COVID-19 has not only changed where we work; it has also changed how we work. Hunching over a small laptop screen for a full working day, for days on end, is very different from doing a bit of work from home over a weekend. In a recent survey, 92 percent of chiropractors said that patients are reporting more neck pain, back pain or other musculoskeletal issues since the stay-at-home guidance began.

A majority of them are not looking to go to physical therapists or chiropractors to fix their problems. Reason – it is expensive and cost every time you go, only available in ‘office hours’ (not an option with kids at home) and risky because the virus is still out there.

It is not like it was much fun to go the clinic anyway. Traditional, in-person appointments are always difficult to fit into a normal workday schedule. For many people, it means an afternoon appointment. If you account for travel time and an hour-long visit, that person could lose two hours of his/her work day. Avoiding that scenario means scheduling an appointment before or after work hours, an option most clinics do not provide. Even when you are able to see the physical therapist or a chiropractor, most of them in traditional clinic setting are still following an outdated process. The therapist shows what exercises will help, give a printout of the exercise program. As soon as you get home, you forget most of it and those sticky figures on a photocopy of a photocopy is hard to understand.

It’s not surprising that up to 65% of people don’t fully adhere to their plans of care.

What is adherence to musculoskeletal (MSK) plan of care?

According to WHO definition, an exercise adherence is “the extent to which an individual corresponds with the quantity and quality of exercise, as prescribed by their healthcare professional.”

To be adherent

  1. The individuals should be exercising
  2. They should be completing the right # of reps and sets
  3. They should be following the correct techniques.

Why is adherence important?

Let’s start with the obvious. The exercise is beneficial for key clinical outcomes such as pain, physical function, and quality of life.

People who adhere to their prescribed exercises are significantly better at achieving their goals and demonstrate a greater increase in physical function. The prescribed exercises for musculoskeletal conditions are targeted specifically at certain joints or muscle groups (depending upon the injury or surgery) and both options (not doing it at all or doing it incorrectly) lead to suboptimal clinical outcomes.

It does not help if the only way to get help is for you to drive to the clinic and see the therapist in-person.

What affects engagement and adherence?

Generally members are faulted for non-adherence, with reasons such as low motivation, pain, poor self-efficacy, and reduced social support. This is not entirely correct. Businesses don’t fault customers if customers are not getting value from their products. The same rationale applies to musculoskeletal care delivery. Lack of access, personalization, adequate guidance, motivation, reminders, reinforcement, psychological therapy and support from therapists are also big factors responsible for poor engagement and adherence to MSK plan of care. The traditional method of providing written information and activity monitoring in physical therapy is regularly completed via a paper handouts, which are often illegible, lost, forgotten about or generally confusing for members to understand.

In addition, outdated plan designs with deductibles and copays per visit create barriers for members when they want to get help.

An effective digital Musculoskeletal (MSK) solution fixes this problem.

A paradigm shift

An effective digital musculoskeletal (MSK) program shifts the control of the treatment from the therapist to the member, making them accountable as their own “therapist,” with the clinician acting as coach. This doesn’t mean that members are being left to get on with things on your own. Rather, the starting point is the individual member, their needs, ideas, goals and the premise that members can and do already have skills and resources to get better. The therapist’s role is to address beliefs that may hinder recovery and provide the member with the skills to successfully manage their musculoskeletal condition.

An effective digital musculoskeletal (MSK) solution is available anytime and anywhere. It assumes home environment as the default therapy setting, and builds the treatment framework that is member driven.

The knowledge, guidance, measurement and monitoring typically addressed in therapist’s clinic is brought to the member’s home. Instead of relying on physical interaction, the program promotes an active, non-invasive management approach involving the use of education, exercise, functional activity training, and behavioral and lifestyle changes. The member is considered an active participant in the recovery process and develops greater control in managing their condition.

An effective digital MSK solution uses a data-driven approach that incorporates features to increase engagement & adherence by using self-monitoring, guided problem solving, education & remotely monitoring adherence rates more objectively. This technology-enabled solution provides a collaborative environment in which the member and therapist work together to develop a member-preferred approach, including feedback and adjustment of the plan of care.

There are 5 adherence-boosting elements of an effective digital musculoskeletal solution, that delivers on better engagement and adherence. These elements are:

  1. Self monitoring and positive reinforcement
  2. Guided problem solving
  3. Tailored Education
  4. Remote Monitoring
  5. Provider Accountability

Self-monitoring and positive reinforcement

A data-driven digital musculoskeletal (MSK) system enables the therapists to provide virtual exercise prescription in a rich, engaging application instead of static paper handouts. Its intuitive app interface helps the member through her prescribed exercises, providing feedback and encouragement in real time.

The members are able to record the completion of their daily exercises, as well as provide their input to the coach. Activity monitors are provided to members that gives them real-time insights on their physical activity and exercise frequency. This helps them take control and become more accountable.

It has been demonstrated in multiple studies that members are more compliant when their therapist provides them with regular and positive feedback. Members who know they are performing the task correctly are more likely to be more engaged. The digital MSK system enables continuous feedback by the coach during the episode, instead of routine 1:1 virtual physical therapy sessions. This is delivered via asynchronous channels such as messaging in between sessions. Not only does it improve exercise techniques, it also act as a reinforcement to complete the exercises.

Guided problem solving

Various studies have demonstrated that members when prescribed 4 or more exercises had a lower rate of compliance than those prescribed 2 or fewer. This is common sense. Anyone who works a full time job or looks after a family does not have time for 8 exercises a day. More importantly is this actually necessary in order for them to get better?

An effective digital musculoskeletal (MSK) program is built on shared decision-making and guided problem-solving. It tailors physical therapy exercise program demands to the member. The goals are specific, measurable, action based, realistic and time framed.

The exercise plans involve gradual exposure to movements, positions, and activities that were once difficult to achieve. Members are introduced to regular exercises in small steps that they feel comfortable to manage, and guided to perform self-mobilization techniques and active exercise sequences to help manage symptoms. For example, in post-surgical rehab, the therapy is divided into multiple phases. The first phase starts immediately after surgery when the body part may be immobilized while pain and swelling subside. Then comes a series of progressively challenging exercises to restore range of motion, stability, and strength. The final goal is to return the patient to a pre-injury activity level. When therapists and members come together during 1:1 video sessions to reassess the symptoms, this approach providers member with evidence and reinforcement that a self-management approach is effective.

Tailored education

Tailored education is a core intervention for people with musculoskeletal (MSK) conditions. Members who are informed have more confidence in self-management practices, more likely to be active participants in their care and adhere to treatment.

Much more so than with traditional care, virtual models of care (supported in digital MSK solution) include a larger educational component. Because the therapist is not physically present to assist with movements or joint stabilization, the onus is much more on the member to learn these techniques and practice them continually.

Virtual physical therapy models place emphasis on the interaction between therapist and member. The live video environment on a smaller screen limits the distraction that members encounter and fosters communication and education between member and provider.

The education component includes a thorough explanation of the musculoskeletal condition, symptoms, mechanism, and management plan and involves teaching and counseling to modify behavior. Effective techniques include repetition, spacing of new information over multiple sessions, and limiting the quantity of material to important points.

Done properly, education bolster confidence and improves self-management, which leads to higher adherence to plan of care.

Remote monitoring

In the traditional in-person setting, the self-assessment of daily activity by members own assessment can be highly variable and subjective. An effective digital musculoskeletal (MSK) system uses an automatic monitoring system that provides an objective measure for adherence.

The virtual musculoskeletal system collects range of motion and other clinical measures and provides an intuitive dashboard to therapists for remote clinical review. If a member is off balance or moving incorrectly, the system provides feedback to the member and flag the issue for their therapist.

An oversight by therapists helps to ensure that members adhere to their prescribed physical therapy programs and complete their exercises safely and accurately. An effective digital MSK program enables both member and her therapist to see if the member performed physical therapy exercises correctly, how often exercises were performed, and how the member is responding to therapy. The therapist has the flexibility to customize exercises and help reinforce that prescription through an engaging experience.

Provider accountability

In the current system, the providers are not held accountable for quality, outcomes or cost. For example, despite demonstrated benefits of guideline-based care, only 54% of physical therapists provide care that aligns with recommendations. After the member visit, the provider provides a service, bill for that service and collect money for that service – regardless of the impact the service had on the member’s well-being.

Since the providers are paid irrespective of the result, they are not always motivated to increase member engagement and adherence to the plan of care. Most of them don’t have systems to track outcomes, nor are they equipped to track what happens outside their clinic.

An effective digital MSK program is accountable for cost and outcomes. It follows evidence-based guidelines to deliver care and measure the effectiveness of the program. It checks the compliance of all the interventions included in the program, care standards and introduce clinical audits as a part of the process, to identify areas in these standardized care processes for continuous quality improvement.

By offering transparent, bundled pricing for different treatments, an effective digital MSK provider is aligned to members and plan sponsors and work collaboratively with them to improve engagement and adherence.

Summary

A digital MSK solution is built to deliver care that truly address the specific needs of the member, while equipping them with the knowledge and skills they need to achieve long-­term success. To achieve higher engagement and adherence levels, an effective solution leverages self monitoring and positive reinforcement, guided problem solving, tailored education, remote monitoring and provider accountability.

Sprite health helps employers and health plans get the most out of their musculoskeletal benefits. Our digital musculoskeletal pain program provides a single point of access for all MSK conditions, across the entire MSK continuum. Our virtual physical therapy services provide a more affordable and convenient way to prevent and treat pain. MSK triage ensures that members get help and advice to pick the right treatment at the right time. Chronic pain management provides an evidence-based, PT-led digital program for chronic joint and back pain that includes personalized exercise therapy, behavioral health support, education & guidance. MSK financial management leverages predictive analytics, clinical expertise and plan administration capabilities to eliminate waste – resulting in over 30% net savings in your MSK spend.

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