When physical or other therapies are prescribed (e.g. for low back pain), the authorized treating provider (ATP) should communicate on a regular basis with the physical or other therapist to whom the patient has been referred. With this communication, the ATP will determine whether functional gains are being realized and whether the patient can return to work at full or modified duty.

If functional gains are not occurring by the end of a specified “time-to-produce-effect” interval, the ATP should confirm that continued therapy is reasonable and necessary. If it is not, the therapy should be discontinued.¹ An alternative form of treatment could be prescribed, the diagnosis reconsidered or, if warranted, maximum medical improvement (MMI) could be declared.²

This article reviews the elements observed in therapy documents for physical therapists and authorized treating physicians.

Although these observations may not apply to your practice, Pinnacol Assurance has frequently observed the following issues.

For Physical Therapists

• Unvarying documentation (or repeated “cut-and-paste”): When documentation is substantially unvarying in the subjective, objective and/or assessment section(s) of subsequent notes, it questions whether the patient is making treatment progress.
• Missing elements: Over one or more clinic visits, missing elements in the medical record (such as the subjective, objective, assessment or plan elements) raise the question of whether the patient is making progress with treatment.
• Pain relief as a goal: This is seen when there are references in one or more notes that a goal of therapy includes complete pain relief. Measurable functional gains are the appropriate primary goal of therapy.³ Complete pain relief is not a proper therapy goal and is often unfeasible. Excessive focus on pain over physical function can lead a patient to have unrealistic expectations, can unnecessarily prolong treatment, and can contribute to patient harm.
• Quantifiable measurement of functional status: Functional status, which includes quantification of range of motion, strength, endurance, performance of activities of daily living and physical performance, should be objectively measured during the initial visit as a baseline and at regular intervals to assess whether functional gains are occurring.⁴ If such measurements are not routinely, reliably and clearly documented in the medical record, functional gains are not demonstrated.
• Measurable goals of care: Realistic and quantifiable therapy goals should be documented early in therapy. They should reflect the patient’s personal goals and specifically advance the patient’s ability to return to work in some capacity. The goals of care should be explicitly documented and referenced at regular intervals.
  

For Authorized Treating Physicians

• Review of the therapist’s notes: As an important part of care coordination, the ATP should regularly review the therapy notes and communicate with the therapist to determine whether the patient is realizing functional gains.
• Psychosocial history: A formal psychological or psychosocial evaluation should be performed within six weeks of the date of injury if a patient is not making expected progress or when subjective symptoms do not correlate with objective signs and tests.⁵
  

Since psychologists are in short supply in the workers’ compensation system, the ATP is not required to refer an injured worker to a psychologist. The ATP can carry out psychological and psychosocial evaluations as part of the normal scope of primary care. An adequate psychosocial history should be documented in the record and used to inform the treatment plan. The results of the psychological evaluation should be used to inform the ongoing treatment plan, which could include appropriate psychosocial interventions.

The DOWC has enumerated several standardized tests for this purpose.⁶ Important elements include past medical and substance abuse history; screening for depression, anxiety, somatization, fear-avoidance, and sleep disorders; work and social relationships and stressors; employment history; and current perceptions of the medical system.

• History of prior work-related injury: It is important to elicit a detailed history of prior work-related injuries, if applicable, to understand how  this might influence the progress of the current injury.
• Opioid use beyond ten days: It has been found that one in five patients prescribed opioids for ten days become long-term users.⁷ Analgesic treatments with acetaminophen or NSAIDs are usually sufficient to permit adequate function. Alternatively, in some instances, a generic neuropathic pain medication might be considered.⁸
  

If your patient has been using an opioid analgesic for more than ten days, have you seriously considered discontinuing the medication? If this is not feasible, providers should follow all recommendations for identifying red flags of substance abuse — such as a patient report of “all-over pain,” psychological comorbidities and a history of substance abuse disorder — and follow protocols related to opioid use in chronic pain.⁹

• ‍‍Opioid in combination with a benzodiazepine and/or a muscle relaxant: An opioid in combination with a benzodiazepine or muscle relaxant is a highly dangerous combination.¹⁰
  

If this applies to your patient, have you seriously considered discontinuing one or more of these medications? If this is not feasible, providers should monitor patients more closely, redouble their efforts to maintain opioids at absolutely minimum effective doses, and ensure that sleep apnea, alcohol use, and other conditions sensitive to central nervous system depression are adequately addressed.

Disclaimer

This Pinnacol Assurance information should not be interpreted as directing the type or duration of medical treatment. A treating provider is expected to exercise independent medical judgment.

As a convenience, Pinnacol Assurance has provided references and links to Internet sites maintained by third parties. Pinnacol does not warrant the accuracy, currency, reliability or completeness of the information provided on third-party sites. Information contained in this publication was, to the best of Pinnacol Assurance’s knowledge, accurate and timely at the time of issue.

If you have questions or need additional information, please contact Pinnacol Assurance at provider_management@pinnacol.com or 303.361.4945.

References

1. DOWC MTG, Low Back Pain, General Guideline Principles #7 and 8. Effective Jan. 30, 2022
2. DOWC MTG, Low Back Pain, General Guideline Principle #14
3. DOWC MTG, Low Back Pain, General Guideline Principle #7
4. DOWC MTG, Low Back Pain, General Guideline Principles #7 and 8
5. DOWC MTG, Low Back Pain, Section 4, Diagnosis
6. Colorado Division of Workers’ Compensation, Comprehensive Psychological Testing: Psychological Tests Commonly Used in the Assessment of Chronic Pain, 2015.
7. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015. Morbidity and Mortality Weekly Report (MMWR). 2017;66(10):265–269.
8. DOWC MTG, Chronic Pain Disorder, Effective Nov. 30, 2017
9. DOWC MTG, Chronic Pain Disorder
10. DOWC MTG, Chronic Pain Disorder

Ensuring Functional Gains in PT and OT

Colorado DOWC Medical Treatment Guidelines, Rule 17