Does Medicare cover maintenance therapy when my condition is not going to improve?

There remains some confusion around Medicare’s coverage of maintenance physical therapy. The general idea is that if a skilled service is required to prevent decline in a person’s condition, then the service is now covered under Medicare.
The following is from the Center for Medicare Advocacy website:

SERVICES FOR BENEFICIARIES WITH CHRONIC CONDITIONS

A chronic condition requiring skilled care services can take many forms and is not limited to a particular set of disease, diagnosis, or disabling conditions.

COVERAGE REQUIREMENTS

The Medicare program recognizes the need for skilled care and related services for chronic, long-term conditions.  For care to be covered, the patient must require skilled services which may be designed to:

• Maintain the status of a medical condition or the functioning of a body part; or
• Slow or prevent the deterioration of a medical condition or body part.

WHERE ARE SERVICES PROVIDED?

Services can be provided in a variety of settings – at home, through Medicare certified home health agencies, in Medicare certified outpatient facilities, rehabilitation hospitals and centers, and in Medicare certified skilled nursing facilities.

WHO PROVIDES SKILLED SERVICES?

Skilled services are those services provided by (or under the supervision of) technical or professional personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists, and audiologists. Services must be a type that are not ordinarily performed by non-skilled personnel.

 

More information may be found at

http://www.medicareadvocacy.org/medicare-info/chronic-conditions/#Coverage%20Requirements

 

Lindsay Haas, DPT at our Castro Clinic featured on Knit and Tonic Blog

Lindsay Haas, DPT at our Castro Clinic is also an amateur knitter, passionate about sharing her expertise in human mobility and movement with other knitters. Interviewed here by Knit and Tonic blogger, Wendy Bernard:

http://www.knitandtonic.net/knitandtonic/2013/02/and-to-think-i-thought-knitting-yoga-was-a-joke-.html

Knitting Tips from a Physical Therapist

“Just one more row.”  I’ve thought it myself countless times- only to realize another 20 minutes has gone by without making any move to stop.  Regardless of your level of skill, anyone who knits has probably dealt with the aches and pains associated with working on a project for too long.  How can you avoid it?  One of the best things you can do is work on developing good habits so you can stop issues before they start.  As a knitter and a physical therapist, I see many patients with overuse injuries.  Here are some basic tips on how to stay comfortable while working:

Good Posture – I know we’ve all heard it time and time again but that doesn’t make it any easier to sit properly.  First, it is important to have good light when you are knitting so you do not need to ‘squint’ down at your project.  A good chair is key- not too hard, not too soft, but just right.  When sitting, your knees should be slightly lower than your hips, and your feet should be flat on the floor.  You should try to have your bottom at the back of the chair and have your weight shifted slightly forward.  Sometimes a towel or roll behind your low back can help provide proper lumbar support.  Your shoulders should be down away from your ears and your shoulder blades slightly squeezed together on your back.  Your elbows should be in at your sides and your chin slightly tucked.

Take Breaks – No one said it would be easy to maintain good posture, especially when you are just getting used to it.  Set a timer for 30-45 minutes and when it goes off, put your knitting down and get up to move around.  You should plan to take a 5-10 minute break.  Walk around, which helps with circulation, or do a few of the exercises below.  Changing your activity will keep you from developing repetitive strain injuries, and gives your body time to recover.

Stretch – Now that you are taking breaks- use the time to move around.  Gently stretch your neck side to side, and slowly look over each shoulder.  Roll your shoulders forwards and backwards.  Try to touch your elbows behind your back.  Make circles with your wrists clockwise and counter clockwise.  Use one hand to gently stretch the other wrist down and up.  Repeat on the other side.   If it feels okay gently twist your torso to the right and the left.  Reach both arms up as if you were to touch the ceiling.  None of these movements should cause you any pain or discomfort, just gentle stretch.  If one bothers you, try to modify it or lessen the intensity, or just don’t do it.

Breathe – When your posture isn’t optimal you aren’t breathing as efficiently.  Many people become ‘chest breathers’ using the neck muscles and shoulders to elevate the ribs.  Ideally you should use the diaphragm (the muscle at the bottom of your ribs, right above the belly button) to fill your lungs.  To do so focus on pushing your belly button out as you breathe in.  No one should see your shoulders moving up and down.

Listen to your body – If you do find yourself getting symptoms, it is important to rest and give your body time to recover.  Otherwise you can be at risk to develop repetitive or chronic injury.  Icing the area may help calm any irritation and decrease soreness (but make sure to put something between the ice and your skin!)  If your symptoms to not resolve with a week of rest, or if they get worse, you should go see a health professional.  You should DEFINITELY go if you are experiencing any numbness or tingling, loss of strength, or radiating pain.

Making small modifications and developing good habits will help you avoid knitting related injuries and ensure healthy knitting.  And remember to stop knitting and rest if you begin to notice any symptoms.

Lindsay Haas is an amateur knitter and a professional physical therapist at san francisco sport and spine physical therapy.  She enjoys helping knitters and other crafters ensure they can continue their projects pain free, as well as comparing notes on projects and learning new techniques from her patients.

Snowboarding, A Physical Therapist’s Perspective

An east coast transplant to California, I’ve fallen in love with the mountains.  In the winter, for me that means strapping on a snowboard to play in the snow in Tahoe.  As those of you who ski and snowboard know, this requires a certain level of fitness.  Aside from the endurance and general strength it takes to have fun out there, there comes risk.  Having the perspective of being on orthopedic physical therapist, I see first hand the injuries that can happen out there, to all different degrees.  I’ve also been injured myself, and was reminded how important it is to take care of my body properly so I can keep snowboarding…until I’m 80 or older!

Having started snowboarding later in life, having more awareness of the risks associated because of what I do, and just some of my personality, I definitely ride more conservatively out there; my main goal being having fun.  I know the consequences of taking more risks with my riding, especially when the conditions are firm or icy.  Now that being said, I still like to get out there, make smart decisions, like calling it a day when I feel that fatigue set in.  Most importantly, I train my body for the hill.  Sure it’s important to work on endurance and cardio, and cross train, but more importantly is balance and core stabilization training.  I make it happen, every day during the week…I pick 4 or 5 quick exercises to keep challenging my stability to increase my response out there, so my body knows how to respond to the variable conditions that present themselves.

Everyone out there should have a program to prepare themselves for the season, and upkeep during the season.  That should include a flexibility program (my foam roller lives up at my ski house during the season), a strength and core stability program (including things that challenge your balance on uneven surfaces), and a dynamic warm up program to start off before the first turns of the day.  With doing those things, you will significantly decrease your risk of injury, your body will be more stable on the hill absorbing those bumps, and you will even perform better.   And when you do have an injury, even a minor one, it’s important to consult with a PT (the movement experts) to minimize your time off the slope and get your body back to functioning quicker.  I didn’t do this when I should have last year, and ended up limited in my summer activities because of it…lesson learned!

Jessica Monaloy, PT CIMT
San Francisco Sport and Spine Physical Therapy
Jessica@sfsspt.com

Did You Know?…

Low back pain (LBP) accounts for 2.5% to 3% of all physician visits in the United States.^1-3 Annual direct health care costs were estimated at more than 85 billion dollars nationally in 2005, up 65% from 1997.⁴ The prevalence of chronic, disabling LBP is increasing, despite increasing spending on the problem.^{4, 5}

Most patients with LBP initially access health care through their primary care provider.^{6, 7} Decisions in this setting are likely to have a substantial impact on outcomes and costs.⁸ Only 7% of people who consult their primary care provider for low back pain (LBP) are referred by their provider to physical therapy in the first 90 days of an episode.⁹ Practice guidelines generally recommend delaying referral to physical therapy for several weeks following initial consultation.^10,11 The rationale for this recommendation is that most patients recover rapidly, and not intervening quickly wastes resources and might impede recovery for some patients by excessively “medicalizing” the condition.^12,13

According to Fritz’s study in SPINE, early physical therapy intervention was associated with decreased risk of advanced imaging, fewer additional physician visits, fewer injections, and less opioid medications compared with delayed physical therapy. Early intervention was defined in this study as commencing within 14 days of initial onset. Total medical costs for LBP were $2736.23 lower for patients receiving early physical therapy.⁹ That is a cost savings of over $2700 per case, on average.

Dr. Gellhorn concluded in a separate study in SPINE that “There was a lower risk of subsequent medical service usage among patients who received PT early after an episode of acute low back pain relative to those who received PT at later times. Medical specialty variations exist regarding early use of PT, with potential underutilization among generalist specialties.”⁷ If the patient is not consuming more healthcare resources in this scenario it is likely because they do not require them. They got better.
Please call us or email if you’d like a referral pad for your patients. We’re here to help you and them return to activity and get out of pain as quickly as possible. 415.593.2532, David@sfsspt.com

1. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine 2006; 31:2724-7.
2. Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain: frequency, clinical evaluation, and treatment patterns from a national survey. Spine 1995; 20:1-9.
3. Licciardone JC. The epidemiology and medical management of lowback pain during ambulatory medical visits in the United States. Osteopath Med Primary Care 2008; 2:11.
4. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA 2008; 299:656-64.
5. Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med 2009; 169:251-8 .
6. Deyo RA, Phillips WR. Low back pain: a primary care challenge. Spine 1996; 21:2826-32.
7. Gellhorn AC, Chan L, Martin B, et al. Management patterns in acute low back pain: the role of physical therapy. Spine (Phila Pa 1976) 2012; 37:775-82.
8. Feuerstein M, Hartzell M, Rogers HL, et al. Evidence-based practice for acute low back pain in primary care: Patient outcomes and cost of care. Pain 2006; 124:140-9.
9. Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: Impact on future health care utilization and costs, 2012. Spine 2012; 25:2114-21.
10. Koes BW, van Tulder MW, Lin CC, et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010; 19:2075-94 .
11. Murphy AY, van Teijlingen ER, Gobbi MO. Inconsistent grading of evidence across countries: a review of low back pain guidelines. J Manipulative Physiol Ther 2006; 29:576-81.
12. Moffett J, McLean S. The role of physiotherapy in the management of non-specific back pain and neck pain. Rheumatology 2006; 45:371-8.
13. Von Korff M, Moore JC. Stepped care for back pain: activating approaches for primary care. Ann Intern Med 2001; 134:911-7.

Awesome Apps for the New Year!

Below is a compilation of apps we, at San Francisco Sport and Spine Physical Therapy have used or had recommended that work well and align with what we do to get people better and help them stay that way!
If you have a particular favorite, please email sturdy@sfsspt.com with your suggestion.

MyFitnessPal — calorie and exercise tracker

http://www.myfitnesspal.com/

The Habit Factor — great for creating new habits around exercise, activity or anything

http://www.thehabitfactor.com/welcome/

Chronic Pain Tracker

http://www.medhelp.org/land/pain-tracker

My Pain Diary: Chronic Pain Management

http://itunes.apple.com/us/app/my-pain-diary-chronic-pain/id338627856?mt=8

Fit Bit

http://www.fitbit.com/

ZamZee.com – Fitness meter for the whole family, including kids!

http://www.zamzee.com/

How to properly prepare for ski and snowboard season.

Ski through the entire season by avoiding injury.

New jacket. Check. Snowboard waxed. Check. Chains on the tires. Check. You’re ready, and there is finally fresh powder on the hill. The anticipation built up over the sunny, summer months is finally about to be unleashed down the hill. And then it happens. All your preparation lost to the jump you landed wrong and your newly torn ACL. It happens. And there is nothing that you could have done, right? WRONG.

We see it in our clinic every season. Knee pain, tears, sprains, wrist and shoulder injuries…many that could have been prevented with the proper preparation. Yes falls will happen, especially with inexperienced athletes, but you can reduce your number of falls and how your body responds to falls with the appropriate training.

What is ‘Good’ Physical Therapy?

Do you think you know what ‘good’ physical therapy is? Is there a difference in the quality of physical therapy from clinic to clinic or is it all basically the same? Do you just go with the first place listed from a Google search? How can you tell what truly good physical therapy consists of?  Would you be able to tell the difference between the two?

There is a lot of difference in physical therapy clinics and we want you to know what that difference is. Getting to a physical therapist is easy, getting rid of your problem and truly moving better is much more difficult. The first step is know what a physical therapist is and does.

The Woes of a Desk Jockey

In my years as a physical therapist I’ve seen all kinds of injuries and heard all kinds of body-related complaints—some from accidents, some from surgery, and some resulting from extreme athletics. But there’s no athletic endeavor that is guaranteed to lead to injury quite like the Desk Jockey. It doesn’t matter the city or the type of therapy practice, the poor, weary Desk Jockey finds me over and over again.

The wear and tear on the body of a Desk Jockey is highly underestimated except, of course, by a physical therapist. We receive reports of neck pain, back pain, leg pain, tingling, and it confirms what we believe most: humans are just not meant to sit in the same position for 8 or 9 or 10-plus hours per day. Nor are they designed to wake up and repeat this pattern day after day. So what’s a Desk Jockey to do?

Essentials for Sleeping Better

Do you have difficulty falling asleep? Do you wake up during the night tossing and turning? Feel tired, achy or sore in the morning? Check out the tips below to get a better night’s rest.

1. Invest in a good mattress.

The lifespan of most quality mattresses is about 8-10 years. But keep in mind that your body changes over time. So what may have worked for you even 5 years ago may no longer be a good fit now.

If you are a side-sleeper you will probably prefer a plush-firm to plush mattress. This allows the bonier and wider hip and shoulder areas to sink in a bit, while giving support to the low back and legs. *Quick Fix: If your mattress is too soft, side-sleepers support your low back pain by putting a folded towel under your waist.

Back and stomach sleepers usually do better with a firm to plush-firm mattress that will support the spine in neutral better. *Quick Fix: If your mattress is too soft, back sleepers support your low back by placing a folded towel under the small of your low back or under your stomach for stomach sleepers.