SWORD Health And Virtual Musculoskeletal Care

TL:DR

SWORD health is a virtual musculoskeletal care provider that uses sensors, a tablet, and a physical therapist you see via telemedicine. You can do one of their 100+ exercises at home, and their Digital Therapist uses data from the sensors to give you live feedback. The information from your sessions goes to your physical therapist who adjusts sessions from your data and coaches you 1:1 over text + interspersed face-to-face telemedicine visits.

The future of the company will depend on how they bridge the online-offline handoff, increase consumer adoption, and show outcomes at scale.

This is a sponsored post - you can read more about my rules/thoughts on sponsored posts here. If you’re interested in having a sponsored post done, email nikhil@outofpocket.health.

Company

SWORD Health is a virtual musculoskeletal care provider. It got its name from the fact that my back feels like a SWORD is stabbing it. Or because they’re “cutting” down the cost of physical therapy haha I’ll be here all night. I need a hobby.

They’ve raised nearly $50M from Khosla Ventures, Transformation Capital, and more.

What pain points do they solve?

Let’s start with a lil’ bit of data to set the stage.

• Musculoskeletal issues are estimated to be the highest spend condition in the US at $381B spent per year with consistent growth. For 40%+ of employers, it’s a top three cost item in their claims.
• Most of the cost is for ambulatory surgeries. For lower back and neck pain, there’s also a considerable amount of spend for inpatient procedures.
• If you use the widest definition, about 50% of the US adults have been diagnosed with some sort of musculoskeletal disorder. About 18 million people report being unable to do a daily function because of one of these disorders. Arthritis and osteoporosis prevalence in particular is expected to jump in the next 10 years due to an aging baby boomer population.
• There are several studies that have found that physical therapy can achieve similar outcomes as surgery (depending on the type of surgery + severity of the issue). Physical therapy is often suggested as a first step before jumping straight to surgery.

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• Lack of adherence is a huge problem in physical therapy. This meta-analysis has found somewhere between 30-50% of home physical therapy exercises are adhered to, and 14% of people don’t show up to follow-up in-person appointments. Common reasons for lack of adherence to treatment were lack of time, inconvenience, pain during exercises, depression, cost, low baseline level of physical fitness, and more. Many people deem physical therapy as ineffective despite not completing a program properly, and opt for surgery if their pain doesn’t subside.
• Surgery has its own risks including infection, nerve damage, and blood clots. Additionally, it’s not uncommon for surgery to not work at all in alleviating pain. This phenomenon is so common that it actually has a name, Failed Back Surgery Syndrome (FBSS), despite not being a medical condition at all and just being...a result? A thing? The prevalence is somewhere between 20-40% of surgeries. Each subsequent surgery after the first has a lower chance of improving pain.
• Opioids are commonly prescribed for musculoskeletal disorders. Though it’s decreasing, nearly a fifth of people who presented musculoskeletal issues at the hospital engage in some kind of opioid use. The bulk of this is long-term opioid usage. Early physical therapy usage has shown to reduce the amount of opioid usage, and is a recommended first line therapy for many musculoskeletal disorders. If we want to address the root cause of the opioid epidemic, making physical therapy + pain management more approachable and utilized properly will be a key component.

On a personal note, I have struggled with lower back pain for 10+ years now. When I back that thang up, it’s serious, and unfortunately my lower back has paid the price. I did physical therapy for about 6 months in 2015 when I was experiencing quite a bit of lower back pain during exercise.

I had to pick a physical therapist based on how close they were to my office and leave in the middle of the day for an hour. I was lucky to be able to do that, but it was a pretty inconvenient process.

PT really helped me - I could feel my back slowly hurting less when I exercised. But after a while it didn’t feel like it was getting much better. So I stopped PT and my adherence to those exercises dropped considerably. But I was supposed to keep doing the exercises for preventive reasons, not just to actively improve.

Today my back pain is manageable, but during lockdown I’ve slowly felt it getting worse since I’m sitting for so much more of the day in admittedly non-ergonomically optimized ways.

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Long story short, this is a pain point I feel acutely (nice) and I was excited to be able to try one of the virtual physical therapy solutions. The problem they’re addressing is gigantic both in the spend and the number of people impacted.

What does the company do?

SWORD Health provides virtual musculoskeletal care that you can do anywhere you want. Your home. A park. An abandoned cabin in the woods on a cold stormy night where a tragic murder happened 100 years ago and the spirit still roams the grounds. Any place you feel like doing PT.

This is the first sponsored post where I actually got to try the product firsthand!

First, you fill out a questionnaire. The questions essentially try to gauge:

• Where is your pain and how long have you had it?
• How severe is it and does it prevent you from doing things (daily activities, things that would make you productive at work, etc.)?
• Are you taking medications and how often?
• How likely are you to get surgery?
• Do you have comorbidities (depression, mood issues, sleeping problems, etc.)?

These questions inform your physical therapist about problem areas but also gauge how much your pain is costing your employer. At the end of the program, if your willingness to get surgery goes down, you can ballpark approximately what the savings to an employer would be.

Once the survey is filled out, you do a virtual consultation with your physical therapist, who will be the one creating your regimen, adjusting it as needed, and coaching you through the program. We talked about my past physical therapy experiences, current pains and goals I’d like to achieve, and my inability to like eggplant no matter how many different ways it’s prepared.

A couple of days later, a package arrived with my SWORD Health kit. Inside was a tablet, sensors, and straps to hook the sensors into. Despite trying to hack the tablet so I could watch anime on it, it only runs the SWORD Health Digital Therapist (no fun).

The sensors sync to the tablet and then you strap them on to the appropriate places on your body. Your physical therapist assigns you a list of therapeutic exercises. As you go through them, the sensors + digital therapist can tell if the movements are correct and how far you’re moving in each direction. The digital therapist has 5000 different types of feedback messages like “don’t bend your knee,” “lean forward more,” and “your squat form is more embarrassing than your Facebook etiquette circa 2009.” You get a score of 1-5 stars depending on how far you move in a direction for a given exercise. My regimen was usually between 17-25 exercises and in total would take me 20-25 minutes.
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I saw my PT every two weeks or so for a quick check-in. More complex patients will get more face time. Between the visits, I would text random questions I had and they would make adjustments to the regimen as needed (2-3x per week). In order to get the full SWORD experience, my body decided this would be a good time to develop ankle tendonitis due to saving children from a burning building and/or generally having flat feet. My PT sent me an additional lower limb kit and we incorporated new exercises to help me recover, strengthen my arches, and help my balance.

The PTs can see all of their patients data, including their compliance, satisfaction, range of movement at a degree level, and difficulty with exercises. The PT can double click into any individual to see exercises they’re struggling with, observe their progress over time, and message them through the portal.

SWORD Health has preventive, post-acute, and post-surgery programs for shoulder, neck, ankle, elbow, hips, knees, lower back, and wrist.

Once you’ve decided that you probably don’t need SWORD anymore, you send them back the kit they sent you, tablet and all. Unless…

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What is the business model and who is the end user?

The company works with + charges employers to reduce the cost of their musculoskeletal claims. Their employees are the end users, and they’ve saved their employer clients 34% of spend after implementation.

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Job Openings

SWORD is hiring for some positions!

• Head of Growth Marketing
• Head of People
• Head of Corporate Marketing
• Sales Talent
• Customer Success Talent

Out-Of-Pocket Take

There’s a lot to like about SWORD Health.

For one, there’s no doubt in my mind that compliance for this is higher than regular PT. I did these exercises every week, just because it was easy and it was in my apartment and I knew my PT would yell at me if I didn’t. SWORD told me 94% of their members complete their programs.

Physical therapy is a low-risk and helpful first step for people suffering from chronic pain or musculoskeletal issues, but the reality is that it’s a lot of work for the patient over a long period of time vs. something like pain medication or surgery. The goal for physical therapy should be to reduce the friction in taking part and increase the chance that someone completes a full course. Virtual physical therapy feels like a meaningful step in that direction.

The main thing that gets me excited about a company like this is the measurement of movement. The sensors create objective, quantifiable data for something that was traditionally eyeballed or estimated. The PT can actually see the degrees of motion for different exercises over time in their dashboard. If you saw a new PT, they’d have a much better understanding of your improvement over time by seeing this quantified progression.
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This is also powerful for consumers. As I’ve talked about before, one thing that sucks about healthcare is that it’s hard for patients to see small, incremental changes and feel like they’re actually improving. This is definitely true for any musculoskeletal rehabilitation.  Every day, you get slightly better though it might be hard to notice. When you quantify these small daily movements, it’s easier to push yourself because you can actually see a number changing.

Here are some open questions I have about a company like SWORD for the future.

What does the online-offline handoff actually look like? The reality is that there are some cases when it would be nice to see someone in person, and some cases where it’s absolutely necessary (e.g. patients with cognitive issues or complex medical issues with their muscles). By starting virtual first, SWORD could potentially create a very different hybrid online-offline workflow for physical therapy.

In the future, will it make more sense to have sensors measure these movements or machine vision? Both technologies seem to be improving quite a bit, so which would be better at capturing the minutiae of small movements more accurately? Especially since I”m sure the cost of the sensors will be much higher than using software + actually setting the sensors up might be difficult for people that aren’t super tech savvy or need assistance.

What do the health outcomes look like as the company grows? SWORD shared some of the self-reported patients outcomes:

• 70% reduction in pain
• 64% reduction in surgery intent
• 24% of members stopped taking medication

They also shared a study comparing their virtual solution vs. an in-person solution for rehab after a total knee arthroplasty. The virtual PT solution performed better against conventional PT for the primary endpoint of Timed Up and Go (TUG) test, as well as most of the secondary endpoints like symptoms, quality of life, and knee flexion.
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They have a study looking at hip replacement which looked at improvements over an 8-week and 6-month time frame and found similar improvements vs. conventional physical therapy over a longer time period. I’d love to see a similar comparison for other types of PT and what those outcomes look like as the patient panel grows.

How will SWORD convince patients to use its virtual physical therapy service vs. traditional physical therapy? In the above study, half of the people eligible refused to participate, but SWORD has strong member satisfaction scores (9.3/10) and user engagement (85%+). To me, this means they need to convince people to use the product and then they like it once they do. Plus, the studies were conducted in a pre-COVID world and telemedicine/virtual programs have become much more popular in the last year. Increasing consumer adoption will depend on customer education/branding, good marketing chops, and virtual PT becoming normalized.

At a personal level, after 4 weeks my ankle is feeling less pain and is looser + my back feels like it flares less regularly. This is partly because I’m not carrying my team in League of Legends anymore, but physical therapy helped. Hopefully, by the end of my course I’ll feel more confident returning to exercises like heavy weight squatting and deadlifts, which I’ve subconsciously avoided because of my back and ankle.

All in all, I like companies that are making physical therapy more accessible. I think they’re solving a meaningful problem with a common sense solution. Virtual-first physical therapy providers will make it easier for people to actually do the exercises correctly at home and stay compliant, which is probably the most important thing in prevention and recovery. SWORD is taking a cool approach here. I’ve enjoyed using it, and I can see virtual physical therapy becoming a bigger part of my life as things start breaking down.
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Thinkboi out,

Nikhil aka. “hurtboi in”

Twitter: @nikillinit

IG: @outofpockethealth