Cardiovascular Damage From Extreme Endurance Exercise

This post is a slight rest from policy and reimbursement issue for physical therapists on this blog.

I include this 21-minute video by cardiologist James O'Keefe called Cardiovascular Damage From Extreme Endurance Exercise because the implications are so surprising, to me, at least.

The evidence is starting to 'coalesce', in Dr. O'Keefe's words, that greater than 2-hour endurance races by older athletes may lead to permanent scarring and stretching of the myocardial (heart) muscle which can increase the incidence of arrhythmias, stoke and sudden death.

I have always tried to promote exercise to my patients with strictly orthopedic considerations. In other words, I've never considered an upper limit on the time or intensity of exercise from a cardiovascular standpoint. Again using Dr. O'Keefe's words, I've always subscribed to the 'more is better' paradigm. Perhaps now is time to reconsider my assumptions.

Since this is a controversial issue, it seems my assumptions are not mine alone - many athletes, coaches and laypersons probably subscribe to the 'more exercise is better' paradigm.



Sudden death is in the media lately.  Google is investigating how the new Google Glass can be used to properly treat athletes drop dead on the court or playing field.

Also, an August 8th post on the ADVANCE for Physical Therapy and Rehab Medicine website also discusses sudden death in younger athletes.

I've competed in over 50 triathlons, ultra-distance races and extreme endurance events in the last 20 years. In setting myself as an example I hope I've not done a disservice to my patients. I don't think so because my advice and example was based on the best evidence available at that time. Now, with new evidence, perhaps physical therapists (including me!) can incorporate better advice.

How to Build a Physical Therapist Network

Growing the Private Practice Physical Therapist Network

The Florida Physical Therapists in Private Practice (FLPTPP) bought a booth to grow the network at the 2013 Florida Workers Compensation Conference in Orlando August 19th -21st at the Orlando World Center Marriott hotel.

Left to right
Tim Richardson
Larry Feldman
Matt Serlo
Chris Mulvey
Armin Loges
not pictured: Ginger Hoang Le

We believe that this marquee event will be the ideal platform for us to promote our FLPTPP brand and begin the dialog for future business opportunities. Thousands of industry participants will be at the event and over 550 vendors. It has grown to be the largest event of its kind in the country.

As a group the FLPTPP are more attractive to prospective insurance companies as the cost associated with connecting with private practice physical therapists individually can be burdensome for insurance companies.

We have come up with a campaign for this booth and the web site called “It’s Personal. Every Time”. We believe this achieves our objectives as it differentiates the private practice physical therapists'  unique business model. It’s Personal because:

• We the owner/members are stake holders with a vested interest in mutual success…
• Many therapists left corporate employment that were impersonal…
• Third party administrators have hindered the case manager’s ability to communicate with the treating therapists…
• Unfair reimbursement can never lead to sufficient quality care…
• As business owners, we pay into this work comp system…
• With “US” it’s personal for the Employee, Employer, the nurse case manager, the insurance company and personal to our own self interests.

We hope you can join the FLPTPP and help us grow!

Private Practice Physical Therapists in Washington DC

The recent trip to Washington DC on the 23rd of July 2013 with the Private Practice Section (PPS Fly In) of the American Physical Therapy Association (APTA) to advocate for permanent repeal and replacement of the Medicare Sustainable Growth Rate (SGR) and overturn of the Therapy Cap.

Kerry (in this photo) also had the 'pleasure' of learning about Medicare Opt Out for physical therapists from us :)



From left to right:  Shamsah Shidi, PT,

Kerry L. Allen (Legislative Aide to Senator Bill Nelson)

Tim Richardson, PT

This next photo is in Congressman Vern Buchanan's office where Shane and I have met on many previous occasions.



Left to Right

Tim Richardson PT

Shamsah Shidi, PT

ShaneLieberman, (Legislative Director for Congressman Vern Buchanan)

Jack Front, PT

In this next photo, Gus Bilirakis had just informed of the pending vote by the House Energy and Commerce Committee on SGR reform. Bilirakis predicted there would be no opposition. Ultimately, the bill passed by unanimous vote, 51-0 on July 31 and would then move on to the full House.

Left to Right

Jack Front, PT

Congressman Gus Bilirakis

Shamsah Shidi, PT

Tim Richardson, PT

Sally Canfield of Senator Marco Rubio's office was present in 1997 when the original SGR formula was constructed. She resisted the temptation to wag her finger at her peers and politicos in Washington DC to say 'I told you so!'. Sally was probably the most well-informed and optimistic of all the congressional aides we spoke to that day.

Left to right:
Jack Front, PT
Shamsah Shidi, PT
Sally Canfield (Deputy Chief of Staff for Policy for Senator Marco Rubio
Tim Richardson, PT

I urge every physical therapist to leave your offices every now and then to get to know your legislators and advocate for physical therapists' patients. These people may control an important part of our future.

What has the American Physical Therapy Association done for you lately?

Patient stories...

Physical therapists hear these stories every day but the APTA is helping to put patient stories where they will do some good - in front of legislators who can determine your Medicare reimbursement.

The APTA coordinated a recent practice visit with the office of Federal legislator Vern Buchanan (R-Bradenton) on Tuesday, August 6th at a private physical therapy clinic in Bradenton, Florida. The following stories are a good example of what the legislator heard that day...

The 82-year old female patient gave a lucid, moving story about how her physical therapist had 'saved her life' by helping her remain living at home after a fall and a hip fracture. She mentioned she was already at the 'hard cap' of $3,700 in 2013 and didn't know how she could continue to pay for the services of her therapist even at the reduced frequency of one time per week.

The male patient, a retired veterinarian, told a very funny story of dislocating his shoulder by, believe it or not, walking his big dog. He was offered imaging and surgery by an orthopedic surgeon who owns therapy services. The patient said he wanted to think about these two options and, in the meantime, could he get a referral to physical therapy? That was three months ago and he now has full passive ROM. He is in no pain. He is also at the 'hard cap' but he credits his physical therapist with preventing what was, in his opinion, an unnecessary surgery.

Therapy Cap is top-of-mind for physical therapists because we deal with it every day but most legislators and their staff have many other responsibilities. Patient stories help make the recent Therapy Cap legislation REAL for members of the Congress by putting a human face on the problem.

The Medicare Access to Rehabilitation Services Act (HR 713) was recently introduced in the House of Representatives by Representatives Jim Gerlach (R-PA) and Xavier Becerra (D-CA).  HR 713 would permanently repeal the $1,900 therapy cap imposed on physical therapy, occupational therapy, and speech-language pathology services.

We asked Congressman Buchanan to support HR 713 by attaching it to another bill that is gathering momentum in Washington DC.   The Medicare Physician Payment Innovation Act (HR 574), introduced by Reps. Allyson Schwartz (D-PA) and Joe Heck, DO (R-NV) provides the following:

• repeal and replace the flawed Sustainable Growth Rate (SGR) formula.
• a clearly defined path to permanent Medicare payment reform.
• it includes a multi-year period of payment stability for Medicare providers.
• a stipulated annual payment rate increase of 0.5% to the Physician Fee Schedule.
• CMS will test and evaluate several alternative payment systems including the Alternative Payment System for therapy proposed by the American Physical Therapy Association. 

For the first time in many years, there is bipartisan support for repealing and replacing the SGR and fixing Medicare reimbursement for physical therapists via HR 574.  There is also a chance to fix the Therapy Cap by attaching HR 713.

To improve our chances you need to contact your legislators with your patient stories.   

A Unique Legislative Update

Guest posted by Adam Geril, DPT, MS, Owner - Geril Therapy

Being part of an organization of medical providers who have banded together to face the challenges of a recovering economy and changing healthcare environment has its advantages.

The Medical Business Leaders Network (MBLN) has been in existence since 2008. This network was formed to share cost savings and revenue producing ideas that spanned topics that included:

• tax law
• human resource management
• accounts payables
• accounts receivables
• marketing
• group purchasing

As this organization has grown to include multiple physician and medical professionals, we have found an audience amongst law makers. Given the recent completion of the Florida Legislative session we were able to secure a legislative update with Representative Dennis Baxley, and Charlie Stone. In order to make it interesting to the MBLN, a list of topics were sent to the Representatives prior to this meeting.

I am happy to say that each and every item on our list (that was compiled by the MBLN board on behalf of its members) was addressed.

Representative Baxley is the immediate past chair of the Health and Human Service Committee and currently chair’s the Judiciary committee. Charlie Stone is newly elected and now co-chairs the Judiciary committee along with the Senior House of Representative Dennis Baxley. Together a summary of the legislative changes that occurred this session was discussed. They included the following:

Why the Governor decided to remove power from the insurance commissioner to control rates in premium hikes. This turned out not to be the case and in fact was related to the affordable care act,

Expansion of scope of practice – Representative Baxley discussed the expansion of the optometrist’s practice specifically to prescribe certain medications. He reviewed how this was a hotly debated topic however laws were passed specifically to benefit the public. CS/CS/HB 239

Medical Negligence Actions – This prompted a personal discussion from Representative Baxley which centered about his fear of more physicians leaving practice in the state of Florida and more attorneys coming to practice in our state. This later progressed to a discussion on tort reform.

Medicaid Expansion – Representative Charlie stone stated that much was discussed however no decisions were made in this session and it will be discussed in more detail in the next session..

CS/HB 413 - Physical Therapy – Pertained specifically to the ability of ARNP’s to prescribe Physical Therapy.

CS/CS/SB 1094 Home Health Agencies - reduces the mandatory fine amount levied against HHAs that fail to file the quarterly report to AHCA from the current fine of $5,000 to a fine of $200 per day up to a maximum of $5,000 per quarter.

CS/CS/HB 1159 - Health Care Facilities – Specific to Nursing Homes – The bill specifically was amended to expedite the Certificate of Need review process if certain criteria were met. The meeting ended with an introduction to Jorge Bonilla running against Alan Grayson’s seat in the State House of Representatives and discussion with Paul Hawkes who is a lobbyist specifically as it relates to Tort Reform. This reform was to keep cases out of the legal system and make compensation fair and equitable to all parties involved.

To gain further valuable input this discussion evolved into scheduling a forum on tort reform in the state of Florida to be co-sponsored by Representative Dennis Baxley, Representative Charlie Stone, and the Medical Business leaders network.

For a full review of the 2013 summary from the Florida House of Representative please see this House of Representatives website.

The MBLN is a group of providers concerned with our collective stake in the health care market place. If you care to learn more about our organization, join, or participate in our upcoming Forum on Tort reform (this month) in the state of Florida.

Please check our website for updates and specifics including date, time, and place.