It's not on yet? Yeah, we're ready. We're ready to roll. Everybody's ready. Okay. Good morning, everybody. I'm David Hoyle. My father was a Methodist minister. It's Sunday morning and it reminds me of church because everybody's to the back. I've got a few announcements that they've asked that I read off before I introduce our panel today. So from a housekeeping standpoint, this session is being streamed. So virtual attendees, welcome to anybody who may be out there. If you haven't already, please download the AOHC 2023 event app. It's called Swap Card. It'll tell you everything you need to know about the meeting. If you need assistance, go to the ACOM membership booth in the foyer on this floor. You can evaluate and claim credit by navigating to this session in the meeting app. There's a link in a neon green towards the bottom left within the session. Restrooms are located on either side of the main foyer out behind you. And ACOM staff have red lanyards and buttons identifying them. Let them know if you need any assistance. You can also go to the membership booth on this floor for assistance. So I'm happy to be here today to work with the panel to discuss assessing and overcoming psychosocial barriers to recovery from musculoskeletal injuries. I'm David Hoyle. I'm a physical therapist by training. I work for Select Medical, the largest outpatient provider of physical therapy in the country. And this is a very specific interest of mine that I've been spending a lot of time over the last probably 10 years trying to educate our clinicians on and provide them with tools that they can use to better manage work comp claims. I am in practice in Storrs, Connecticut at six hours a week. And then the rest of the time is spent working more on national initiatives. I'd also like to have our panel introduce them. So Dr. Francis Burke, if you'd give yourself an introduction. Well, my background is I started out in emergency medicine about 18 to 20 years and began doing occupational medicine on a part-time basis back in 1983. And at that point, I was good friends with the president of the American Occupational Nurses Association. And Suzanne Smith was kind enough to pass me around to all the major refineries and chemical companies in the Philadelphia area. So I had worked on some work for Arco, Golf, British Petroleum, and really understand the exposures in that industry. And then I had a practice for a number of years where I began full-time occupational medicine after working in level one clinical trauma centers, where each day I had a different specialist, a former head of knee surgery, a pen, working in my office one day, a shoulder surgeon, two hand surgeons, and PM&R. So they were a great wealth of information in terms of teaching me and educating me on neuromuscular diseases and treatments. I currently serve as the medical director for concentric in the Philadelphia center city area and have continued to work with them in terms of improving our programs for therapy and rehab and identifying these types of issues that will be beneficial for treating difficult patients in a form of this category. Thank you very much. Good to have somebody local here representing Philly. Next, we have Adam Seidner. Hello, I'm Adam Seidner, and I'm an occupational environmental physician. I'm currently the chief medical officer at the Hartford. I've been involved with the payer side for over 26 years now, and I'm still educating physicians, family medicine, and occupational environmental medicine, as well as medical students. I'm involved with a number of academic institutions around the country to research and answer critical questions to help prevent delayed recovery and return injured workers back to function. Thanks, Adam. And then Miranda Kofeldt. Hi, I am a clinical psychologist with a background in behavioral medicine, addiction recovery, health behavior change, and trauma-informed care. I'm currently the vice president of clinical services at Estella's Behavioral Health, where we connect injured workers to behavioral health care providers in order to aid in their return to work and recovery, improving their functional status and overcoming psychosocial barriers that are getting in the way of getting back to full duty. Thank you. Disclosures, as required, are up. Very few. And the way we've set this up is to kind of present some information about what the problem is and why we need to address this. Then we're going to go into some ways to screen for these kind of problems, and then finally talk about solutions. We would love to have involvement from you all and hope to save some time at the end where you can ask some questions. But if you have anything that's burning at the moment, feel free to jump in. So disability, due to musculoskeletal problems, is a huge issue in the United States, with more than 9 million US citizens on Social Security disability. And that number continues to grow. The vast majority of those are considered by the Social Security Administration as being workers. The largest part of those, and the quickest growing part, is actually musculoskeletal injuries, which has overtaken other conditions, such as cardiovascular and cancer. In terms of work-related injuries, again, there's over a million recordable cases to OSHA in a given year. And about a quarter of those, or a little bit more, are actually musculoskeletal in nature. This is, in terms of recovery, when claims managers were asked a number of years ago, what was the number one problem in terms of resolving claims and getting people back to work, the answer was psychosocial issues. Recently, this study was updated. It's been replaced by the availability of transitional work, with psychosocial factors still up towards the top of the list. In terms of psychosocial factors, we need to really think about more of a biopsychosocial model in terms of care, where most of us are medical professionals, so we get the whole biological component, the injury, the red flags, things that might make us think it's going to be a prolonged recovery from a standpoint of the nature of the injury. Spinal cord injuries, TBIs, full rotator cuff tears in an elderly individual, or an elderly worker, or an older worker, which I put myself in that category because I'm over 55. But then there's these other things, these psychosocial factors. And so we're going to concentrate predominantly on psychological things in this talk today, but we'll touch a little bit on social things as well. So here's some of the psychosocial barriers that we're going to look at. So fear of pain, which can ultimately lead people to inactivity, which can lead to things like deconditioning, and also lead to kinesiophobia. Job dissatisfaction, kinesiophobia, which is fear of movement, anxiety, perceived injustice. This shouldn't have happened to me. This isn't my fault. It's somebody else's job to take care of this because I'm not responsible for my injury. Depression, recovery expectations, self-efficacy, which, again, a lot of the control in the work comp environment is taken away from the individual worker, and things are prescribed for them. They're sent to providers, and a lot of their choices are removed. And then distress. So we want to set the stage here with the type of person that we're talking about. And we're going to use back pain as an example. So let's say we've got Bob and Jim. They both work maybe as CNAs in a hospital, and they're transferring a patient. Something happens during that patient transfer that they both end up having kind of an awkward movement, and they both feel like they've strained their back. Bob goes to employee health and lets him know that he's got a little problem, but returns to work that day or the next day, whereas Jim goes and lets them know that he can't possibly work and is sent to a specialist where there's imaging done. And they're sent to therapy. And beyond therapy, when they fail to recover adequately, they end up having more imaging, and ultimately may end up with spinal fusion and never go back to work again. They both work at the same location, so social factors, a lot of those will be similar. But what's going on that causes one to respond one way to a similar trauma and the other one to respond a different way? So what we want to talk about is identifying these risk factors for delayed recovery, and then ultimately talk about the ideal scenario in terms of providing the assistance that these people need to get back on track. There's a lot of screening tools out there that are self-report measures. I actually have instituted the arabromusculoskeletal exam questionnaire where I work. We get about an 80% compliance rate with getting that at the first physical therapy visit for our patients that are referred to us under workers comp. And that data shows that in recent years, that tool puts people into a high, medium, or low risk for delayed recovery and prolonged disability. And about 40% of the patients that we see come in in that high risk category. That's a little higher than some of the traditional research using that specific tool. And I would put some of that to the fact that originally that tool was used in primary care, so people that didn't even need physical therapy, which might make that a little bit lower. So in terms of that, we've got representation up here from kind of frontline occupational medicine. We've got insurance. And then we've got psychological services. I've said what I do in physical medicine from a screening standpoint, which is to use that Arabro tool at the first visit. I'm interested in kind of what the rest of the panel does in terms of screening. So Frank, maybe we can start with you. Well, I see work injuries at least four or five days a week and doing it for many years. And my background in emergency medicine, I think, gives me a different perspective. I've actually seen people after worse, amputations, open fractures, hip dislocation, shoulders. So when I see somebody come into the office with a musculoskeletal injury, obviously we're going to ask the questions, what happened? What was the mechanism of the injury? And from there, I think that's very important. For example, was it a motor vehicle accident? Was it a lot of kinetic energy that was impacted at the vehicle? Was it much damage to the vehicle? Did the airbags go off? And we triaged the emergency room, or was it just a little side swipe? And then, obtaining the history, the other questions I'll always ask about motor, sensory, vascular. And are patients reporting symptoms that don't make any neuromuscular sense in terms of circumferential numbness of an arm or a leg? All of a sudden, the radar goes off. Usually, that would be atypical. And then, so we obtained that history. And I think the important thing also is the past medical history. Have you ever had any work-related injuries before? Slip or fall injuries, motor vehicle accidents, military. Did you have any disability as a result of that? For example, how long were you out of work? Did you have any imaging? We all probably know who the providers are in a region that are kind of hooked up with a plane of attorneys. And did any of those people offer care or treatment for you? Was there litigation? Was there a settlement? I think those are important questions right from the get-go. And then, I think for social history, I always ask, single married, would have divorced? So we know that, do you have any children? How old are they? Anybody have a caregiver to an elderly parent? The kids are healthy. And so sometimes, when patients aren't responding from a musculoskeletal perspective, then some of the social history information becomes very informative in terms of what we're going to do and how we're going to approach that patient. So you go through your physical examination, and then you see, are they responding to things that are appropriate? Do they suffer from numbness? Do they resist a range of motion? And then from there, you have a biological medical treatment plan, so physical therapy, imaging, that may be necessary. But I think it's very important to get the patients to know what the treatment plan. And what I've learned from preparing for this is, what are the patient's expectations? Do they expect a good outcome? Are they positive from the get-go? Are they negative from the get-go? And I think I've learned that that's very important to ask every first visit, so we can arrange therapy. And I try to make it convenient for the patient to try to find if they're going to be out of work at a therapy center that I'm familiar with that is perhaps near where they live or work, if they're back on modified duty. And then when they go to the therapy centers, much like David said, I'm a big believer in getting the disability guidelines. He has Westry Scale Index for low back pain. I like to have that done if it's a back injury. I like to have the, thank you. Speak up, I'm sorry. Here, here. Also, the DASH score, if it's an upper extremity injury, and the Obrego score. So if I can see a patient's been going to therapy for quite some time, and give me a favorable response every three to four weeks on those questionnaires, then I feel optimistic we're going in the right direction. However, if the patient comes back and several weeks after reporting they're not getting better, therapy's helping, then all of a sudden, that's an indication to me that perhaps there's something else going on from a psychosocial point of view. So I let the patients know that when we're getting imaging, we try to send them to some of the best centers that are academic institutions, where they have musculoskeletal radiologists, they have neuroradiologists. And when they come back with the imaging, I always review every MRI with the patient, and go down by line by line, and explain the findings from the radiologists. So I think a lot of people like to see their own images. They like to understand what the report shows. And I can say to them, there's something here that requires surgery. Nothing requires surgery. And I think that's important. So I found that it's also important, if there appears to be a psychological issue, the pre-existing history of depression or anxiety, which probably 10% of the population is taking SSRI or SNRI, that may be something holding them back, then sometimes we can get EAP involved. And for the most part, that can be a black hole. I can say over the past year, we have sent patients to EAP, and have probably received two communications back from the EAP. And so that could be somewhat troubling. So I think in other instances, I've learned from preparing for this, that there are other resources that are available, such as the services that Amanda's organization provides, and that perhaps that is an avenue we should be going. It appears to be a psychosocial component to what's holding the patient back from improving. So when somebody is outside a morbidity curve, also I will pick up the phone and call the therapist and speak to them personally. How is the patient responding? How is the patient getting better? Are you making any progress? To make sure that we're both on the same page. Do you have an endpoint? Did you see where they're going to be better? So I think that is very important, in terms of good patient outcomes, and working with a therapist, in terms of coming to a conclusion as to how we can bring the case to closure. Thanks, Frank. Couple of key points there. One is that patient expectation has been shown over and over again in the literature to be predictive. And generally, people who say that it's going to be more than a week or two for them to go back to work, they're absolutely right. And they tend to underestimate the time that it actually takes them to get back to work. So that's a real simple thing that you can do that can kind of clue you in, in terms of what is this case going to look like from a psychosocial standpoint. And then, Adam, so you usually don't have the patient right in front of you. But you have a fair number of resources, I take it. This is a big problem. What kind of things are you working on? So as you heard, pretty comprehensive evaluation and discussion with the patient. But we really need to understand the complete whole patient, if we're going to be able to address and ensure what we're trying to prevent, and you are as well, delayed recovery. We don't want people to have any delayed recovery. So really, to identify early on and apply the right interventions to make sure that they recover in a timely manner. So there's a number of things that I look at through the medical records and my medical directors as well and one of the things I would just recommend is that you consider your patient's health literacy. It's sometimes often overlooked but they may not have any clue as to what the heck you're talking about or they may have a different health belief model that needs to be at least addressed as you're having conversations with them. The other thing is if there's going to be some kind of change in their activity, you need to think about their willingness to change. Are they willing to make any lifestyle changes, exercise, diet, etc. And then finally skills. Do they have the skills to get there? And so you know there's a generalized self-efficacy score that you can look at and see if the patient has the skills, needs the skills. You can make referrals to individuals that can help them get to that point and again we've got a lot of other resources in the payer side so that even though it may not be explicitly stated what the individual issues are that may delay their recovery, we have pretty good data science. We've got a lot of data and so it's important I think for us to share that data with treating providers and the physical therapists, the doctors, etc. as they go forward if we identify an issue. So while they're yellow flags, and we can talk more about the yellow flags in a minute, you know we also need to consider other areas that I just mentioned and more. But we have a question so I'm going to pause and let the questioner ask. Go ahead. I very much liked your idea of medical literacy. It's one of the biggest obstacles. I think that we should abandon the concept of patient. We should consider them as partners in recovery. Don't call them patient anymore. I think that's an excellent point that we consider our patients as partners because that's where you learn about their expectations and understand if there are yellow flags, if there are other issues. And I'll talk about also we should understand their social determinants of health and what that's going to do with regard to their outcome. Are there cultural issues? Are there racial issues? Are there ethnic issues? But on the socio-economic front you may turn around and say the patient's not compliant or adherent and the simple matter is that they don't have transportation. Do you know that? And as a payer we're willing to set that up. So we can talk more about that but behind the scenes again we've got predictive models that can pick up other things such as passivity. So even though we may have a whole host of yellow flags and other flags and we maybe should take a little time to talk about the different types of flags, someone that's passive you know really falls into the lower self-efficacy range and we need to address them. It's like whatever you tell me doc I'll do. You know they need to be a partner. So to your point they need to be a partner as part of this and shared decision-making, another concept that we should talk about a little bit more, should be part of all of this. But we have another question so let's pause and get that question. I'll be brief. I really appreciate what you guys are saying and I direct a clinic in upstate New York where we see two-thirds of the patients are musculoskeletal and they struggle. So what we've noticed is we have the social worker active immediately and I'd like to hear each of you speak about and she becomes a friend almost you know we don't even use the word social worker necessarily right away because someone might have a stigma around that. So we're finding that early psychosocial intervention is really important but I'd like each of you to speak to the timing because what I was hearing you say was that you know once they're not progressing that might be a psychosocial thing but where in the timing you know can we speak to that? Yeah yeah so for those who are just coming in I'm a psychologist so I think one of the struggles within the injury field is that they do get to us too late. So by the time they come to us they've already had a period of time on scoring that arebro without seeing improved scores and so we see this far into the spectrum where we're then trying to catch up. But it is kind of difficult to have a patient and partner who's already involved in five different types of care and now we're throwing another thing at them too right. So you have to be very mindful about the timing the intention the need at some point it may be that there are professionals out there who can do enough psycho education around how psychosocial factors are impacting them and that's enough for a certain group of that you know of the injured to be able to respond to and kind of accommodate and get a little support that's helpful. But there may be those who need more assistance in building the skills resilience and knowledge around how to overcome those barriers interfering with their care. And so yes early is wonderful if you have the resources and ability to provide that to those patients and if the simple kind of momentary intervention at the beginning isn't useful then kind of stepping up the care throughout the course. So these screenings on here are some that a lot of these can be utilized. They don't necessarily have to be by mental health professionals and they're also being integrated into the primary care. So when we're talking about the PHQ 9 GAD 7 you're seeing those have become very popular at that first primary care appointment. And so those should be utilized right away to kind of give an indication of those that might need this additional referral. Same with the catastrophe from the psychological perspective and those yellow flags that are out there. Whenever we do screening when we get referrals for injuries that we're talking about today those last three are really key in pulling out catastrophizing being fearful of movement and avoiding hurt not knowing the difference between hurt versus harm. So those are some other skills utilizing early on can really be helpful to find out might this person need additional intervention when we're prepared to make those referrals. Maybe just to add to that earlier better but there may be critical windows and so our data and our data analytics allow us to figure out what are those critical windows either for imaging for physical therapy for behavioral health interventions. All of that needs to come into the picture as well. And episodes of care we don't do a great job I think in work and workers compensation occupational medicine. It's difficult but trying to identify episodes of care the timing in those episodes is something that again working with the payer we've got a lot of data we can help identify those critical windows. Let me just add to you know timing is critical but I think using a tool that risk stratifies because we also have seen at least in some studies specifically you know in Europe using the start back tool that too much of a good thing may be a bad thing. Right. So we can over medicalize the problem by throwing additional resources at the issue. And there's some people that are low risk that we kind of just need to like get out of the way and let them do their thing. And if we start them interacting with more people or more imaging or whatever we'll actually slow down the entire process in terms of recovery. And then along with that right. There's a cost factor although I think probably most of us in the room would probably agree too much is probably long term less costly than not enough and letting somebody truly become chronic and go down a bad road in terms of recovery. But we still need to be cost conscious. I you mentioned working with your payers. I live in England and I have yet to have a payer actually pay for this social work psychological intervention behavioral therapy. So I'm curious to know how you actually make this come to fruition with the payers. Well I'll start. I mean I've got some payers that I work with who up front you know have said that they're bought into this. They've got their own network of professionals that they work with and they're looking for that recommendation. But I think you know from a payer perspective where does that recommendation come from and what is the path to that Adam. So again I think looking depending on which provider you know even if physical therapy the doctors identify the issue and share it that it's going to get be delayed recovery. I can share with you some numbers that once we identify that what the incremental cost is that gets the payers attention if they've looked at their own data they'll understand the equation is y equals 2 to the n. So if you identify just one psychosocial behavioral health issue well it's 2 to the 1. It's gonna cost twice as much on the medical. If you they've got two issues comorbidities plus a behavioral health issue it's four times and we've seen three times with comorbidities true psychological conditions and behavioral health eight times more expensive. So not intervening isn't an option. Ten twenty years ago adjusters claim handlers they didn't want to hear anything about psychological or social determinants but you know what it's got the biggest impact as I've just pointed out on what the claim costs are going to be that includes delayed recovery lost time days however you want to measure it in dollars. And so all of that I think just identifying it letting them know and really it's a communication issue. So communication with the payer a communication with the injured worker so they can advocate for themselves as well and communicating with you're the treating provider but any other providers that are involved. And remember we have CPT codes so jump back 10 years ago I think it's been at least 10 years we have CPT codes now that get payers less nervous. It's a behavioral health assessment or evaluation of a musculoskeletal condition. So it's not you know you're going to be on the sofa for 30 years. It's like five sessions. We know it's five to 10 sessions at most. And the people wind up getting the care they need the skills they don't have maybe. And just addressing other issues such as sleep. And we can talk more about digital therapeutics but. And I think the other thing is counseling is only one component to combat some of these. One of the biggest problems that I see as a physical therapist is somebody taken out of work that doesn't need to be out of work. Right. That starts a cascade of events as you know the physician. And again hopefully not as much in Ahmed but unfortunately I live in a state where you pretty much go to anybody you want after the first visit and you go back to your family medicine physician and let them manage your case and say I want to be out of work. Right. And they take them out of work. Well now we've got you know depression associated with isolation. We've got a change in who I think I am. I increase my fear avoidance because I've been sent the message I need to rest to recover. Right. And there's a whole cascade of events that can happen. So that's really where it needs to start is does this person really need to be out of work or can I send them back. And if I can send them back to some sort of employment safely can I convince the employer to actually take them back. Right. When we go back to one of those original slides psychosocial factors were ranked number one by claims managers about six or seven years ago. Now transitional work is looked at as one of the major barriers to recovery and claim resolution. And we should be headed in the other direction. Right. With the ADA. Right. Workers comp now falls under the ADA and there's all kinds of regulations about not only in terms of engaging the employee about transitional duty but even what constitutes a request for an accommodation. So if you go to the EEOC Web site they actually say that a physician writing a restrictive work note and sending it to the employer that that constitutes that that physician is requesting an accommodation on the part of the injured worker even with the injured workers not aware of it. So it's interesting. Any other comments here. No. Good. When you have it when you are if it's appropriate I don't want to derail the presentation but I've noticed also some psychosocial factors are also an issue culturally. Right. So that they're just there's a cultural factor to this as well in terms of how people respond to their illness. Yeah. Yeah. That's appropriate to enter into the discussion. I'll just I'll just mention you know we talk about biopsychosocial if you want to take it to the next level and really get granular. So this is where the data comes in and what we're able to look at is look to James Friction's work Fickton's work out of the University of Minnesota. He looks at a human system approach which really fits in with the biopsychosocial but it gives a lot more granularity very much detailed including spiritual issues and things like that which I you know we don't usually explore but maybe part of the issue when it gets into some of those cultural aspects as well. I mean you know certain cultures you know they're having conversations with and they know that with someone that's not there but that's a cultural issue in some cases they're not really hallucinating. Thanks so much. Good morning. Thank you for answering our questions. My question is that I'm in a unique position I do occupational medicine but I also do primary care and urgent care in my site so I'm lucky but also it's a complex I guess practice. What I see is there are times that like the PHQ or PHQ-9, G87 that's where I start but when I want to refer somebody to a mental health counselor such as yourself when it becomes beyond the scope of what I can do whether it be as a primary care physician or even I'm doing it as an occupational medicine physician but I see that there's a mental health component to their to their recovery there is there's not that many of you out there. No there aren't. And it's a challenge. There's even less of people who prescribe like the psychiatry where sometimes okay this is a person who has significant mental health issues that is psychosomatic so it's contributing to the lack of recovery. I would love to get your input on what do you recommend in terms of dealing with such circumstances where people need a psychologist or licensed social worker and there isn't anyone for another six months and that could mean them losing their job one and number two about prescribing physicians who where they might need antipsychotics or something that's beyond the realm of what I can do as a primary care. So just your input on that. Sure. Loaded questions. Well yeah it's intense but that's okay. So I think the challenge a lot of people face when you're in that occupational med space is what's work related related to that injury and what's not right and so when they're first coming to you it is kind of trying to help tease that apart and if there's the pre-existing severe mental illness or a long history of problematic things that may impact the delay in their care it's like okay is this privately needed support versus do you think you need some sort of psychological evaluation to determine is there anything caused by arising out of the work injury that then would be covered under a comp or whatever that may be right. So you've kind of got these paths you've got to figure out first. My company works within workers comp and so in that situation that's when we accept referrals into workers comp. But if you're working within the community it is hard to find mental health professionals who have had experience in this realm of recovery. And so you do want to be looking for rehabilitation psychologists psychologists with a behavioral medicine background who have worked in hospitals have worked in the military. They usually have a pretty good perspective of providing effective care. And I'm saying psychologists because I am one but the realm of behavioral health professionals that are able to provide those services out there. So you want to kind of look for the specialty but as you're right access is very hard. And so I often promote people getting involved in policy and advocating with your legislatures your boards to increase access to care and reimbursement rates. I think a huge challenge with getting mental health care engagement is fee schedule. And so accessibility is already low. Providers aren't going to necessarily you know risk or invite too many fee schedule kind of arrangements into their practice. And so there's a lot of advocacy that has to happen around that and access is hard. And so I think part of it is anticipating some wait times and trying to make good partnerships with providers you find because you can build those partnerships and have good referral sources and they'll even hold parts of their schedule for certain patients if you can build relationships with them. Thank you very much. So no doubt about it that there are barriers especially when there's a true mental health issue. I think one of the things that we need to think about as practitioners is in cases where it's more psychosocial factors and less mental health issues. How do we either stop those from kind of escalating and how do we reverse them as a physical therapist. Again I look back to the start back tool and what they did that was successful in England and they trained physical therapists to take more of a psychological approach to therapy. They taught them new skills that they could implement. Things that should be common sense and we should be doing already. Things like goal setting and making sure that the injured worker knows where they are in terms of progress towards those goals, and if they're not making progress, having a discussion about why that is. So that seems to have been successful overseas. We have yet to kind of demonstrate, I think in this country, a study that we can do that for a variety of different rules, but I think the concept still applies and we need to continue to work towards that, whether we're physical therapists or an MD or a PA. So thank you for that last question, by the way, that was really related to what I'm about to ask. And I think a lot of my colleagues here will be able to say, hey, when I'm seeing somebody for a pre-employment, I kind of get that feeling where there's maybe a 50 chance that in the next year I'm going to be seeing this person for a significant work-related musculoskeletal injury just because of the underlying risk factors that we're seeing. But I also work in a fairly rural area, and so a lot of my folks are either uninsured or underinsured. And so one of the challenges that we face is even when we feel as though there's a pre-existing portion of that injury, even if there's some mild contribution from the work-relatedness itself, there's no ability to get any of that treated because they may not be able to go to care, especially if it's getting denied on the workers' comp side. Are there any of those instances in which the workers' comp kind of pair, recognizing that this is just not going to get better if that doesn't get addressed, has any resources that might be beneficial for us in those situations? Yeah, absolutely. So a couple things to think about. Again, we're maybe a little more progressive than our competitors, but when we realize we have clinicians. We have clinicians that are behavioral health specialists. Before we even have behavioral health specialists get involved, we have health coaches. So if we, again, identify someone that has the need for some skills that are dealing with other things, including, I mentioned sleep is a big issue, but just the yellow flags, their thoughts about fear avoidance, things like that. We're able to, with a health coach, usually address what it is. So we've got a stepped approach internally, and then once it goes beyond what our internal expertise is. So it's something to think about and ask other carriers if they have any of these supports inside their organization. Then you can go to external. But as part of this, remember technology. We need to leverage technology. So we got telehealth, telemedicine after COVID, a lot more use of it. And this is where I think you can access. Also there's digital therapeutics. So there's online programs that can help people walk through pain management, any of the issues as well. There are different programs that are out there. If it's an OUD or substance use disorder, paratherapeutics is out there that you can prescribe if that's the barrier that you've identified, reset, reset O for opioids. And so I think looking at these digital therapeutics and other things touch on some of the behavioral health aspects of all this. So I think you need to recognize what the full spectrum is of potential interventions. And again, just start talking in your note about delayed recovery, things like that. That should get someone's attention so that they're going to pay more attention to that individual and hopefully get them the resources that you're recommending. Make the recommendations. Thank you. We are streaming this too. So we've got some questions coming in from that avenue. One of them was just a remark that through COVID, it seems like employers are less likely to take people back to transitional duty. And I won't disagree with that. One of my jobs is to kind of look at the physical therapy cases across the country in our network that are exceeding the ODG benchmark and try to help our clinicians problem solve those. And so, yeah, definitely through COVID, we've seen a rise in the number of people that are screened as being high risk for delayed recovery. And then that's complicated by lack of return to work options, whether that's transitional duty or even being let go maybe a little more quickly than they might have otherwise been, you know, because the workforce has been kind of downsized. That's turning around now though, right? I mean, I've got post-offer employment clients that have stopped their programs because they just can't hire. Hi, I'm a physical therapist. So coming from that perspective a little bit, David, I think we've all operated really with one hand tied behind our backs, so to speak, because we don't have adequate information from employers about what the jobs that our patients have to do, what those jobs are in a way that's meaningful for us as practitioners. And certainly from the functional side, I can speak to that quite a bit as can David. But my question is, how do we, first of all, get employers to help us develop these documents so we can help them? And how do we include that psychosocial piece? Because then maybe we can begin to justify care and get payment, as was the question a little bit earlier. It's interesting, right? In terms of recovery, one of the things that would fall under kind of the black flag, right? We've been throwing these things out, yellow flags, psychosocial factors, black flags, more kind of systemic factors, red flags, right? Problems that this could be a serious health condition. And then blue flags, which are sort of the interaction of different things, including maybe the work situation with the individual worker, you know, and those kinds of things. I think one of the things that falls into that black flag category is the size of the employer, right? Recovery tends to be pretty quick in a small mom-and-pop shop where there's some direct accountability usually. And really large companies seem to be paying attention to this and will have good programs in terms of defined return to work, good job descriptions that they're posting on the internet, they're using those to make sure that the employee knows what the job duties are at time of hire, so that they can actually kind of self-select themselves out of the position. I don't want to do that, or I can't possibly do that, or I've got an injury and I fall under an illness, and I fall under ADA and I need an accommodation. But it's sort of those mid-sized companies where I think that's really kind of a barrier. And when I say mid-sized companies, you know, 200 to 700 employees where they can kind of get lost in the system, and yet because the system is either not well-developed or there isn't that direct accountability, you know, to the owner of the company itself. Yeah, I would just add that, you know, it really does come down to policies and procedures that the employer may or may not have in place. And what are the resources? So whether they're big or small, I mean, there are ODEP, the Office of Disability Employment Policy, you know, has the askjan.org website where you can actually get some information around job accommodations and placements and things like that. And then it's up to a multidisciplinary team, I think, to help the employer to update their policies around modified work, work on MAT, so if someone's on medication-assisted treatment for opioid use disorder, things like that, and how they deal with bringing people back to the workplace. It's critical, not just for the individual, but for the safety of the workplace as well. So we really need to look at it as a multidisciplinary team revamping, not just legal, not just, you know, the senior leadership team or HR, everybody together, including a medical person to help advise on some of these policies. So one of the bottom lines is that all the research indicates that a multi-modal approach or a multidisciplinary approach to return to work, especially when somebody becomes chronic, is the most successful. We've moved away from that in this country. And so I think one of the questions is, how do we kind of reinstitute that without having a day program that's very, very intensive for even smaller-type injuries? I want to just kind of go through what we have up on the slide right now and talk about some, you know, key opportunities for interventions, and one of those certainly starts, you know, at my level and at Frank's level and probably at most of your level in terms of that initial contact with the patient and kind of setting the expectations, the words that we say, the things that some of you have already alluded to in terms of being more of a coach, right, and helping them through the process rather than kind of dictating what that process will be. And there's a lot of literature around, a lot of literature, probably about 15 studies around therapeutic alliance and what it takes to kind of get on the side of the patient so that the patient trusts you, believes that you have their best interest in mind, and you're going to help them navigate that system rather than looking at it as, I got sent here because this is the company doctor and they're going to take care of the company, right, which is ultimately what we really don't want to have. So again, getting on their level, setting goals with them, asking what their opinion is about what they need can be very insightful, and then really trying to coach them through. Frank talked about reviewing imaging studies with the particular patient and, you know, there's mixed data on that. Some of the data is the more escalation we do in terms of studies, the longer the person's likely to take to recover, and probably in a musculoskeletal situation, the more we're heading down a surgical route, right? And that's certainly been shown over and over with low back pain. But on the other side of the coin, a study came out recently that looked at what physicians thought patients felt were important for back pain in the first session versus what the patient felt was important. And the biggest discrepancy was on explaining what was going on, in that physicians with low back pain tended not to think it was important to kind of get to a cause, but patients really wanted to know that. The other disparities were actually on talking about imaging and surgery, where the physicians thought that that was more important to patients than what the patients thought, along with medications. So just some things from a patient provider perspective. We've talked about the employer concept and the importance of return to work. It's also really important that the patients stay engaged with the employer. And so an employer who reaches out regularly to somebody who's out of work, there's a trend where those people recover quicker, right? So some of it's accountability, some of it is feeling part of the team, right? There's a lot of psychological components to that. From a case management standpoint, Adam, anything special that you guys are pulling in that could be helpful? Again, there's lots of different resources. I think one of the areas that may help, because a lot of questions were asking about what resource and coverage would be there, is to consider vocational rehabilitation as well. Because we do pay for voc rehab, and they have a lot of good skill sets and can help people through this as well. So that's maybe an easier sell, or at least easier to get covered from a payer perspective, if you think that person's going to benefit from voc rehab. Yeah. Yep. And that was a question that came up on the streaming as well. What are the resources for injured workers who don't have those types of things? So definitely contacting and reaching out to the insurance. Frank, did you have anything to add? One of the comments that had come up, and we only have about three minutes, but they brought up the partnering with chiropractors for holistic musculoskeletal injuries. So there are patients that have gone to chiropractors. Louder. There are patients that go to chiropractors. We do refer to chiropractors, but I find that they're very good for setarthropathy. I find that they sometimes are more hands-on in terms of, I see a patient coming back and their hip flexion, straight leg raising has not improved over six to eight weeks. They're not doing a home program. I tell the patients that half of the responsibility is yours to do a home program. But sometimes with the chiropractors, they can do some facet manipulation, relieve some of that tightness in the tifidus muscles, and actually help patients get back to work in a timely fashion. So we do use chiropractors when they aren't responding to physical therapy. And I think those professions better be merging, right? Because there is best evidence for certain problems, and if we're not all doing that, then we have to be a little introspective and think about what's going on there. So last year when we were all in Salt Lake, I was able to present with an MD and a chiropractor on low back pain. So a physical therapist, a chiropractor, and an MD walk into a bar. Wait, no, they walk into an exam room to see a patient, right? Questions? Yeah, I have a question to the expert panel. It was an excellent discussion. Well, it all boils down to work postures, whatever work is being done, whether in the office or in the factory. And one of the aspects of case management is one-to-one. What is the view of the expert panel in providing skills, training, and skill implementation on work postures to different office employees so that we can prevent these problems in the first place? What would be your view, whether we should have such programs in workplaces to prevent these problems? That is my question. I'll start, Adam. So I run some programs for the airline industry as well as other industries, and I actually provide ergonomic surfaces for one of the major work comp and other payers in the country from an office perspective. And I think that's a tightrope that we're walking there. We definitely need to support people, but there's not a lot of evidence for a lot of the training that we think we should be doing, right? The whole bending at the hips and knees when you go to lift stuff up. There isn't research to support that that necessarily reduces injuries, and on the other side of the coin, it does start to get some kinesiophobia going in people. The other thing is that depending on the work environment, it may not be practical to lift that way, even if we had evidence that was a good way to do it. It takes longer. It takes more energy. It's fatiguing. It increases more muscle groups, right, which is all the rationale behind teaching that, but on the other side of the coin, if you ever go and try to do that in a fast-paced environment, then it's almost impossible. So does that mean we slow the work down and decrease productivity? Probably not. There's probably other issues, and it seems to me, and again, I run these programs. We do training. We support people out there. We work on stretching. We do do education in terms of keeping things close so that there's less stress, but in terms of actually telling somebody how to lift, there's a lack of research to support that. Is that along the lines of what you're thinking? Well, I would just add that, you know, I'm all for prevention, which I think is what you're getting at, being able to identify individuals early on, maybe make changes to the individual or the workplace, depending on what the demand is, and that's what it comes down to, right? What's the psychological, what's the physical demand versus what control do they have? So is there a difference between a manufacturing facility and an office? Yes. And so we need to understand that, going back to some of the black flags, the patient, you as a physician, may have no ability to make any changes to that, but you can make some other recommendations. The other thing is to identify, is the person at risk for anything? So on a musculoskeletal side, there has been some excellent research done around weight, so we've got an obesity problem here in the U.S., and basically strength. And so one of the doctors that's doing the work has a beautiful dataset now and can give a relative risk, if you will, of a musculoskeletal injury based on their strength. Usually they're only looking at shoulder and knee as the indicators on a Cybex machine, and then against their weight. So they can turn around and say, hey, we need to do more physical therapy or have this person do some work prior to going back or going into the workplace in the first place. All right. We're out of time. We will stick around for any questions, I think, but any last words just from panelists? I would say let's make this more than just aspirational. We really need to have the education of all the stakeholders and also make sure that we have good communication. So keep the communication pathways open, and let's make this a reality. All right. Thanks. Thank you very much. Thank you.

psychosocial barriers

recovery

musculoskeletal injuries

biopsychosocial approach

early intervention

employers

accessing mental health services

multidisciplinary teams

patient outcomes