Monday, May 18, 2020

HSA, HRA, FSA Oh My!

by Lauren Sweeney, Office Manager
As high-deductible plans become more common, people are more vigorously seeking methods of off-setting their health care costs. One of the most efficient ways to do this is with a tax-favored health plan, such as a health savings account (HSA), a health reimbursement arrangement (HRA) or a flexible spending arrangements (FSA). Each plan has its own benefits and considerations, and as not everyone wants to read the IRS's Publication 969, we're going to lay them out here.

Part of the allure of all three types of account is that they are tax-exempt, so the plan-holder can access the greatest benefit of their funds. This money can then be used to pay for a number of medical, dental, vision, prescription and over-the-counter expenses.

Unlike the other two types of account, HSAs are owned directly by the plan-holder: while the plan-holder may change jobs or insurance carriers, the HSA follows the plan-holder regardless. Plans with an individual deductible of $1350 (or a family deductible of $2700) or higher are generally eligible for an HSA. Contributions can be made by the plan-holder, the employer, or both, and can be made year-round. These contributions are either made pre-income tax or, if made by the plan-holder after income tax has been taken out, are eligible for reimbursement on yearly taxes. HSAs also allow for a fair amount of flexibility - the balance of the account can be carried over from year to year, so a year of relatively light medical expenses could make it easier to afford a more expensive procedure down the road.


HRAs, conversely, are owned solely by the employer - the plan-holder cannot make contributions, and the plan is tied to employment. As the name implies, the plan-holder pays for qualified medical services out of pocket, then submits the receipt to the HRA for reimbursement. There is no limit to amount that the employer can contribute to the HRA, and contributions can be carried over from year to year. Since the plan does end when employment ends, any balance remaining in the HRA can be returned to the plan-holder. And unlike the other two, HRA funds can be used to pay insurance premiums.


FSAs are also owned by the employer; however, both the employer and the employee can contribute. Unlike HSAs or HRAs, the funds in an FSA do not roll over, meaning that the plan-holder is incentivized to spend the balance of their FSA prior to year-end. Plans can have up to a 2.5 month grace period to use the funds following year-end, so there is a small amount of leeway if the plan-holder has a large expense that doesn't occur until, say, January 3. Generally, FSAs are also used to reimburse the plan-holder for the money spent on qualified medical expenses, and require the most documentation of all three types: a written statement from an independent third party - for example, a statement from a doctor's office - as well as a written statement that the balance in question hasn't been paid by insurance, all in addition to the receipt. Any balance remaining in an FSA cannot, unfortunately, be returned to the plan-holder if employment ends.


Physical therapy is considered a qualified medical expense, so if you're worried about the details of your coverage, your HSA, HRA or FSA can be used to offset the cost of visits. It's important to know the details of your plan, but that knowledge can mean real savings at tax time and on your out-of-pocket costs!

References:
https://www.irs.gov/pub/irs-pdf/p969.pdf


Monday, April 27, 2020

Strong Calves, Steady Bodies

by Julia Glick, PT
Whether we've tripped over an unexpected item in our home or over our own feet walking down the sidewalk, nearly all of us have taken a tumble - and those risks only increase for older adults. In fact, up to one third of people over 65 will have a fall each year (Sherrington et al. 2016), so balance and fall prevention is a huge part of what we look at in the clinic. Since there are already many resources that discuss the negative impacts of poor balance and falls - especially in the elderly - let's focus on balance and its relationship to calf strengthening.

But first, how do we define balance? According to a 2012 Cochrane review, balance is “the ability to stay upright and steady when stationary and during movement.” Let's break that down a little bit: if you are walking, sitting, standing, running, or even juggling balance is your ability to stay upright. If you start losing your balance or falling, balance also includes the ability to return to the upright position. It is thought that balance declines with age for a variety of reasons such as decreased strength, range of motion, reaction time, and awareness of where the body is in space (proprioception) (Howe et al. 2012).

Naturally, there are a number of interventions to help patients improve their balance. In a 2016 study by Maritz and Silbernagel, patients were given a general balance training program, but what was novel about it was that it incorporated calf strengthening. The researchers found that the group that incorporated single leg calf raises over 5 weeks into their program had greater improvements in balance than the group that did not. But why would doing calf raises make someone’s balance better?

A study conducted by Fujiwara et al. (2011) helps shed some light on why calf strengthening may help with balance. In this study, participants performed 100 calf raises daily for 2 months. They showed improved strength of the soleus (part of the calf) and improved reaction time with reaching activities. Fujiwara et al. suggested that calf strengthening promoted these improvements by promoting an "ankle strategy" with balance. Calf strengthening has the potential to improve someone’s ability to react quickly with small ankle movements and other postural muscles to prevent the need to take a big step if someone loses their balance. A smaller movement requires less energy and decreases the chances of someone stepping wrong and getting hurt. 

Single leg calf raises
Double leg calf raises
If you are already working on a balance program try adding double leg calf raises to your program and if those are too easy try single leg calf raises. If you are having difficulty with your balance or are having falls please contact a medical professional.










References: 
Fujiwara, K., Toyama, H., Asai, H., Yaguchi, C., Irei, M., Naka, M., & Kaida, C. (2011). Effects of Regular Heel-Raise Training Aimed at the Soleus Muscle on Dynamic Balance Associated With Arm Movement in Elderly Women. Journal of Strength and Conditioning Research, 25(9), 2605–2615. doi: 10.1519/jsc.0b013e3181fb4947

Howe TE, Rochester L, Neil F, Skelton DA, Ballinger C. Exercise for improving balance in older people. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD004963. DOI: 10.1002/14651858.CD004963.pub3

Maritz CA, Silbernagel KG. A prospective cohort study on the effect of a balance training program, including calf muscle strengthening, in community-dwelling older adults. Journal of Geriatric Physical Therapy 2016; 39:125-131.

Sherrington C, Tiedemann A, Fairhall NJ, Hopewell S, Michaleff ZA, Howard K, Clemson L, Lamb SE. Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD012424. DOI: 10.1002/14651858.CD012424

Wednesday, April 1, 2020

Telehealth at Lakeshore Physical Therapy is Here!




In light of the recent health concerns regarding the COVID-19 pandemic, we have been working behind the scenes to quickly roll out a telehealth option for you.

Here is what you need to know!

What is telehealth? 
An online, web-based option to virtually meet with one of our experienced clinicians to receive evaluation and treatment for your musculoskeletal injuries/ conditions. 


A physical therapist providing exercises via a laptop


What can a physical therapist provide in a telehealth visit?

There are many benefits to meeting virtually with your physical therapist! We can:
  • Update your corrective exercises
  • Teach you self-care techniques to promote tissue health
  • Assist with posture modifications and work station set-up
  • Provide post surgical monitoring
  • Complete a functional movement assessment
  • Provide an injury screening
  • Continue to give you our individualized attention in a virtual setting

Okay, I’m interested - tell me more!
Due to some patient barriers to receiving in-person care, we have established an interactive solution to your physical therapy needs. We are utilizing the web-based platform Doxy (www.doxy.me) which does not require you to download anything or create a profile of any sort.

Does my insurance cover this?
We are working with major insurance carriers to properly bill and cover telehealth services. As this is a new and ever changing situation, this is still underway. For more information on your specific insurance benefits, please contact us directly. 

So what payment options do I have?
We are currently offering a competitive self-pay rate of $75 per visit for a quality one-on-one session with your physical therapist. Don’t forget, your HSA or FSA card can be used towards these visits!

This sounds great! How do I schedule an appointment?
To book your telehealth e-visit, please call one of our offices directly.

Your pain can’t wait and neither should you!


Wednesday, February 26, 2020

Imaging: A Closer Look

by Constance Taras Karwandyar, PT
When we talk about injuries, we often hear of primary care physicians and orthopedic specialists performing imaging in order to assist patients in treating musculoskeletal pain. Imaging can include, but is not limited to, MRIs, X-rays, or CT scans. Although these tests may help feed our curiosity to “look under the hood,” they may not always be the best place to start.

In a world today looking to decrease healthcare costs, imaging can be a large line item: a study done by Parker et al estimates that musculoskeletal imaging costs are projected to reach $3.6 billion dollars in 2020. While the cost might be worth the peace of mind brought by the imaging results, studies have found that imaging does not actually ease fear and worry about the cause of pain. Once being labeled with “degenerative disc disease” or “knee arthritis,” patients tend to define themselves in terms of these issues. Additionally, abnormal findings are not always directly related to the pain a person is feeling. A patient with severe knee pain may have an MRI that reveals no abnormalities, or a patient with acute but mild back pain will have an MRI showing severe degenerative changes of their discs and two herniated discs.

In particular, non-coordinated findings can be very frustrating for a patient and leave them feeling confused as to the next best step to take. To make matters even more confusing, the literature indicates that positive imaging findings are common and may not be the best guide for future care decisions. A 2020 study performed by Horga et al on 115 asymptomatic (without any pain) adults revealed that 97% showed abnormalities in their knee MRIs. These findings included meniscal tears (30%), cartilage abnormalities of the patellofemoral joint (57%), and moderate tendon lesions (21%). Similar findings are present in low back pain: Brinjikhi et al performed a systematic review gathering information about positive low back imaging findings on asymptomatic adults. Data gathered on over 3,000 people revealed that by age 20, there was a 27% prevalence of degenerative disc findings and by age 50, that number rose to 80%. According to their findings, it is more common to have degenerative changes beginning at age 30 than to not - and this was in an entire population of people without back pain!

Prevalence of abnormal MRI finding in the low back for 3,110 asymptomatic individuals (Brinkikji et al).
It is important to understand that imaging has its place in healthcare and can be very helpful and necessary in certain situations. The American College of Physicians and the American Pain Society published a joint clinic practice guideline regarding the diagnosis and management of low back pain in 2007. According to this guideline, clinicians are recommended to only perform diagnostic imaging if: severe or progressive neurologic deficits are present, serious underlying pathology is suspected or the patient is a potential candidate for surgery or epidural steroid injections. The guidelines also suggest that clinicians should not perform imaging for patients with nonspecific low back pain. 

In summary, imaging can be helpful to rule out serious pathology, be diagnostic when surgical intervention is indicated, or guide a physician when epidural steroid injections are indicated. Routine use of imaging, however may be causing more fear, more confusion, and more cost than necessary. 

If you are confused about your recent imaging findings or have pain but are unsure if you need imaging in the first place, stop by Lakeshore Physical Therapy to discuss it with one of our experienced therapists. We offer complimentary injury screens to decide what is the right next step for you. We want you to feel confident in your healthcare decisions and clear on your road to recovery!

References: 
Brinjikji, P.H. Luetmer, B. Comstock, B.W. Bresnahan, L.E. Chen, R.A. Deyo, S. Halabi, J.A. Turner, A.L. Avins, K. James, J.T. Wald, D.F. Kallmes and J.G. JarvikSystematic Liertaure Review of Imaging Features of Spinal Degeneration in Asymptomic Populations. American Journal of Neuroradiology. April 2015,  36 (4) 811-816

Flynn, T.W., Smith, B., Chou, R. Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder That Unnecessary Imaging May Do as Much Harm as Good. Journal of Orthopedic and Sports Medicine. Nov 2011, 41 (11) 838 – 846.

Horga, L.M., Hirschmann, A.C., Henckel, J. et al. Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal Radiol (2020). 

Lewis, J.S., Cook, C.E, Hoffman, T.C., O’Sullivan, P., The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice. Journal of Orthopedic and Sports Medicine. Jan 2020, 50 (1) 1-4.

Thursday, January 16, 2020

Nervous About Flexibility

by Jill Jonda, PT
Do you stretch frequently and still seem to feel tight? Are you concerned you can’t touch your toes or can’t get your pecs to loosen up? When this happens, we usually talk about flexibility - the amount of mobility around a joint or multiple joints – but muscle tension isn’t always the cause of the sensation of “tightness:” in fact, neural tissue (tissue which makes up the nervous system) tension can provide a very similar sensation. Let’s take a look at how neurodynamics can affect the body.

According to Dutton, neurodynamics is “the study of the mechanics and physiology of the nervous system.” The nervous system is comprised of the central system (brain and spinal cord) and peripheral system (spinal nerves and cranial nerves). Peripheral nerves, the nerves that trigger parts of the body to work, can get “stuck” and develop dysfunction along their pathways. As these nerves exit the spinal cord and travel to their target tissue, they must be able to adapt to movement in relationship to their surrounding tissue, which would allow for normal neurodynamics.1 If tissue is compromised anywhere along a nerve, such as injury creating adhesions or inflammation, it can produce more stretch on tissue, yielding potential nerve related symptoms (tightness, numbness, tingling, pain, or even muscle spasm).

A diagram of the nervous system. 
It is impossible to move any joint without also moving a nerve
Here are some actions and activities that can result in abnormal neurodynamics:
  • Sustained postures. Holding a position for prolonged periods of time can cause adaptive shortening of connective tissue around nerve. This could include sitting at your desk at work for 6-8hours with rounded shoulders, a forward head, and rounded low back.
  • Direct trauma, such as orthopedic injuries, yielding either primary nerve injury or secondary due to damage of surrounding tissues. For example, if a golfer takes a stroke that hits more of the ground instead of the ball, it might jar the arm and injure muscle around the elbow. The muscle may become inflamed and compress the nerves, which pass through and around the elbow.
  • Extremes in motion, which put excessive traction on the nerve.  An example would be a “stinger,” which places excessive traction on the brachial plexus (a network of nerves which exit the neck).
  • Electrical injury.
  • Compression, such as a disc bulge in the lumbar spine that places compression on nerve as it exits the spine.

In the clinic, we perform different tests and measures to determine whether or not neural tissue is tight or if it’s just muscle tension. Here are 2 tests we use to rule in nerve tension. 

For leg symptoms: Straight Leg Raise
  1. Lying on your back, raise one leg up toward the ceiling.
  2. Pull your toes back and point the opposite direction, pumping your ankle. If this produces tightness in the back of the thigh, it’s a positive test for neural tension, as pulling the toes back puts the nerve on a stretch.
  3. Another way to “sensitize” nerve tissue would be to bend the neck, drawing the chin toward the chest with the leg raised in a neutral position. Pain in the back of the leg produced upon neck flexion would be a positive test for abnormal neurodynamics.

For arm symptoms: Upper Limb Tension Test
  1. Pull your shoulder blades down and back.
  2. Raise one arm out to the side with the elbow bent at a right angle. 
  3. Next, rotate the palm up then begin straightening the elbow, wrist and fingers. The combination of these joint movements places the nerves that exit the spine at the neck on stretch. 
  4. Tilt your head away from the arm being tested to stretch the nerves even more. Tilt the opposite way to put the nerves on “slack.” Slack is placed on the tissue by bending the wrist/fingers. Pain in the arm with neck or wrist motion would indicate the presence of nerve tension.

If you try either of these tests and feel nerve tension after the first few steps, no need to sound alarms quite yet! It’s normal to experience a degree of nerve tension: you’re putting the nerves that pass from your spinal cord down the leg or arm in their most stretched position. This sensation can sometimes be confused with muscle tightness or trigger point tenderness. If you’re experiencing tightness in your limbs and it’s accompanied by other nerve symptoms, specific muscle stretches may not alleviate your discomfort.

If you have nerve symptoms that aren’t going away, consider making an appointment with your physical therapist to help improve your neurodynamics!

References:

1. Dutton, Mark. “Neurodynamic Mobility and Mobilizations: Chapter 11.” Dutton's Orthopedic Examination, Evaluation, and Intervention, edited by Joe Morita and and Brian Kearns 3rd ed., McGraw-Hill, 2012, p. 406.

2. Dutton, Mark. “Improving Range of Motion: Chapter 13.” Dutton's Orthopedic Examination, Evaluation, and Intervention, edited by Joe Morita and and Brian Kearns 3rd ed., McGraw-Hill, 2012, p. 444.