“Early referral for outpatient rehabilitation may reduce the utilization of health services that carry greater risks or costs in those with nontraumatic knee pain.”

While not surprising, the statement from researchers adds to the growing body of evidence showing early physical therapy may offer the best outcomes for injured workers with knee pain. It also results in much lower costs for the employer/payer.

The Study

Researchers from the University of Pittsburgh culled through 2 years-worth of data on Medicare beneficiaries with nontraumatic knee pain (NTKP). They wanted to find out the proportion and timing of people who received outpatient rehabilitation services (including physical therapy) and the association with other treatments. Their findings were published in the American Physical Therapy Association's scientific journal, Physical Therapy.

Evidence-based clinical guidelines from the American Academy of Orthopaedic Surgeons and other organizations recommend therapeutic exercise as a first line treatment for people with NTKP.  But only 11 percent of the 52,504 patients included in the study were prescribed outpatient rehab. Among those who were, slightly more than half were prescribed rehab within the first 15 days.

“The likelihood of using narcotics, nonsurgical invasive procedures, or surgery was significantly less for those who received early rehabilitation when compared to no rehabilitation,” they reported.  

Here’s what they found specifically:

• The adjusted odds for the use of narcotic analgesics in beneficiaries with NTKP when exposed to early rehabilitation is 0.67 times lower when compared to those who did not receive outpatient rehabilitation services. 
• The adjusted odds of NTKP beneficiaries using nonsurgical invasive procedures when exposed to early rehabilitation was 0.50 times lower when compared to those who did not receive outpatient rehabilitation services.
• The adjusted odds for beneficiaries with NTKP having knee surgery when exposed to early rehabilitation is 0.58 times lower when compared to those who did not receive outpatient rehabilitation services.

These statistics translate to less pain, lower costs, and better return-to-work rates. It suggests that providing physical therapy to injured workers with NTKP within two weeks of reporting it can truly be a win-win for employees and employers.

Discussion

NTKP is extremely prevalent among injured workers, especially older employees. In fact, among people over the age of 65, there has been a 65 percent increase in the rate of NTKP cases in the last 20 years. This also coincides with the tremendous increase in total knee replacement surgeries — something we see all too often in the workers’ compensation system.

As I explain often, NTKP is by and large a function of the aging process. Rarely is it the result of a workplace injury. Yet many payers approve this route for injured workers instead of first trying less invasive and less expensive physical therapy.

An interesting point from the study was the timing of the rehab. It showed those who received early rehab — within 15 days — had by far the lowest use of other medical treatments, compared to those who started physical therapy later or did not receive any outpatient rehab .

They say timing is everything, and certainly it is in the case of injured workers with NTKP. Getting medical care to the injured worker as soon as possible after the injury should be the goal of all organizations. This study showed a clear association between early physical therapy and a much lower use of other services.

Another important finding from the study was the low percentage of patients that were prescribed rehab at all. The 11 percent, or 5,852 of the more than 52,000 people with NTKP means medical providers for the vast majority of patients prefer to use other, riskier and more costly treatments and ignore the overwhelming evidence that points to physical therapy and other non-pharmacological, non-invasive services first.

“We were surprised to find a low percentage of patients received outpatient rehabilitation for their knee pain,” said lead author Joel M. Stevans, DC, PhD. “Our research further emphasizes the importance of working with colleagues from other disciplines to better understand how patients can be directed.”

Conclusion

Knee pain can be debilitating and result in extended disabilities for many injured workers. We know that by thoroughly examining the employee and setting up an active plan of care which includes certain movements and exercises we can make a substantial difference in their ability to return to function and work.

This latest study has its limitations and the authors say more research is needed. However, as they also say, “our results suggest that finding ways to promote prompt access to outpatient rehabilitation services for people with knee pain may be important for reducing utilization of health services that place patients at greater risk. This specifically relates to opioid use, nonsurgical invasive procedures, and surgery.”