Archives for category: Medicare

We looked up shoulder arthritis on the web, as our upcoming lecture series for PTs and other medical professionals will be focusing on common shoulder problems and arthritis. Here are a few of the things we found, and hopefully some elucidation and clarification of some of the common information found on the web.

One definition we found of “shoulder arthritis” is, in our opinion, a bit oversimplified and overblown. We’ll leave out the link, out of respect to the author. “In shoulder arthritis, the smooth cartilage that normally covers the surfaces of the ball (humeral head) and socket (glenoid) is lost. The result is that there is bone on bone rubbing between these two joint surfaces.” This is an accurate definition of very advanced arthritis. But arthritis, if broken down into it’s component parts “arthro-; of a joint, relating to joints” and “-itis; denotes inflammation” more literally means inflammation of a joint. It (arthritis) usually is not diagnosed as such until the inflammation has existed long enough for concomitant changes to have taken place. Even once changes have occurred, it is only at an advanced stage that there is complete cartilage destruction and bone is actually in contact with bone.

So, that may be interesting reading, but you may be thinking, ‘what can I do earlier to prevent this change?’ and ‘if my shoulder is irritated and inflamed, can I reverse that before the cartilage is gone and bone is contacting bone?’ Or, maybe you’re wondering more about what cartilage does and want to understand the anatomy and function, and why joints get irritated and cartilage breaks down in the first place.

Articular (joint) cartilage is the hyaline cartilage that lies on the surface of bones. This cartilage may be described in terms of four zones between the articular surface and the subchondral bone. It’s function is to provide a smooth contact surface to bear load and allow a joint to move, so we can in turn function.

Inflammatory by-products have been shown to have a negative impact on articular cartilage, accelerating the rate of destruction. If your activities cause prolonged inflammation, then the metabolic by products of the inflammatory process can accelerate cartilage degeneration and lead to earlier arthritic symptoms. Over loading of joints can stimulate a low grade inflammatory process, as can instability of a joint resulting from past ligament injury, or dislocation of a joint.

A couple articles that might be of further interest around this topic:
http://www.pnas.org/content/83/22/8749.short
http://rheumatology.oxfordjournals.org/content/41/9/972.short
http://www.ncbi.nlm.nih.gov/pubmed/22550965

According to the American Academy of Orthopedic Surgery, “Physical therapy exercises may improve the range of motion in your shoulder [relative to arthritis]”. Physical therapy ought to be able to do more than just that. In conjunction with increasing joint range of motion, a physical therapist should be able to teach someone with arthritis strength exercises to improve joint stability, muscle stretches to enable maintenance  of the range of motion gained, and techniques to manage and improve function without aggravating symptoms of arthritis.

One major risk of arthritis is that people become less active in response to pain. This may result in decreased conditioning, strength, balance (if the legs or back are involved) and a further decrease in range of motion as use of the joints declines. Use it or lose it, really does apply here. We like to say move it or lose it. So what we work on is how to manage the use and movement of joints and your body without provoking further pain, symptoms and without increasing unnecessary wear and tear on your joints.

WebMD lists “Performing physical therapy as assigned by the doctor,” as a treatment option for arthritis. The problem with this quote, is that a physical therapist is the person, the professional, that evaluates and decides on the course of physical treatment in concert with you. The doctor is not there. And when all the information the medical doctor provides is “shoulder pain”, or “OA R shoulder”, this may provide a false impression that the “doctor” is in control, directing and assigning treatment, when in actuality the physical therapist, who is more often now a doctor than not, is gathering information, assessing your goals with you, and making decisions around your plan of care to achieve your goals. The great thing about physical therapy and exercise, in our opinion, is that once you’ve learned what works for you and how to integrate it into your routine, you can keep doing it for as long as you own your body. Unlike medications, or treatment that temporarily relieve pain, you don’t have to keep paying for your exercise routine over time.

More resources and studies that might be of interest:

http://physther.net/content/85/12/1301.short
http://annals.org/article.aspx?articleid=713255
http://www.jrheum.org/content/28/1/156.short
http://annals.org/article.aspx?articleid=713967
http://171.66.123.206/content/18/6/375.short
http://www.sciencedirect.com/science/article/pii/S002192900700382X
http://orthoinfo.aaos.org/topic.cfm?topic=A00222
http://www.webmd.com/osteoarthritis/guide/shoulder-osteoarthritis-degenerative-arthritis-shoulder

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“Each year, one in every three adults age 65 and older falls. Falls can cause moderate to severe injuries, such as hip fractures and head traumas, and can increase the risk of early death. Fortunately, falls are a public health problem that is largely preventable.” – CDC
http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

This is a frightening statistic, but one that we can impact positively. Even if your balance is good, maintaining your strength and balance is something everyone should work on.

Many people become less active as they age and challenge themselves less physically. But a few simple exercises can help with balance, strength and falls prevention. Here is a suggestion of 2 simple exercises you may try.

  1. Sit down in a dining room chair and stand up (without plopping into the chair) 5-10 times. Use good form by keeping your back straight (not vertical) and getting your weight over your feet. Your goal should be to do this without using your hands, but feel free to use them for balance if you need.
  2. March in place. The slower you go, the more emphasis you will be putting on balance. Make sure to place a hand on a wall or counter until you are steady enough to do this slowly without holding on. If you are really good, you can pause for 5-10 seconds on each leg and remain balanced.

Remember that these suggestions are only that, suggestions, and not a replacement for skilled physical therapy and exercise instruction. If you are apprehensive about doing these, or find yourself too unsteady to do them safely, please contact a physical therapist familiar with balance issues in older adults to be evaluated and have an exercise program designed specifically for your needs.

Squat over chair:
squat over chair

Marching in place:Marching

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