic dysfunction, muscle pain, joint pain, or neural symptoms. Paired-samples t-tests and the Wilcoxon signed-rank test were used to analyze normally distributed and non-parametric data (α = 0.05), respectively, to compare pretest and post scores.

RESULTS

Based on 89 participants, paired-samples t-tests showed statistically significant differences in function [t(87) = 20.71, p < .0001] and pain [t(82) = -8.15, p < .0001]. Wilcoxon's signed-rank test showed statistically significant differences in ability to perform job (Z = -7.345, p < .0001).

CONCLUSION

This study demonstrated that in a cohort of individuals with multiregional musculoskeletal pain, there was a decrease in pain and improvements in function and ability to perform job after direct access telehealth physical therapy.

We Don't Know Our Own Strength: A Survey of Strength Training Attitudes, Behaviors, and Knowledge in Physical Therapists and Physical Therapist Students

OBJECTIVE

Strength training is frequently utilized by physical therapists; however, there has been discussion about whether physical therapists utilize strength training adequately. The purpose of this study was to describe and compare the strength training attitudes, behaviors, and knowledge of physical therapists and physical therapy students and to determine how participant characteristics influenced knowledge scores.

METHODS

An anonymous survey was created in 3 rounds. For round 1, researchers used textbooks to create items assessing demographics, attitudes, behaviors, and knowledge regarding strength training. Rounds 2 and 3 consisted of feedback from 7 content experts until 80% consensus was reached; items were added, removed, or edited based on feedback. The final survey was distributed through social media, list servs, and email targeting physical therapists and students based in the United States. Response frequencies for all items were reported. Overall knowledge scores were calculated by summing correct responses for each item, with a maximum score of 13; scores <70% were considered low. Binomial logistic regression determined which characteristics (demographics, attitudes, or behaviors) influenced whether participants adequately utilized strength training principles (scored ≥70% on knowledge items).

RESULTS

There were 777 physical therapist and 648 student participants. Nearly 90% of therapists and students reported frequently prescribing strength training. Over 48% of therapists felt their professional education did not prepare them to apply strength training (compared with 24% of students), and 68% believed that strength training is inadequately applied in physical therapy (compared with 40% of students). Sixty-two percent of therapists and 55% of students scored ≥70% for knowledge items. Additional strength training education and regular participation in strength training increased the odds of scoring ≥70% on knowledge items.

CONCLUSION

Physical therapists and physical therapy students frequently prescribe strength training despite similarly low knowledge scores. To increase knowledge, greater emphasis on strength training in professional education, continuing education, participation in strength training, or all 3 is warranted.

IMPACT

Strength training is an important intervention used in physical therapy and must be used appropriately to improve the health of patients. According to these findings, strength training education may not currently be optimal, as demonstrated by low knowledge scores by both therapists and students. Further work is needed to determine how knowledge of strength training relates to patient outcomes and also how best to implement strength training in physical therapy education and practice.

Minimal physical therapy utilization compared with higher physical therapy utilization for patients with low back pain: a systematic review

Aim: Currently there is a large and perhaps unwarranted variation regarding physical therapy utilization for individuals with low back pain (LBP).  The purpose of this systematic review was to compare the effects of minimal physical therapy utilization/education (two visits or less) versus typical physical therapy utilization (three visits or more) on patient-important outcomes for patients with LBP. Methods: Two independent reviewers searched Cochrane, Medline, CINAHL, Web of Science, and PEDro from database inception until March 2017. Eligible studies used a randomized design, included subjects with LBP, and compared minimal versus higher utilization. The GRADE approach was used to provide an overall level of evidence regarding utilization. Eight articles (1153 individual subjects) met the inclusion criteria. Effect sizes for each outcome measure were calculated using Hedge's g and were adjusted for baseline values at each time period. Findings: When compared with minimal utilization, higher utilization demonstrated no significant differences on pain, disability, or quality of life at the 1-year follow-up. However, two of the three studies that analyzed cost-effectiveness found higher utilization to be more cost-effective at 1-year follow-up. Moreover, there was insufficient evidence available to investigate patient subgroups (acuity, risk for chronicity), multiple levels of utilization dosage (low, typical, and high), or intervention type. Conclusions: This review identifies the need for further research on the dosage of physical therapy among various subgroups of patients with LBP. While higher utilization may not result in significant improvements in patient-important outcomes, it may be more cost-effective for patients with chronic or complex LBP conditions when compared to minimal utilization.

Immediate Physical Therapy Initiation in Patients With Acute Low Back Pain Is Associated With a Reduction in Downstream Health Care Utilization and Costs

BACKGROUND

Physical therapy is an important treatment option for patients with low back pain (LBP). However, whether to refer patients for physical therapy and the timing of initiation remain controversial.

OBJECTIVE

The objective of this study was to evaluate the impact of receiving physical therapy and the timing of physical therapy initiation on downstream health care utilization and costs among patients with acute LBP.

DESIGN

The design was a retrospective cohort study.

METHODS

Patients who had a new onset of LBP between January 1, 2009, and December 31, 2013, in New York State were identified and grouped into different cohorts on the basis of whether they received physical therapy and the timing of physical therapy initiation. The probability of service use and LBP-related health care costs over a 1-year period were analyzed.

RESULTS

Among 46,914 patients with acute LBP, 40,246 patients did not receive physical therapy and 6668 patients received physical therapy initiated at different times. After controlling for patient characteristics and adjusting for treatment selection bias, health care utilization and cost measures over the 1-year period were the lowest among patients not receiving physical therapy, followed by patients with immediate physical therapy initiation (within 3 days), with some exceptions. Among patients receiving physical therapy, those receiving physical therapy within 3 days were consistently associated with the lowest health care utilization and cost measures.

LIMITATIONS

This study was based on commercial insurance claims data from 1 state.

CONCLUSIONS

When referral for physical therapy is warranted for patients with acute LBP, immediate referral and initiation (within 3 days) may lead to lower health care utilization and LBP-related costs.

Utilization and out of pocket (OOP) payment for physiotherapy services in public hospitals of Shahid Beheshti University of Medical Sciences

Background: Physiotherapy services constitute a principle part of health care systems, and interest in their use has increased in the recent decades. This study was conducted to investigate the utilization and OOP payment for physiotherapy services in public hospitals of Shahid Beheshti University of Medical Sciences in Tehran, Iran.

Methods: This cross-sectional study was conducted using the data of physiotherapy department of three public hospitals. The study sample included 6528 patients who had received 7257 episodes of care. Data were extracted through hospital information systems and analyzed using multivariate regression analysis by SPSS17.

Results: The average episode per patient was 1.11 and 12.6 session per episode. The average cost of each episode and treatment session was 1 784 660 IRR (USD 59) and 142 023 IRR (USD 4.7), respectively. The OOP payment share for physiotherapy was 31%. Age, OOP amount, having insurance coverage, insurance type, and service type significantly affected physiotherapy utilization. Number of treatment sessions, having insurance coverage, type of insurance coverage, and gender were related to OOP payment.

Conclusion: There is a large variety in utilization and OOP payment in the insurance funds, which could restrict the accessibility and utilization of services by patients, leading to inequalities in utilization. Therefore, policymakers should conduct an overall review on the tariffs and service packages of insurer organizations to provide better conditions for the elderly, unhealthy, and vulnerable population to mitigate inequality in service utilization and decrease OOP payment.

The Feasibility of Community-Based, Supervised Exercise Programs to Engage and Monitor Patients in a Postrehabilitation Setting

Objective. To evaluate the feasibility of disease-specific, community-based supervised exercise programs (CSEPs) to improve biometric and functional outcomes among persons with a variety of chronic medical conditions. Design. Feasibility, cohort study. Subjects were recruited through community placed flyers and provider offices. Exercise programs consisted of aerobic and resistance training that adhered to American College of Sports Medicine guidelines. A Wilcoxon signed rank test was used to assess program outcomes. Setting. Ten, community-based, medical fitness centers. Subjects. A total of 382 total participants. The number of participants in each CSEP ranged from 38 to 119. Individuals were 18 years of age or older and treated for various chronic medical conditions. Results. Varied by cohort, but generally consisted of (a) favorable changes in body composition ( P < .05), (b) significant improvements in submaximal exercise tolerance and functional outcome measures ( P < .05), and (3) significant increase in self-reported exercise behaviors ( P < .05). Conclusion. CSEPs improve outcomes in patients with chronic medical conditions and may be relevant within the continuum of care in outpatient rehabilitation medicine, particularly among bundled or value-based payment models. Further research is needed to evaluate outcomes from CSEPs versus controls.

The influence of dosing on effect size of exercise therapy for musculoskeletal foot and ankle disorders: a systematic review

OBJECTIVE

The purpose of this review was to identify doses of exercise therapy associated with greater treatment effect sizes in individuals with common musculoskeletal disorders of the foot and ankle, namely, achilles tendinopathy, ankle sprains and plantar heel pain.

METHODS

AMED, EMBASE and MEDLINE were searched from 2005 to August 2017 for randomized controlled trials related to exercise for these three diagnoses. The Physiotherapy Evidence Database scale was used for methodological quality assessment. Exercise dosing variables and outcome measures related to pain and function were extracted from the studies, and standardized mean differences were calculated for the exercise groups.

RESULTS

Fourteen studies met the final inclusion. A majority of the studies showed large effects and two small trends were identified. Patients with plantar heel pain may benefit more from a daily home exercise program than two supervised visits per week (SMD=3.82), but this recommendation is based on weak evidence. In achilles tendinopathy, a relationship was also seen when sets and repetitions of eccentric exercise were performed as tolerated (SMD=1.08 for function, -1.29 for pain).

CONCLUSIONS

Session duration, frequency, total number of visits, and overall length of care may all be dosing variables with limited value for determining effective exercise prescription. However, the limited number of studies prevents any definitive conclusions. Further investigation is warranted to improve our understanding of the influence exercise dosing has on treatment effect sizes. Future randomized controlled trials comparing specific exercise dose variables should be conducted to clarify the impact of these variables.

Low Back Pain: Investigation of Biases in Outpatient Canadian Physical Therapy

BACKGROUND

Previous research suggested that physical therapy services can be influenced by patient characteristics (age, sex, socioeconomic status) or insurance status rather than their clinical need.

OBJECTIVE

The aim of this study was to determine whether patient-related factors (age, sex, SES) and the source of reimbursement for physical therapy services (insurance status) influence wait time for, frequency of, and duration of physical therapy for low back pain.

DESIGN

This study was an empirical cross-sectional online survey of Canadian physical therapy professionals (defined as including physical therapists and physical rehabilitation specialists).

METHODS

A total of 846 physical therapy professionals received 1 of 24 different (and randomly selected) clinical vignettes (ie, patient case scenarios) and completed a 40-item questionnaire about how they would treat the fictional patient in the vignette as well as their professional clinical practice. Each vignette described a patient with low back pain but with variations in patient characteristics (age, sex, socioeconomic status) and insurance status (no insurance, private insurance, Workers' Compensation Board insurance).

RESULTS

The age, sex, and socioeconomic status of the fictional vignette patients did not affect how participants would provide service. However, vignette patients with Workers' Compensation Board insurance would be seen more frequently than those with private insurance or no insurance. When asked explicitly, study participants stated that insurance status, age, and chronicity of the condition were not factors associated with wait time for, frequency of, or duration of treatment.

LIMITATIONS

This study used a standardized vignette patient and may not accurately represent physical therapy professionals' actual clinical practice.

CONCLUSIONS

There appears to be an implicit professional bias in relation to patients' insurance status; the resulting inequity in service provision highlights the need for further research as a basis for national guidelines to promote equity in access to and provision of quality physical therapy services.

The Influence of an Active Treatment Approach in Patients With Low Back Pain: A Systematic Review

Introduction. Low back pain (LBP) is one of the most common medical conditions in the United States. Clinical practice guidelines recommend active treatment approaches; however, there continues to be a significant disparity in how patients with LBP are treated. Therefore, the purpose of this systematic review is to evaluate the reported efficacy of active treatment approaches as recommended by clinical practice guidelines on LBP treatment on patient outcomes. Methods. Between the months of June and August 2015, a comprehensive search of the PubMed, Medline (EBSCO Host), and CINAHL (EBSCO Host) databases was performed. The search was restricted to articles that were published in a peer-reviewed journal, published in the English language, examined patient outcomes with a determined scale, determined the usage of an established clinical practice guideline for LBP treatment, reported at least one outcome measure, and specified either nonspecific or acute LBP. Results. Fifty-three articles were initially identified, with 4 articles ultimately meeting the criteria after screening. Articles scored between 17 and 20 points based on a maximum total score of 26 on the modified Downs and Black checklist. Conclusion. Studies identified in this review indicate that adherence to an active treatment approach as recommended by clinical practice guidelines may result in improved patient outcomes.