Musculoskeletal Care


Keeping on top of current medical literature and monitoring industry trends are essential ways we help ensure your members receive quality and affordable care. By understanding how our industry is evolving, we’re better able to tailor our solutions to meet the needs of your organization, your providers, and your members.

Created for health plan leaders, our Trio series spotlights compelling trends in complex medical specialties for your organization. In this edition of Trio, Richard Valdesuso, MD, National Medical Director of the Musculoskeletal Solution for AIM and Kerrie Reed, MD, National Medical Director for our Rehabilitation Solution and Back Pain Guide, share three important trends to watch in musculoskeletal care.

Trend 1 – Knee and hip replacements using robotic technology on the rise

Roughly 900,000 knee replacements and just over 500,000 hip replacements were performed in the U.S. in 2020. While many of these procedures were performed using conventional methods, a significant number incorporated robotic technology. According to the American Joint Replacement Registry annual report for 2021, the percentage of elective primary total hip arthroplasty cases using robotic assistance now exceeds 5 percent; for knees, the percentage is nearly 12 percent.1

While more expensive than traditional, manual procedures, robotically assisted total knee and hip replacement protocols were developed to achieve better patient outcomes and longer implant survivorship.2 The technology offers the potential for shorter hospital stays, less postoperative pain, and reduced early postoperative physical therapy requirements.3,4

The disadvantages of robotically assisted surgeries include the need for a preoperative CT scan, which increases radiation exposure and cost; longer operative times; and a significant learning curve.5,6 Most proprietary robotic systems also require the use of the manufacturer’s implant system, which can be costly.

Early data reveal that patient outcomes of replacements incorporating robotic technology are at least on-par with conventional methods and potentially better.3,4 However, long term studies with survivorship and outcome data are still scarce.

As the adoption of robotic technology for total joint replacement increases, iterative improvements are nearly certain, offering potential for even better patient outcomes and suggesting that the technology is here to stay.

Trend 2 – Increased adoption of virtual rehabilitative therapies

One of the many trends accelerated by the pandemic is digital or virtual physical rehab programs. This mode of care delivery offers clear benefits to the member, including expanded access, increased convenience, and lower cost.

The quality and content among the multitude of virtual physical rehab programs vary considerably. Some of the more salient, distinguishing features among the programs include:

  • Whether physical therapists—rather than athletic trainers, health coaches, and other non-therapists—are directly involved in guiding the member’s care and to what degree. For instance, whether they interact one-on-one with a member or simply oversee the program behind-the-scenes.
  • Whether specific equipment is required to participate, such as wearable sensors or a program-issued digital device
  • Whether the rehab consists solely of exercises or includes education and ancillary offerings, such as nutritional, addiction, lifestyle, and/or behavioral health services
  • How customized the interventions are
  • Whether there is collaboration and coordination among those who work with a particular member

While the pandemic necessitated virtual physical therapy, longitudinal studies are lacking for most programs on the market. Given the advantages of virtual physical therapy and virtual therapies more broadly, claims-validated outcome studies will play an important role in establishing their comparative effectiveness versus traditional care in the post-pandemic years.

Trend 3 – Pain mechanism classification proving effective in addressing chronic back pain

Chronic low back pain persists as one of the most common and unsolved conundrums in healthcare. Studies reveal that 70-80 percent of people will experience low back pain at some point in their lives.7 Of these, 20 percent will experience progression to chronic pain.8

Among patients complaining of low back pain, 85-95 percent do not have an identifiable pathoanatomical cause such as a bone fracture, disc tear, or muscle strain. For healthcare providers, identifying relevant and meaningful treatments that reduce chronicity for these patients with non-specific low back pain (NSLBP) is challenging. Fortunately, progress has been made towards uncovering the causes of pain.

A key understanding in treating NSLBP is that the cause usually is a mechanical or nervous system malfunction.9 To administer proper treatment, it is critical to identify the type of pain—whether it stems from an anatomic structure, due to a peripheral or central nervous system mechanism, or a combination of the three. This is especially true because some of these mechanisms are closely related to psychosocial factors that are predictive of poor response to traditional interventions.10

Applying this paradigm to low back pain will drive higher-value care decisions. That’s why identifying the cause of a member’s lower back pain is a driving focus of our back pain management program.


References

  1. https://www.aaos.org/registries/publications/ajrr-annual-report, accessed 11/11/2022.
  2. Kim YH, Yoon SH, Park JW. Does Robotic-assisted TKA Result in Better Outcome Scores or Long-Term Survivorship Than Conventional TKA? A Randomized, Controlled Trial [published correction appears in Clin Orthop Relat Res. 2021 Jun 1;479(6):1407]. Clin Orthop Relat Res. 2020;478(2):266-275.
  3. Kayani B, Konan S, Tahmassebi J, Pietrzak JRT, Haddad FS. Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty: a prospective cohort study. Bone Joint J. 2018;100-B(7):930-937.
  4. Mitchell J, Wang J, Bukowski B, et al. Relative Clinical Outcomes Comparing Manual and Robotic-Assisted Total Knee Arthroplasty at Minimum 1-Year Follow-up. HSS J. 2021;17(3):267-273.
  5. Nogalo C, Meena A, Abermann E, Fink C. Complications and downsides of the robotic total knee arthroplasty: a systematic review [published online ahead of print, 2022 Jun 18]. Knee Surg Sports Traumatol Arthrosc. 2022;10.1007/s00167-022-07031-1.
  6. D’Amore T, Klein G, Lonner J. The Use of Computerized Tomography Scans in Elective Knee and Hip Arthroplasty-What Do They Tell Us and at What Risk? Arthroplasty Today. 2022;15:132-138. Published 2022 May 5.
  7. Thiese MS, Hegmann KT, Wood EM, et al. Prevalence of low back pain by anatomic location and intensity in an occupational population. BMC Musculoskeletal Disorders 2014;15:283. Published 2014 Aug 21.
  8. https://www.ninds.nih.gov/sites/default/files/migrate-documents/low_back_pain_20-ns-5161_march_2020_508c.pdf, accessed 11/21/2022.
  9. Smart KM, Blake C, Staines A, Doody C. The Discriminative validity of “nociceptive,” “peripheral neuropathic,” and “central sensitization” as mechanisms-based classifications of musculoskeletal pain. Clin J Pain. 2011;27(8):655-663.
  10. Lentz TA, Beneciuk JM, Bialosky JE, et al. Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results from the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort [published correction appears in J Orthop Sports Phys Ther. 2016 Sep;46(9):813]. J Orthop Sports Phys Ther. 2016;46(5):327-343.

Richard Valdesuso, MD, MBA, MA

National Medical Director, Musculoskeletal

Kerrie Reed, MD

National Medical Director, Rehabilitation and Back Pain Management

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