Thomas Denninger Interview Transcript

Thomas Denninger is the Regional Director of Clinical Excellence at ATI Physical Therapy. This interview took place on September 28, 2018.

 

To start off, could you describe your current role and the work that you do?

I am a physical therapist, I work for ATI Physical Therapy. My current role is in the Department of Clinical Excellence, overseeing different components of clinical care from education and training, post-professional development, and components of our research agenda.

How long have you been in that role?

I’ve been in this role for three years.

How do you see the role of physical therapy when it comes to pain management?

I’ve been a physical therapist for ten years. In a clinical setting, my patient population has primarily been folks with spine-related complaints, specifically complex pain presentation such as fibromyalgia, lyme disease or post-back surgery, things along those lines. I’ve also worked closely with pain management and rehabilitation physicians the entirety of my career. It’s obviously a population I’m very familiar working with and I really do feel like physical activity, not just specific physical therapy but physical activity, is so important to individuals currently under the care of pain management and rehabilitation clinicians because it’s part of the issue. We see some of the decline that happens with these individuals in that they either have insidious onset or there’s a traumatic headplace and there’s this slow spiral down where they’re hurt so they move less, they move less so they become deconditioned, they’re deconditioned so they become more sensitive, and they’re sensitive so they move less. It just kind of completely spirals down. Physical therapists are uniquely positioned to introduce movement and function back into someone’s life in a logical way without doing it in such a way that people enter into this cycle where they’re like, “Oh, I’m really going to overcome this. I’m going to go and walk five miles!” And that person might be successful at walking five miles, but they might not be able to move for the next week. If anything, they enter into a flare-up zone and now their nervous system has become more sensitive so they’re doing less and they’ve increased their medication usage, and now they are less responsive so they are taking more. I believe PT is really essential for patients under the care of PM&R clinicians as a way to be part of the long term solution and return people to function and hopefully return them back to just life.

It’s interesting what you’re describing as sort of this downward spiral where, the fact that if they’re injured, they move less and when they move less, it makes it more difficult to get out of that. For your steps, you start them incrementally and then a little bit in the beginning and then a little more after that. Is that kind of how you’ve planned out the trajectory of their PT?

Yeah, absolutely. If we’re talking about very involved patients, many of these ones that have the largest opioid problem insurance  was I think they’re on the medication they are because of the clinical presentation that they had. A lot of them are multidimensional in their management, whether that’s mental health providers or behavioral therapy and things like that. These people often have pre-pronounced biopsychosocial involvement. On top of that, they have maladaptive belief systems related to their pain and their presentation, most of them have very pathoanatomically based diagnoses that they cling to whether that’s appropriate or not. A lot of the initial management is addressing sort of those fears and beliefs using cognitive behavioral therapy or therapeutic neuroscience education and helping them reconceptualize what pain really indicates. We talk a lot about pain being an output and not an input, that you have nociception, you have sensations that go in the brain relief places, the value on whether you are at risk or not and then helping people understand that pain doesn’t equal damage, you can get people a little bit more willing to move because quite frankly, many of them are very scared to move because their experience has been “when I do more, I hurt more.” A lot of people think that patients with chronic pain or opioid addiction are lazy, but most of them have actually tried many times, whether it’s quit cold turkey or really try to push through things, and they’ve end up worse off. By the time they’re reaching me or a medical provider, they tried things. I have a lot of people who say “I don’t know why I’m here,” “I’ve tried this, I didn’t have enough force for it,” “the last physical therapist I saw just killed me, I couldn’t move for days,” a lot of it is bringing down those fears, helping them reconceptualize why they’re here, what their system is telling them, and then, getting back to your original point, progress them in a stepwise way. A lot of what we do is try to keep them below the threshold for bringing on their pain. They can go into a little bit of discomfort but when you have an centrally sensitized system, where their pain is less associated with their tissues and more associated with the sensitivity of their nervous system, such as fibromyalgia, you want to work them in a way that is logical, that allows physiologic adaptation to happen, but you’re not pushing them to the point where the system says “Danger, danger, danger. Shut it down, upregulate sensitivity,” that drill. It becomes very sequential. “You did for thirty seconds on Tuesday, you’re going to do this for sixty seconds on Wednesday,” or “Oh, is that starting to bother you now? No, we don’t want to stop it completely, but I want you to go a little bit more slowly so that way we can influence the nervous system a little bit.” We want to have someone feel like they’re making progress, have the system exposed to movement and function but not in a way that’s going to reinforce their fear of movement.

I know that the patients you have have fibromyalgia or certain other conditions, taking that into account, on average, how long does it take for a patient to go through the course of PT treatment? Or does it vary so much that it’s hard to find an average number?

It’s absolutely variable. Our goal is not to have someone in PT for a long period of time. We want to influence their behavior we really want to empower individuals, so the ultimate goal, especially with complex pain, is to say, “I don’t want you dependent on me. I don’t want to see you two times a week for the next three years or even six months.” I think a lot of times, people feel that they’re so involved that why even begin PT because they won’t be able to commit to this for as long as it would take to actually make an improvement. As I’ve previously described, in terms of helping people reconceptualize what’s going on with them, what we often find is that there are some patients who aren’t ready. They’re going through a lot beyond the four walls. Some people are unresponsive. We don’t have a 100% success rate, nobody does when dealing with a tough patient population like this. But when someone is ready to hear some things and try some things out, they get some good vibes their first couple of visits, you have some people saying, “okay, this is something, you’re not hurting me, some of this makes sense. This is different.” Often times, we’re seeing people between six and ten sessions, maybe up to twelve, over a six week period, but I would say that’s pretty much the norm when talking with this patient population, not half a year, multiple years. Really the goal is to help people gain autonomy in that they can maintain physical activity and they know how to progress things and they’ve established more healthy habits whether that be from a sleeping perspective or even from a nutritional perspective, which is kind of part of the entire wholistic presentation.

 

I know that the discussions about pain management, especially in light of the opioid crisis, has talked about the expanded view of pain management where physical therapy is being mentioned more and more. At least with the patients you’ve had that have been on opioids for their pain management, do you feel that over time, physical therapy makes them less dependent on the opioids for pain management?

 

Yes. I think there’s a couple of layers there. By the time people hit pain management, often times they are in bad regimens. Most of the pain management physicians that I work with sometimes say, “I should have been managing this person a long time ago, and now my role is really to help get them back.” And PT is really part of that solution in terms of teaching self management techniques to individuals so that they are less reliant. That can range from self-guided meditation to breathing exercises to movement-based strategies for when people are having flare-ups and things like that to help them from just reaching for the pill bottle every time something is a little bit higher. In addition to that, there are pain relieving modalities that we have. Classically speaking, whether it be heat or electro types of modalities. On top of that, hands on care. Manipulation, mobilization, soft tissue based techniques, things like that, certainly do help. Another piece of that too is that aerobic exercise in and of itself is a tremendous pain reliever, getting people to essentially channel the medicine cabinet in their brain and get some of the descending pain inhibition that’s kind of inherent to all of us. There’s some past studies that essentially found that twenty minutes of aerobic exercise at 65% percent of your max heart rate is equivalent to around five milligrams of an opioid itself. I can’t exactly tell you what that citation is, but aerobic exercise is a significantly under-utilized form of pain relief. We often find that if people keep to their exercise regime and stick to the stretches and things like that, that they are not reaching for the pill bottle when they have flares. And I think that’s important, because I think most people would tell you that they still have pain but it’s more tolerable or they’re better able to manage it. For a lot of these individuals, it’s not necessarily a curative situation. They’re going to have discomfort, it’s all a matter of how they respond to it and how they deal with it. And over an elongated period of time, whether they reach that independence where they really are managing it and returning to their life instead of being a victim of their pain.

When it comes to insurance coverage, like how much of the physical therapy is covered or how many sessions, what has been your experience with the patients that you had?

It’s so variable. A lot of folks are on Medicare, so Medicare was at a cap system for a long period of time. Recently, that has actually changed where there’s less of a Medicare cap now. But, depending on the insurer, some of them have a baseline of ten PT visits for the year, and that’s a hard cap. Other ones have no limitations, some insurance companies require documentation with justification of “this person needs this many sessions,” and if you’re looking to go over that, you need to have demonstrable change and range or strength or endurance or numeric pain values. And for others, it’s not monitored at all. Many of these patients that are opioid dependent are on government payers whether it be Medicare disabilities, Medicaid, things along those lines. The way that Medicaid is managed, it’s a state program, so that’s highly variable with local plans per state, whereas Medicare is a bit more consistent across the board. Workmans Comp is an entirely different situation, where often times, it’s following the physician’s lead in terms of how many visits are initially approved. That can be kind of difficult for these patients, if we’re simply talking about these complex patients and physical therapy is being utilized as part of their regime to step down their dosage. Often times, it is harder to show objective change. You may hurt your shoulder and you can only raise it to your elbow, and after two weeks you’re reaching straight up above your head. That’s a very easy objective improvement to show. If you have someone who is coming in and they’re at 9 out of 10 pain and their function is very very low, it might be harder to at least initially justify that they are doing better. That objective improvement might be that they’re actually taking less medication, or that they are utilizing caregivers less. They’re able to more independently care for themselves even though their pain still might be unchanged. They might still be a 9 out of 10, but if we can show that they’re doing that and they’re functioning better, even with less medication, that’s something I’ve seen a change in in the last year to two where insurance companies are allowing or are more in favor of some of that substantiated gain outside the traditional system of “their range hasn’t changed and their strength hasn’t changed.” It’s not because of their range or strength, it’s because of their pain.

 

So it’s almost like they’re looking at indicators that aren’t necessarily the most relevant to the kind of progress testing made, because progress, even if it’s not with both measures, when it comes to less dependence on medication, they are making progress.

Absolutely. I think it has been better recognized as an indicator of change. The way that insurance companies were kind of locked in, it was much more nociception or traditional musculoskeletal type injuries. You sprain your ankle, there’s significant impairments. You have pain but there’s also substantial reductions in your range of motion and strength. If I’m asking you to show progress, I should see that your range and strength is getting better and that should correlate somewhat with your pain. Whereas, for many of these individuals, they are more pain patients than a shoulder or neck or back patient. The indication in and of itself might be that they have an improved level of function or on a lower dose of opioids because the reason for involving PT or part of the reason for involving PT is to be able to reduce these people’s prescriptions.

 

Did you ever have situations with patients where you could see that they were making progress, but it was difficult for them to continue your sessions because their insurance provider either put a cap or was focused on things like muscular strength and things like that, so that sort of made it more difficult for them to continue sessions?

Yes, I think that’s not the biggest problem but that has been a problem either when you are working with someone and they are showing progress and now it has come under more scrutiny because they are identified as a high utilizer or something along those lines. Or you’re working with either a system or a case manager who is more accustomed to patients with typical musculoskeletal complaints. I think that’s improved, I think this has become such a large problem that so many systems don’t really have answers for patients with complex pain. If a physician is happy with some of the step-downs that are happening with a patient, and the patient is engaged in physical activity, I’m finding more and more that as long as everyone is on the same page, we don’t face the same type of barriers. Some of those processes are exemption processes, so there might be interruptions in care. Ultimately, they might say, “okay, keep going,” but by the time all of the documentation is in and they’ve approved more visits and things like that, now you’re dealing with someone you might not have seen for two or three weeks and they might have reverted back to some of their behavior just by not having someone holding them accountable or being consistent. It is an issue, like I’ve said, I think it’s becoming less of an issue because people are seeing PT as a viable option for these patients, especially the ones that are engaged. And on top of that, the nice thing about physical therapy is that it is relatively inexpensive and it’s very very safe. If we have people moving and participating, there are much worse things we could be doing with our health care dollars.

It looks like the physical therapist or the doctor can do some paperwork to apply for an exemption that would allow a patient to continue to have more sessions. Is that what you’re describing?

Yes. Most systems, even if they have a hard cap or have a cap on visits, they’re usually in some form of the exemption process. I think people are better recognizing situations where someone might not fit underneath that cap and they need more and they’re making progress and we can demonstrate change even if it’s based off something like reduced dependence. The biggest challenge associated with that is it does seem to propagate interruptions in care.

And is that exemption applied by the physical therapist or by the primary care physician?

Usually by the physical therapist. Some providers might require more documentation from the referral, whether it’s primary care or PMR or something along those lines, but often times it is based off of the PT documentation or a specific form that a particular insurer utilizes.

You mentioned that even after the exemption is granted, the challenge is that there could be a gap in sessions while that’s being processed.

Yes.

What would you say is the single biggest challenge that you’ve seen as a physical therapist in improving the quality of life of your patients?

That’s an overarching question. I would say that the biggest thing that I’m frustrated with is we’re at a point now, where the opioid epidemic has hit, whatever the stats you want to look at whether it’s 115 deaths per day or something like that, it’s very frustrating to think about how many of these could be avoided or how many could have been avoided. It’s kind of what we talked about before, most PM&R physicians will say “it never should have gotten here. Now I’m trying to walk back things that never should have become like this.” Even though we’ve made some progress in the past couple of years such as curtailing prescriptions and things like that, there is a dramatic body of knowledge that shows that most of these cases should have been avoided. Most of these people never should have been prescribed this or prescribed in the way that it is in terms of a very long episode regime. I think there’s pretty sizeable research in terms of if you give someone a ten day prescription of an opioid versus a thirty-day prescription of an opioid, the rates of addiction at one year and two years are dramatically different. It’s just a matter of saying that we shouldn’t be here. We have to deal with this problem, there’s no doubt about it, but there’s still so many behaviors within the medical system that are continuing to beget this problem. Most of these individuals, there’s some statistics saying, if you track it all the way down to heroin overdose, well 80% of heroin users started on a prescription opioid. If you look at prescription opioid users, the vast majority of those individuals started their opioid regime based off of musculoskeletal injury. You just take the next step back and see that it really shouldn’t have been the initial management for these individuals. It should have been proper utilization of non-steroidal anti-inflammatories. Or, I’m a physical therapist, I have a bias, but I think PT as a primary intake into the medical system and a primary treatment for individuals with musculoskeletal pain is significantly underutilized at this point. I love my job, I know it’s hard to be a physician, I know you’re seeing someone in pain and they are asking you to help them with that, the compassionate thing to do is to give them something that will help them with that pain as quickly as possible, but often that winds up in the form of an opioid medication. When I see patients and they are in pain, I don’t have that option. They’re not asking me for a prescription so it’s not even an option, so I know I have that advantage. I know I can help them but I know it’s not as easy as taking a pill. So, to go back to your question, I guess my biggest frustration is that we’re still not managing these patients well. People with musculoskeletal complaints come in and they are overprescribed and overimaged and they’re not getting to the right places early on. The answer to the opioid epidemic is prevention because for most of these individuals that have a transition to addiction, it’s a really hard road and not necessarily one that has a high success rate. If we think about how backward the system is wired, in many health plans opioids are cheaper than surgery and surgery is cheaper than physical therapy.  If money is an issue you are financially incentivized to do the most harmful and potentially least helpful things.

If somebody gave you a magic wand that allowed you to change any policy, any healthcare policy, in order to more effectively alleviate the opioid crisis, which policy would you zero in on?

I would just say probably anything that is a restriction to care early on. I think many of these individuals are folks who let complaints persist for a long time so that the time they are seeking care, it is more chronic or more severe. So, I think that anything that relates to accessing standard levels of care for problems early would be my area of focus. The easiest thing to pinpoint for that is the rising cost of deductibles and out of pocket maximums which dissuade people for seeking care for many of these things. For instance, someone who has a knee osteoarthritis, that if they were to access the system early enough, they would be referred a non-steroidal anti-inflammatory, they would be sent to PT, their knee would get much better, their function would remain high, as opposed to what we see. People do not want to go see the primary care physician or the orthopedic because they think, “well, that’s going to be $400 that I don’t have right now. I have a $3,000 deductible so I’m going to wait until it’s so excruciatingly bad.” And 9, 12, 18 months down the line, the MRI will lead to a total knee arthroplasty and exposure potentially to opioid addiction. I understand why insurances work the way that they work, in terms of patients being cautionary and making responsible decisions, but I would say that the system has created situations where people are restricted from accessing care early, which would have kept their entire trajectory of care less expensive and more effective.

 

I know that there’s been a lot of discussion surrounding the fact that when patients are prescribed opioids, there are generally very few insurance issues. They get it, they get an insurance reimbursement. Whereas when it comes to something like physical therapy, then you have these significant copays or deductibles. You deal with these financial hurdles for the patients and even for things like medication-assisted treatment or a similar issue where a patient has to pay a higher deductible for medication-assisted treatment than they had to pay for the opioid, which caused their opioid use disorder in the first place. It seems, looking at it from an economic perspective, that there’s a misalignment of incentives.

I would absolutely agree with that. The things that are safe and effective are the ones that are expensive or inaccessible, whereas things that are less effective and/or quite dangerous are very easy to access. I would agree with your language that there is a misalignment in management.

As a physical therapist, what was the most memorable experience that you had, whether it was something you observed or something you heard someone say that stuck with you?

There is a physical therapist, his name was Adriaan Louw, and Adriaan is very experienced, a very accomplished researcher, has his own private practice treating a lot of these individuals with complex pain and things like that. The two most memorable things that I really took from hearing him and forming a relationship with him is that these individuals are not people who certainly want to be this way, and it’s not just people who are destined to end up in a bad situation. That was kind of confirmed in my practice. I’ve treated former CEOs that are now unemployed and are thinking of filing for bankruptcy because they got hooked from something early on that arguably should have been managed much much better. This idea that these persons are junkies or these are people that were inclined to end up in bad situations, I think is such completely and utterly false. No one chooses to have this and it affects people of all ages and demographics and socioeconomic statuses. It really touches everyone. In my personal practice, there are several individuals that really taught me lessons but the easiest case that stands out to me was when I was referred a college professor.  A PhD individual, a young, brilliant individual who had a heart condition that required her to have a pacemaker early on. She had to have several revisions, I believe her first pacemaker was at seven, and now I see her in her late thirties, and really this is an individual who could no longer drive herself to work. She could not go grocery shopping, she could not unload or load a dishwasher. What she had to do to get through her day as a college professor with several PhD students underneath her that she was an advisor for was astronomical and it all traced back to how her pain wasn’t well-managed after her last pacemaker procedure. She went in, it was going to be a fairly standardized standard procedure, and when they got in there they found it was a more complicated procedure than was expected. They had to change kind of the pocket in which the device sits in. There was a more involved procedure than the level the individual was expecting, so there’s certainly a level of psychosocial involvement there in terms of “this isn’t what I signed up for, what happened?” But then, on top of that, her pain pump had gotten disconnected in the middle of the night, and essentially she was unmedicated post-procedure. They only discovered this the day after. There was even more of “how could they do this to me?” type of feelings that were brought on. And this is someone that had failed PT at five or six other providers, she had higher and higher pain management procedures, she was really in this downward spiral that we started our conversation with. I guess what it really taught me was, helping her understand that it wasn’t her neck or her back or her hips or her shoulders that were the problem, it was much more her nervous system and her sensitivity, and that this was an individual who just simply needed an explanation. So much of her presentation, and worsening, was based off of anxiety from not knowing or having multiple different explanations. Just the fact that she didn’t feel like she had been heard through this entire process of twelve to eighteen months as her condition worsened. So just listening to someone and just offering them a feasible explanation that helps them understand why they’re experiencing what they’re experiencing, offering hope that a lot of realisticness in terms of “there’s no reason you can’t get back to ‘x’”, but also being realistic with them. It’s not going to happen overnight, there’s no miracle cure for this, this is going to be a process of helping your body become less addicted or less dependent or less sensitive. I guess the big thing that strikes me is that it affects everyone, but there is hope for the vast majority of people. And if they are managed correctly, we can either prevent these situations from occurring or we can help a lot of people regain large chunks of their life that they have lost and are on a path to lose everything.

Were there there any other thoughts or additional ideas you would like to share?

I really thank you for the opportunity. I have a fairly standardized slide deck that better hits on actual research regarding opioid addiction and physical therapy that I would love to send your way. I’m sure you have more than enough material, but whether it be a couple key articles that you could reach out to the researchers or just have a piece of where PT fits in this problem, whether it be from a preventative standpoint or treating people who are addicted and understanding that PT is part of their step down program. I think it’s worth noting that all rehab programs really really value physical activity as part of the recovery process. I know that doesn’t immediately register with most people who are addicted as well as I think large parts of the medical community and the public as well. It’s amazing what exercise can do. If we could put that in a pill, the benefits of exercise, we would all be in very very good hands.