Rehabilitation is good for claimants and insurers. The benefit in serious injury cases is self-evident. The insured gets better rather than staying injured and insurers don't have to pay out so much.
However, there is a growing realisation that rehabilitation could benefit more moderate types of injury, particularly musculo-skeletal injuries.
So our understanding of what rehabilitation means has changed. Most people would immediately think of physiotherapy, chiropractics and osteopathy as rehabilitation. This implies there is something actively done for the patient. However, there is evidence to suggest that, in many cases, external intervention is not the most effective form of rehabilitation.
What is increasingly seen as effective is giving patients the tools to complete their own rehabilitation – education about their injury, encouragement to mobilise at an early stage and self-training instruction and home exercise programmes.
If insurers increase the level of spend on external intervention, then some of that will be unnecessary and clinically ineffective.
In the Quebec Task Force study on whiplash-associated disorders (WAD), Dr Nikolai Bogduck recommended a moratorium on physiotherapists' fees, because the study found physiotherapy treatments were ineffective for this type of injury.
Not surprisingly, this view has come under attack but, based on detailed analysis of the relevant studies, he holds the view, based on the clinical evidence, that:
There is growing evidence that, for many musculo-skeletal injury types (commonly back and necks), patients do well when they:
An example of the success of this type of approach can be seen in a five-year Norwegian study of two groups of patients with sub-acute low back pain. The objective was to determine the long-term efficacy of education, reassurance and encouragement to resume light activity. One group received conventional treatment and the other received education, reassurance and encouragement to return to activity. This was delivered four times over the course of a one-year period. At these sessions, the clinical findings were explained to the patients and they were provided with information on the nature and cause of low back pain and encouraged not to be fearful of the condition. The patients set their own goals for activity resumption within the general guidelines provided.
The results at the five-year follow-up stage were: n 66% of those treated conventionally had returned to work
This demonstrates the power of giving the patient the tools and know-how to get themselves better.
In a different context, the centre for clinical effectiveness at Monash University in Australia received a request to investigate whether physiotherapy after a Colles fracture affected patient satisfaction and outcomes.
When someone begins to fall, they almost always extend their hand to reduce the force of hitting the ground. When they fall on the outstretched hand, the sudden impact of their body weight on the hand may cause the end of the lower arm bone (radius) to fracture just above the wrist. This is known as a Colles fracture. It can be a serious condition and some patients may not regain full mobility in their wrist.
The outcome of the investigation was that, having looked at the relevant clinical studies, self-training programmes and encouraging the patient to mobilise their wrist themselves at the earliest opportunity, provided an optimum outcome in most cases. Only in more serious conditions, when patients have severe stiffness or those who cannot execute their self-training programme, do people need to be referred to a physiotherapist.
What does this mean for insurers? In motor insurance, they stand both sides of an accident in terms of underwriting before the event legal expenses and then defending claims against their policyholders. In the former case it would be possible to provide their customers with education and advice regarding the common injury types.
In employers' liability claims, the employer could have access to a range of advice and recovery type material supplied by their carrier. In defending claims, insurers could offer a range of rehabilitation including education, exercise programmes and advice.
Medescope, in partnership with Priory Rehabilitation, has been piloting with a major insurer a modular way of providing education, advice, pain management and tailored home exercise within the medico-legal reporting process. Patients attend a centre where the modules are delivered and the data collected helps a doctor prepare a medical report at the end of the programme.
The patient/customer satisfaction has been amazing, with 100% of those attending rating the program as excellent or good. Of particular relevance is the education element and understanding how individuals could take responsibility for their own recovery.
