With the evidence clearly indicating positive benefits from early use of physical therapy to decrease costs for musculoskeletal conditions, it continues to astound me when individuals get injured on the job and worker’s compensation fights against having physical therapy.

I am sure every reader of this blog has a story to go along with the following:

Chief Complaint: 28 y/o female presents with right knee pain, knee giving-way, difficulty walking and inability to work after injuring her right knee while at work on August 30th, 2014.

MOI: Pop in knee with immediate pain while turning her body.  She is a cook at Pizza Hut and is on her feet twisting/turning all day making pizzas.

Initial action: Continued to work through pain and RICE principle once she returned home.   Symptoms did not improve so sought care from ER (she doesn’t have PCP).  Initial diagnosis of knee sprain with referral to orthopedic physician.

Secondary action: Consult with orthopedic physician who performed cortizone injection in the knee (relief only 1-2 days), prescription for patella stabilizing knee brace, and prescription for MRI.

Tertiary action: MRI read showing a small meniscal tear and a previous subluxation of the patella.  Referral to physical therapy.

Quaternary action: As soon as my office received the order, we proceeded with obtaining authorization.  It took two weeks and multiple calls by my office to get approval due to lack of return calls and communication by worker’s compensation.

Quinary action:

Initial evaluation for physical therapy finally performed on November 13, 2014—-YES, 75 days after injury.

Oh it keeps getting better.

Notable initial evaluation findings:

Medication usage: Norco and Mobic 3 times/day.

Sleep: Over 50% of night disturbed due to waking from knee pain.

Walking: Patient is unable to walk at all without pain.

Standing: Patient is unable to stand > 15 minutes without having to sit due to pain.

Pain rating: Current: 6/10, Worse: 10/10, Average: 6/10

Disability per Lower Extremity Functional Scale: 24/80. I calculate this as 70% disability.

After 4 visits (3 week span) of Physical Therapy:

Medication usage: none.

Sleep: No difficulty sleeping now.

Walking: Patient is able to walk 45 minutes without having to sit due to symptoms/fatigue.

Standing: Patient is able to stand > 60 minutes without having to sit due to symptoms/fatigue.

Pain rating: Current: 0/10, Worse: 4/10, Average: 1/10

Disability per Lower Extremity Functional Scale: 59/80. I calculate this as 27% disability.

Let’s break this down for typical medical care:

Time-frame of injury to initial PT evaluation : 75 days

Healthcare costs of an ER visit, 4 additional orthopedic physician visits, knee brace and MRI : exponential

Time and income lost from 86 days out of work : exponential

Disability and pain: No different

Let’s break this down for physical therapy:

Time-frame thus far: 21 days

Healthcare costs of PT for 4 visits: MUCH less 

Disability: Per LEFS, down from 70% to 23%

Pain: Average down from 6/10 to 1/10

Function: Increase standing and walking time by 3-5 fold

Sleep: Was 50% reduced, now normal. The benefits of overall health are astounding.

 

Plan: Return to work in 2 weeks while continuing PT to improve balance, remaining pain, strength, confidence and reduce fear of re-injury while at work.

Courtesy: HighStakesBassin.com

Up one on me! Give me your current story on ridiculousness for America’s workers.

 

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3 comments

  1. you’re lucky Harrison. Usually at this point their ‘pain’ never goes away and they get disability the rest of their lives. Good job!

    1. Yes, I agree Lenny! I think this is a case of where she just needed the right “medicine” vs continuing to get differential diagnosis through imaging and clinical exam. Some cases, just like this, in which our treatment is differential diagnosis.
      Thanks for reading!
      H

  2. Harrison, I deal with worker’s comp a lot, mostly when i am trying to work with high level laborers who have finished orthopedic therapy but are needing to transition into work conditioning type programs to get them to the level of fitness needed for readiness to return to work. It’s stroke producing frustration that I get sometimes with L&I (Labor and Industries) with getting authorization. I have found that often people regress when they are out of therapy waiting on authorization (whether this is due to not doing their program as I asked, or simply not having the therapeutic touch and guidance I don’t know but I see it clinically) and we have to work to get back to where we ended with the completion of the first dosage of visits. What is crazy, is this costs them more money in the long run to delay authorization, yet they are tight fisted about giving out visits? Makes no sense!! For a healthcare system that is supposed to be “evidenced based” clearly no one in worker’s comp is taking the time to read the literature. I figure the burden falls on us to tell them and be able to send them data on what we can do and maybe with a grassroots effort like this we will change things..
    What kills me is the national managed care effects… Do you have Care Core in Virginia? I had a patient with a diagnosis of ACL tear (both on PE and confirmed with imaging) and they gave me like 4 or 6 30 minute visits?!?!?! What kind of deal is that? Its maddening man, I feel ya.. C’mon man!!

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