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Rehabilitation after a shoulder replacement: What’s the norm?

“There is growing belief among orthopaedic providers that how much formal physical rehabilitation a patient receives is influenced by the patient’s insurance and its willingness to pay for various postoperative therapies.”

This makes sense. Many patients aren’t aware of how much their insurance will cover regarding physical therapy. For example, Medicare will cover 80% of physical therapy after the deductible is met. The deductible is $183. In our state, average coverage of physical therapy is about $90/session. This means that the patient would be responsible for 20% of the $90, or $18/session. This makes the assumption that the patient does not have a secondary insurance that may cover the 20% that Medicare doesn’t cover.

Medicare will cover all PT that is considered medically necessary and cases that go above $3,000 are subject to a manual medical review. This would be about 33 visits per year. Speak to your PT about this in order to verify this information. Each clinic charges a little differently than others and these are the averages in my experience.

Unfortunately, many people that have Medicare as their primary insurance do not understand the physical therapy benefits associated with this insurance.

“A recent study challenged the need for formal physical rehabilitation after anatomic total shoulder arthroplasty (TSA), finding that a home-based, physician-guided therapy program provided similar results with lower costs.”

If a patient can get better without going to PT, we should all be in support of this.

This study tracked patients with Human, which included 20.9 million people. This is a huge sample size. This information was compared with a 5% sampling file of patients utilizing traditional Medicare. The study collected data for a long period of time, from 2010-2015 and the patients had to undergo a TSA or RSA (reverse shoulder arthroplasty). Rehablitation visits were tracked for 6 months after surgery, by tracking charges that are traditionally utilized in rehabilitation. Any date that a specific charge was utilized was counted as 1 visit.

The grouping was paired as follows: 0 visits of rehabilitation, 1-5 visits of rehabilitation, 6-10 visits of rehabilitation, 11-15 visits of rehabilitation, 16-20 visits of rehabilitation, 21-25 visits of rehabilitation, 26-30 visits of rehabilitation and greater than 30 visits.

“The study included 16,507 patients”

This was a huge number of patients. This strengthens the reach of the research. The more patients that are included in a research study, the stronger the statement can be made (regardless of the statement) at the end of the study.

“In general, the Humana cohort had higher overall physical rehabilitation utilization than did the Medicare population across all factors.”

Patients with Medicare are not treated in physical therapy as much as non-Medicare patients.

“The Humana and Medicare populations had a similar percentage of patients with 0 visits.”

“The Humana population had a higher percentage of patients in all visit categories above 1 to 5 visits”

“…with the Midwest having significantly less physical rehabilitation utilization, which is best demonstrated by 69% of patients in the Midwest undergoing only 5 or fewer physical rehabilitation visits, compared to only 54% of patients in the Northeast and 53% of patients in the West.”

This is the anomaly that I would like to know more regarding. Why do patients in the Midwest choose to not utilize PT? This could be poor education of patients regarding the importance of PT. It could also be that PT’s in the Midwest are following more of a HEP based protocol and only having patients return to update the HEP.

“the possibility of patient-directed rehabilitation at home having equivalent outcomes to formal office-based physical rehabilitation was brought to the forefront after Mulieri et al demonstrated equivalent outcomes after TSA when comparing the 2 therapy programs.”

This is a study that I will attempt to get in the next couple of weeks. If a patient does not need PT services in order to improve function, then Boo Hoo for our profession, but we have to do what is best and right by the patient. Should this study demonstrate that PT’s aren’t able to provide additional value beyond not performing therapy, then patient’s should not seek out PT.

I’d like to believe that we have a place in the rehabilitation process post TSA, but I also don’t think that our place is one of > 20 visits.

Excerpts taken from:

Wagner ER, Solberg M, Higgins LD. The Utilization of Formal Physical Therapy After Shoulder Arthroplasty. J Orthop Sports Phys Ther. 2018;48(11):856-863.

 

One piece of equipment that may benefit your rehab process after a shoulder surgery is the following:

https://amzn.to/2BHMpX7

I find that over the door pulleys are easy to use and quick to install.

 

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Plantar Fasciitis and Ultrasound: questionable at best

“The plantarfascia is a thick, nonelastic, multilayered connective tissue crossing the plantar part of the foot. Plantar fasciitis is the main cause of pain in the plantar surface of the heel.”

The plantarfascia is located at the bottom of the foot, between the heel and the toes.   It is very thick and a tough band.

A part of physical therapy school includes dissecting the human body.  Some people find this disgusting, but it is actually an honor.  We were told that only 5% of college students will ever be able to dissect the human.  The bottom of the foot is very intricate. There are multiple layers of muscles, but the plantar fascia is a very taut band that requires a scalpel in order to tear.  In other words, it is very strong tissue.

“In the United States, more than 2 million people are treated for plantar fasciitis every year…the most common signs for identifying plantar fasciitis are pain and tenderness in the medial …heel bone, as well as an increase in pain when taking first steps in the morning and pain in prolonged weight bearing.”

First, plantar fasciitis is mostly diagnosed through a patient’s history.

Second, there are a lot of people with plantar fasciitis that seek out treatment.

This leads us to the next statement from the article

“…researchers have not determined the most effective combination of treatments due to the dearth of high quality research in this area.”

Feel good about this condition yet? So many treatment options are available, but few with solid research to back them up.

If you are interested in learning more, check out this  Link

“One of the most widely used electrical devices among physical therapists in Israel and worldwide is therapeutic ultrasound…Yet there is insufficient high quality scientific evidence to support the clinical use of therapeutic ultrasound in treating musculoskeletal problems.”

I find it funny that PT’s should know this information and yet they act opposite of what the evidence indicates.  There are running jokes that using ultrasound may be just as effective turned off as when turned on.

If your PT continues to utilize ultrasound, ask why?

Sometimes the answer may simply be: it is easy, it can be charged and it will do no harm.

Treatment:

Both groups were given stretches for the Achilles/calf and the plantar fascia.  One group was issued ultrasound at a higher intensity in order to create a thermal effect and the other group was given ultrasound that was low intensity and not postulated to have any physiological effect, as the intensity was low and the depth of treatment was considered more superficial.

There was no significant difference in the number of treatments per group.

Result: There was no additive effect of ultrasound on the treatment of plantar fasciitis for pain, function or quality of life.

There are reasons to use ultrasound from a business perspective, but the more and more that I read research I find fewer reasons to perform the intervention medically.

Reference:

Yigal K, Haidukov M, Berland OM et al. Additive Effect of Therapeutic Ultrasound in the Treatment of Plantar Fasciitis: A Randomized Controlled Trial. J Orthop Sports Phys. 2018;48(11):847-855.