An Interview with Dr. Stuart McGill

Hi, my name is Sasha Sibree, PT.

First, I would like to thank Tim Richardson, PT who has kindly allowed me to do a guest post on his blog.

I recently had the opportunity to interview Dr. Stuart McGill about his work with rehabilitation exercises for the lumbar spine.

Here are some excerpts from the interview...

***Begin Transcript***

PhysicalTherapyContinuingEducation.Org: "Well, we know from your work that Transverse Abdominis (TrA) is not the whole answer to spinal stabilization, but isn't it beneficial to still prescribe Transverse Abdominis exercises to make sure that muscle is working well?"

Dr. Stuart McGill: "Well, I think I've just caught you in a nice little clinical controversy."

PhysicalTherapyContinuingEducation.Org: "Okay."

Dr. Stuart McGill: "Show me one study that says the Transverse Abdominis is not working."

PhysicalTherapyContinuingEducation.Org: "Well, Dr. Paul Hodges' work.
Plus I recall there was an article in JOSPT recently about Australian Football players."

Dr. Stuart McGill: "Okay.
Well, if you think Hodges' work, let's stay with that.

He's never shown that the Transverse Abdominis is not working."

PhysicalTherapyContinuingEducation.Org: "I stand corrected.
The TrA doesn't fire correctly."

Dr. Stuart McGill: "He's shown that in a very, very tightly controlled experiment of people standing - and they sort of have to relax in a very special way - and they jerk one arm into flexion.

That's the only time that he's found, in a few back pain patients, about a 30 millisecond delay in activation.

It'’s not that the TrA isn't working. It's slightly delayed in onset.

A lot of people have tried to replicate that experiment.

They haven't got as much press as Dr. Hodges has and they haven't found that pattern.

They've found delays in other muscles, absolutely, but when they sub-categorize the various flavors of back pain they've been able to show that certain back pain patients have no delays at all.

Some have much bigger delays in Erector Spinae.

There have been all sorts of studies that show Latissimus Dorsi has huge delays in rowers, for example, with back disorders.

Anyway, my point in this, it's only in this very contrived arm raise task.

You show me one other task where Transverse isn't working?

It's a myth."

***End of Transcript***

I thoroughly enjoyed speaking with Dr. McGill during this thought provoking 36 minute interview. I hope you enjoyed this excerpt.

I invite you to visit my site to listen to or download the entire interview.

My site is called Physical Therapy Continuing Education.Org.

Basically I found a way to combine my love of learning and being an internet geek. I hope you take advantage of the whole series of free interviews I am doing with some of the top rehab experts in our field.

Thank you,
Sasha Sibree, PT
PhysicalTherapyContinuingEducation.Org

Free Falls Risk Reduction Toolkit for Physical Therapists and Patients

Get the Falling LinKS Toolkit from the Wichita State University Regional Institute of Aging

This is a very user-friendly document with clinical and personal vignettes that "paint-the-picture" for patients, payers and professionals who may not be fully aware for the risks and the resources available to help prevent falls.

The toolkit hits the "big drivers":

• Overmedication
• Vision deficits
• Inadequate physical activity
• Environmental risks in the home

The toolkit lets patient assess their own risk by checking off boxes and scoring the results simply by accumulating the total - the more "yes" answers the higher your risk.

There is an exercise section with pictures of safe techniques that are functionally-oriented (no leg raises!) with a balance component.

There are checklists to create an exercise plan, a vision plan, a medication plan and a safe home environment plan.

Implementing all of these plans will take a commitment from the whole family, the physician and the physical therapist

I have sent my dad a copy and I will help him implement these steps when we visit at Christmas.

Physical Therapists: The LAST, Best Choice!

Many of my physical therapist friends say that Physical Therapy is your FIRST, best choice for consumers - before drugs, before surgeries, before scary, invasive, expensive diagnostic imaging like MRI and CAT scan.

Physical therapists can treat and prevent painful disability - this is the kind of problem that, unlike heart attacks, strokes and cancer - may NOT kill you but may leave you paralyzed, immobile or wheelchair bound.

You may have difficulty with simple things in life:

• Getting up out of a chair
• Playing with your grandkids
• Climbing stairs

But, I want to show you why physical therapy may also be your LAST, best choice!

From the journal Health Affairs (Sept 2005):

This rather hairy image shows that spending for LEAST disabled persons is rising almost as rapidly as for the MOST disabled.

"Among community-dwelling elderly, spending growth among the least disabled grew more quickly than among the most disabled, which offsets some of the cost savings associated with declining disability rates."

The good news is that disability rates have been falling, relative to population growth, for several years:

People are living longer, in less pain and less disability.  Costs, for this cohort, are not costs - they are an investment.  We are investing in better quality of life for America's seniors...

Outpatient Therapy Task Force 2

Notice that the 85-89 year old people are the highest users of therapy?

They use, on average, $857 in outpatient therapy per year - higher than any other group of Medicare beneficiary.

Can we attribute the declines in disability to the higher utilization of therapy services? Do survivors tend to use therapy services disproportionately?

Currently, therapy services are "defaulted" when physicians can't find a surgical lesion to cut. Or, when medical marketing fails to convince seniors that yet another injection, drug or operation will help them feel better

If therapy services can be shown to reduce disability in America's oldest cohort then American's may want to continue spending in this area by targeting therapy dollars to the group most able to benefit - America's oldest citizens.

Physical therapy may be their last, best choice.

Free Help Guide for Physical Therapists

Get this free help guide to biostatistics for Physical Therapists from MedPageToday.com

The guide contains familiar terms to physical therapists such as "reliability", "sensitivity" and "specificity" but it also goes into new and important concepts such as "odds ratio", "likelihood ratio" and "relative risk".

As Guy G. Simoneau and Stephen C. Allison comment in the October 2010 Journal of Orthopedic and Sports Physical Therapy:

"...more attention is needed to improve our understanding of the accuracy of commonly used diagnostic tests."

Not all tests are created equal - some commonly used physical therapy tests are nearly worthless.

And, many medical screening tests are sufficiently predictive, simple to use and within the scope of practice of physical therapists. This guide will help you understand the tools and concepts needed to evaluate the tests.

I hope you download and enjoy this free help guide from MedPageToday.com.

Take Home Message from APTA State Government Affairs

I recently attended the American Physical Therapy Association(APTA) State Government Affairs meeting in Portland, Oregon as one of the Florida delegates. This meeting is intended to create advocates for the physical therapy profession by creating awareness of the common struggles we all face at the state level.

State level advocate physical therapists keep politics local and create national awareness of the inherent value physical therapy brings to medicine and to society. A local "grassroots" effort can complement the Federal advocacy by APTA in Washington DC as well as the more expensive and long-range public relations and "branding" campaigns initiated by our leaders.

State of the States – many issues are dealt with at the state level but have national commonalities from which we can all learn. This was an inspiring subject because of the many “success stories” told by our peers in other states.

• Dry Needling
• Dry needling is NOT mentioned in the Guide to PT Practice. Many therapists in Europe and the USA are learning dry needling techniques.

• Infringement
• massage therapists want to practice joint manipulation.
• Physical Therapists successfully partnered with chiropractors in Virginia to prevent advertising the term “physical therapy” without a PT present.
• Medicaid
• PT is an optional service for adults but will be required for children under Health Care Reform.
  
• Direct Access
  
• PTs can “diagnose” and should avoid equivocating between a “physicians’ diagnosis” and a “physical therapists' diagnosis”.
  
• Excessive Co-Payment Barriers
• New York is fighting a tough battle with $50 co-pays for plans with a $50 PT benefit.
• New York has crafted their own legislation that would mandate co-pays no more than 20% of the benefit amount.
• Vetoed by the Governor as a tradeoff for increased Work Comp fee schedule.
• Any states seeking such legislation need to ensure that PT is a “mandated benefit” otherwise insurance companies will allow the co-pay but drop the benefit.
  
• Federation of State Boards of PT
• Seeking a recertification process to protect public safety.
• APTA is not disagreeing with FSBPT.
• Consistent with physician licensing, but…
• …is there a demonstrated need (eg: evidence of harm from malpractice insurance carriers?)
• Many state boards are controlled by physicians (not in Florida!)
• In states where the Board is controlled by physicians or agendas set by powerful administrators PTs need to develop a “culture of autonomy”.

Health Care Reform (HCR) – this is a “hot topic” made even hotter by the concise, hard-hitting analysis by Justin Moore, PT and two outside experts – quality “gurus” who were passionate about the next stages in HCR.

• the regulatory approach (influencing policymakers) is preferable to the legislative approach (eg: South Carolina and Washington state).
• Anti-POPTs legislation too expensive.
• HCR will unfold over the next 5-6 years, allowing PTs time to influence policymakers.
• Cost arguments will dominate the conversationDr.

"Quality Gurus"

Edward Keenan, PhD from The Foundation for Medical Excellence spoke on Achieving Health Care Reform Require Transformation Not Reform

• HCR grants access, NOT quality
• 15-minute visits (encoded in CPT) prevents quality and encourages “silos”.
• “Health Care” may contribute only 10% to “Health” but education may contribute 40-50% to “Health”. 
•  Lifestyle, genetics and culture also contribute to “Health”.

Jack Friedman, CEO of Providence Health Plan spoke on The Impact of Health Care Reform on Health Benefit Design

• HCR will create “tiers” of healthcare;
• primary care is 1st tier,
• PT may be 2nd tier 
• instrumented spinal fusions should be 3rd tier.
• Small practices will have to integrate with Accountable Care Organizations (ACOs) to participate in bundled episodes of care.
• PT’s need to demonstrate “Value” to the ACO.

Starke Anti Self-Referral Laws

• Starke affect Medicare patients only but needs revision:
• Sharing of health IT (EMR) is currently prohibited among providers.
• Integrated Accountable Care Organizations (ACOs) may be prohibited under Starke.
• PT is a professional service, NOT an ancillary service (Hogan/Hartz whitepaper)
• PT is more akin to radiation oncology than any other service in its scope, usage patterns and timing.

AMA Scope of Practice Guidelines

• The AMA is attempting to write the PT scope of practice ‘for’ us.
• Physicians have an unlimited scope of practice.
• The APTA rejected the AMA's premise that the AMA can define the PT scope of practice.
• Physicians define everybody else (including PTs) as “limited license practitioners”
• APTA believes that physical therapists should define our scope of practice through updated versions of the Guide to PT Practice.

Action Plan for the Future: In the private practice setting innovation may become more rewarding.  Traditionally, the words innovation and Medicare have seldom been used together.

How Can Private Practice Physical Therapists Innovate?

1. Choose the lowest cost means of communicating with your patient - (e-mail)
2. Assume all the performance risk of the outcome - what can you do to improve the outcome that you have not traditionally done? For outpatient physical therapists, this might mean home visits to visualize the patients' home environment assessing for specific risks, eg: in older patients throw rugs, pets and stairs may increase falls risk. As the therapist you can modify these risks to prevent future resource use.
3. Is the small private practice the way to go? ACO's will want to contract with ONE therapy provider. Would a Independent Practice Association (IPA) of several small PTPP practices enable better negotiation with the ACO? What about a merger? A sale?
4. Stay tuned - there is no fixed definition of an ACO.  Some will be hospital-based and some will bebased on large physician practices .