Episode 118 - Question and Answers 2.0, part 1: Robert Medcalf and Mark Miller

Robert Medcalf PT, Dip MDT & Mark Miller PT, Dip MDT


In episode 118 we're privileged to hear two senior faculty in Mechanical Diagnosis & Therapy field YOUR questions - from specific clinical issues to professional growth advice to big-picture healthcare positioning discussion and more!


Mr. Robert Medcalf is a graduate of the Georgia State University Physical Therapy program. After advanced studies in New Zealand with The McKenzie Institute in 1991, he was granted the McKenzie Institute International Diploma in Mechanical Diagnosis and Therapy of the Spine. He was subsequently named to the teaching faculty of The McKenzie Institute and has taught numerous courses on the McKenzie approach to physicians and physical therapists throughout the United States and internationally. He has participated in published research studies on low back pain and cervical pain responses to mechanical interventions and the diagnostic accuracy of McKenzie’s mechanical assessment. Robert is Director of Spine Rehabilitation at Resurgens Spine Center in Atlanta, Georgia.

Mr. Mark Miller is an honors graduate from the University of Windsor in Human Kinetics,  and went on to pursue his degree in Physical Therapy in 1987 at the University of Toronto. He received a Diploma in Mechanical Diagnosis and Therapy from the McKenzie Institute in New Zealand in 1991. He joined the Canadian branch faculty that year and the USA faculty in 1993. Mark was appointed to the International faculty in 1995. Mark has been actively involved from a scientific committee and a guest lecturer perspective in many McKenzie and non-McKenzie related scientific conferences. He currently works in his private practice in Tallahassee, Florida. He is also the Vice-President of Integrated Mechanical Care (IMC), a company designed to connect MDT trained clinicians to perspective payers, while maintaining MDT quality control.

Show Notes:

Question 1: Joel Rogerson from London, England asks about bridging the gap between being an inexperienced therapist to an expert clinician.


    Robert shares his early discovery of MDT, and how finding mentors and working with more experienced clinicians allowed him to be more successful applying the method. He encourages those of us with more background in MDT to help those new to the method gain confidence by treating more straight-forward patients after taking Parts A and B to ensure proper application.

    Mark remembers his early frustrations prior to obtaining the Diploma in Mechanical Diagnosis and therapy. He recalls his time in New Zealand with Robin McKenzie, and his “aha” moment that MDT is not a trick to put in a bag with other tricks, but that the system is the “bag of tricks”. He encourages all levels of practitioner to reach out to faculty and diplomats to discuss troublesome cases and seek advice.


Question 2: Sarah from Dallas, TX asks a question regarding educating patients with chronic pain behaviors and the psychosocial aspects of pain according to the Therapeutic NeuroscienceEducation system.


    Robert reports that while he is not an expert in dealing with psychosocial barriers, he stresses the importance of going through the assessment as often these patients are mechanically classifiable. He refers to the traffic light analogy and emphasizing the difference between hurt and harm when educating patients with chronic pain behaviors.

    Mark also stresses understanding the mechanics, as well as dealing with some non-mechanical aspects of pain. He also encourages clinicians to have conversations with their patients to help them understand the thought logic of the system, as well as when symptoms or mechanics are not responding in a way that is understandable.


Question 3: Allison from Ithaca, NY asks aboutvalue based reimbursement models, and how chronic pain patients or slow responders might provide a disincentive for practitioners to see their patients through, whereas the rapidly reversible situations may not give us enough financial incentive.


    Mark speaks about a case rate model, where clinicians can prove that outcomes within specific classifications will respond within a set timeframe, and how this can allow therapists/clinicians to negotiate payment based off of realistic outcome expectations. He encourages us to speak up and provide research in order to ensure that payers do not make our clinical decisions for us.

    Robert notes that if we as clinicians see a random sampling, we will generally be seeing more rapidly responsive patients than chronic patients. In this case, we will be able to “pay the bills,” but often we see chronic pain patients for longer periods of time, in which a case rate negotiation may be effective.


Question 4: Joel Dykstra asks about restoration of function, including timeline and reassessment.

    Robert notes that in straight-forward situations, the recovery of function phase occurs when all symptoms are abolished and mechanics are restored for several days. In situations where force progressions and alternatives do not clear symptoms and mechanics, reassess patients with a clean slate and clarify your provisional classification. He encourages us to reintroduce function during maintenance of reduction phase, and test provocative movements early in recovery so as not to foster illness behaviors.

    Mark shares a story about his time in New Zealand when Robin told Mark that many clinicians don’t return their patients to function fast enough. This is not specific to return to provocative movements, but to general function and exercises, thereby instilling self-assessment and helping change fear avoidance behaviors. He goes on to talk about a fear of flexion often seen in clinicians learning MDT early on.


Question 5: Joel also asks about Accountable Care Organizations (ACO’s) and MDT


    Mark and Robert agree that there are no ACOs they are aware of utilizing MDT as a standard for decision making. They refer to Vikas Agarwal, an MD from Kansas City who is trying to convince his ACO as to the benefit of MDT in the initial assessment of all patients with musculoskeletal complaints. Mark shares more of his expertise on the matter, and stresses the importance of MDT clinicians being at the forefront of this emerging opportunity in order to be proactive, rather than reactive.