Why Can't Connor Ride His Bike?

My eight-year old son has a friend named Connor. Connor is a normal eight-year old boy except in one respect.

Connor can't ride his bike.

Connor is in physical therapy at school working on gross motor control, lower extremity strengthening, jumping, hopping and climbing activities. I've seen Connor run - he's a bit slow but otherwise normal. Jumping is a bit awkward but he makes it. Hopping is status quo.

So, why can't Connor ride his bike? Why does he walk when all the other neighborhood kids ride by - leaving him pushing his bike?

It turns out that Connor is scared of falling off of his bike.

Connor fell of a smaller bike when he was two years old and broke his arm. He has been scared to ride his bike ever since. His mom has asked many of the neighborhood dads (even Connor's karate instructor) to help Connor get over his fear. I've tried to work with him a few times.

Connor seems to demonstrate what Hart et al describe as...

"Evidence (of the) possible existence of fear avoidance beliefs or pain-related fear in people who have other impairments or who may not have pain, perhaps because of learned behavior after previous painful episodes or misconceptions about pain."

In Screening for Elevated Levels of Fear-Avoidance Beliefs Regarding Work or Physical Activities in People Receiving Outpatient Therapy in the August Physical Therapy Journal Hart et al found that fear avoidance beliefs can be described as High or Low (rather than a score) and that one screening question can measure the level (rather than 21 questions in the Fear-Avoidance Beliefs Questionnaire - FABQ).

What Can You Do?

Physical therapists can find out if musculoskeletal pain patients have elevated fear-avoidance beliefs early in the course of care so that reducing the level of fear-avoidance becomes a goal of therapy.

The fancy term for reducing fear-avoidance beliefs is Cognitive Behavioral Therapy (CBT) which is a distinct psychological specialty but one from which physical therapists might be able to learn some management strategies for chronic pain patients.

Hart et al recommend the first step is to screen your patients for high levels of fear-avoidance with these two, simple statements:

1. "I should not do physical activities which (might) make my pain worse."
2. "I should not do my normal work with my present pain."

Statement #1 predicts the response (high/low) on the Physical Activity sub-scale. Statement #2 predicts the response on the Work sub-scale.

We've used the FABQ (21-item) but now I'm making these statements a part of my intake patient (self-report) forms that will be indicated with checkboxes indicating agreement or dis-agreement.

Co-morbid factors like fear-avoidance, age, depression and self-reports of function turn out to be bigger drivers of chronicity, cost and resource utilization (eg: PT visits) than traditional impairment measures like strength, ROM and swelling.

Physical therapists may be able to improve overall patient management and increase reimbursement by screening for fear-avoidance at the first and last visit.

Just as important, we may be able to more accurately detect those at risk - those people like Connor.

Mo' money

Treating fear-avoidance early in the course of care may allow physical therapists to 'risk adjust' an episode fee capped at, for instance, ten visits for uncomplicated lower back pain.

Today, all of your Medicare visits are reimbursed fee-for-service (FFS) but nobody expects Medicare FFS to last much longer in its present state - nor is Medicare FFS sustainable if it does last past this current legislative session.

Al Amato, PT wrote an article in IMPACT (PPS log-in required) called Value Purchasing in Physical Therapy in March 2006 that described the effect of risk adjustment on an alternative payment system. Mr. Amato wrote...

"Risk adjustment allows the comparison of a patient with a specific profile to a similar risk-adjusted group of patients in a large database.

This allows the ability to predict the efficiency and effectiveness of an individual treatment because of the profile of the similar risk-adjusted group of patients from the national database."

In the future, you will need to identify which patients are likely to have poorer outcomes (based of elevated fear-avoidance beliefs) but you will be able to request more treatment sessions. Or, you can treat the elevated fear-avoidance beliefs from baseline, get the patient better in fewer visits - and get paid a bonus.

Who Could get Better by Learning About Fear?

In 2007, there were 97,900 outpatient therapy providers billing the Medicare program in the United States: about 19% of these are Occupational Therapists and 7% are Speech Language Pathologists (table 7 & 10).

The intent is to transition all of these providers to a 'value based' payment program that allows providers to succeed and patients to get better.

Hart's study is a big step in the direction of value-based payment (Hart and Amato work for the same company) because this study shows clinicians how to quickly and accurately screen people like Connor for elevated fear-avoidance beliefs.

Improved screening for this, and other, psychosocial factors that influence chronicity can improve the effectiveness and efficiency of our physical therapy treatments.

Physical Therapists: Ready for some Risk?

Manatee Memorial Hospital - an acute care hospital at risk

Medicare wants to push $26 billion dollars in risk onto America's private health care providers.

Are you ready?

The timeline is 2010 - just over six months from now.

The risk is in managing the 'episode of care' rather than the patient visit.

The 'episode of care' is gaining traction as an alternative payment model designed to stem Medicare spending increases due greater 'per person' use of the system, not just more users.

What is the episode of care?

For instance, a patient goes into the hospital to get her knee replaced, she stays two days, sees three doctors and gets discharged with home health PT for two weeks - then she gets sent to outpatient PT for one month. All costs, including the pre-hospitalization exam and imaging studies would be 'bundled' into one flat rate.

The current payment model is mainly fee for service during a patient visit - you do the work, you bill for it and you get paid. Fee for service risk is borne almost entirely by Medicare - the private practice or hospital provider only has the risk that not enough patients will show up to cover rent, utilities, salary, etc.

The current administration's budget proposal recommends the 'episode of care' that pays acute care hospitals a single payment for all services connected with a single episode of care, such as a total knee replacement.

This new version of the episode of care as the acute care hospital as 'the banker' - doling out payments to providers down the chain: doctors, surgeons, home health agencies and independent physical therapists.

Surgeons are currently paid using the episode of care model for surgeries.

Physical therapy is considered 'ancillary service' (I hate that term) which is not currently bundled with the surgeon's service.
 
Some of the details are described in the President's budget proposal, this APTA response letter to Senator Max Baucus (D-MT) and in other sources.

Where does risk come from?

Hospital risk is mainly from re-admissions within 30 days of discharge.

Private practice physical therapy risk comes from visit outliers that use more therapy visits than expected.

How can physical therapists manage "Episode Risk"?

Outpatient facilities are judged on functional outcomes - rated by the therapist or self-reported by the patient.

What can you do to improve your patients' functional outcomes?

• Ask your patients about medication compliance (especially use of prescription inhalers for COPD patients).


• Screen each patient for medical pathology (eg: DVT, depression, elevated fear-avoidance beliefs).


• Provide standardized functional outcomes.
  


• Treat pain early - don't use the emergency room for medication refills.

Am I ready for risk?

Other than providing high-quality, patient-centered care I don't feel qualified to evaluate the risks in contracting with acute care hospitals, accepting a fixed payment and bearing the cost if the patient takes 20 visits to get better instead of 10 visits.

Are you ready?

Can physical therapists diagnose depression?

Mary began crying in physical therapy the other day.

Tears streamed down her face as she told me the story of her automobile accident and her subsequent attempts at recovery.

She told me how difficult work and school had become - sitting and studying were too painful with whiplash and headaches.

Sleep was interrupted by pain and she got up every morning not rested, with dark, red circles under her eyes.

"I just can't go on like this", she said.

Physical therapists treat chronic pain patients whose somatic symptoms may contain an emotional component.

Physical therapists can consider the whole person when we assess the patient and we can screen for depression by asking two questions:

1. "During the past month, have you often been bothered by feeling down, depressed or hopeless?"


2. "During the past month, have you often been bothered by little interest or pleasure in doing things?"
   

These questions are taken from the Primary Care Evaluation of Mental Disorders Procedure (PRIME-MD) and are referenced in Physical Therapy Journal (December 2004 Haggman et al).

In The Cultural Context of Depression by Robert J. Hedaya, MD asserts:

"...depression is rapidly becoming the second leading cause of disability in the world."

Physical therapists treat disability using, primarily, physical interventions (eg: exercise, manual therapy, modalities, etc.).

If we try to treat problems that are emotional with physical interventions we risk making the conclusion that our interventions are ineffective.

It may be appropriate to refer our patient to a professional with training and credentials to treat depression if our screening tests are positive.

Mary answered yes to both of my evidence-based screening questions. I called her primary care physician who arranged for a referral to a physician specializing in depression.

Mary is continuing physical therapy with concurrent management of her depressive symptoms.

Does depression affect physical therapy outcomes?

I've not seen the literature that quantifies the effect of depression on physical therapy outcomes but the prudent clinician should bear the depressive diagnosis in mind when designing a restorative plan of care.

Physical therapists can diagnose the link between depression and Mary's activities:

• sitting
  
• studying
  
• sleeping

...by using a decision-making framework like the International Classification of Function (ICF) disablement model.

	ICF descriptor	ICF code
Body Functions
	Pain in Head and Neck	b28010
	Regulation of Emotion	b1521
	Psychomotor control (agitation)	b1470
Activities & Participation
	Maintaining a lying position	d4150
	Maintaining a sitting position	d4159

By studying the outcome of Mary's therapy health policy-makers will understand the impact of depression on physical therapy outcomes overall.

Adding depression to 'risk adjusted' outcome models prevents the mistaken belief that physical therapy treatments are ineffective for patients like Mary.

Adding depression to the model assumes physical therapists can assess the condition initially.

I think we can.

It all begins with your diagnosis.