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Plantar Fasciitis: Heel to Toe Pain

Overly stretched, tiny tears can lead to inflammation and pain in the arch of the foot. This condition, called plantar fasciitis, accounts for nearly one million doctor visits per year. Our foot has a thick band of tissue called fascia that runs from our heel to our toe. This troublesome foot issue is actually more common in women than men. We need to spend time on our feet moving, so this foot problem, if left untreated, can cause excessive pain and greatly limit our mobility.

Contributing Factors

Plantar fasciitis is more common as we age (specifically between ages 40 and 60), but is also more likely to occur in someone who is overweight or constantly on their feet. It is very common in runners. Activities that are known for high rates of plantar fasciitis include ballet, dance, long-distance running, and ballistic jumping. There are a few other contributing factors which include wearing shoes that are worn out and have thin soles or wearing high-heels. The mechanics of how you walk (your stride) involves your foot position. If you have flat feet or a tight Achilles, the body will compensate for these dysfunctions which can lead to injury of the fascia.


Pain starts to occur near the heel towards the bottom of the foot. Most people feel the pain in the morning right when they get out of bed. This is known as “first-step pain”. This can also occur if you have been sitting for a long period of time and then stand up. The plantar fascia acts like an absorbing shock spring in our foot. Repetitive stretching and tearing of this area results in a stabbing pain.


If pain persists, seeing a doctor can help detect this condition. He or she will check the tender areas of the foot. The good news is that plantar fasciitis does normally go away on its own. There are several treatment options. A doctor might prescribe anti-inflammatory medication or a steroid injection. Physical therapy and massage can help as well as shock wave therapy to stimulate blood flow. A Tenex procedure can remove scar tissue in the area or surgery can be done to remove the plantar fascia off of the heel bone. Wearing the right shoes or using shoe inserts oftentimes does the trick, so be sure to try these simple fixes first. Ice and soaking the heel can also help alleviate pain.

A good home remedy is freezing a foam cup of water then rubbing the top of the cup on the heel for 10 or so minutes. Stretching the calves and Achilles tendon can help over time and there are ways to tape the area of the foot to position the heel correctly with each step. Night splints worn to hold the foot at a 90 degree angle help when stretching the fascia.

There’s no doubt that we use and abuse our feet, bearing vast amounts of weight on them while performing all of our daily functions. As we walk from point A to point B, getting those 10,000 steps in, we must practice self-care from head to toe to heel. Sometimes foregoing that cute pair of shoes even at the gym is worth the fashion sacrifice to walk without pain.

Megan Johnson McCullough, owner of Every BODY’s Fit in Oceanside CA, is a NASM Master Trainer, AFAA group exercise instructor, and specializes in Fitness Nutrition, Weight Management, Senior Fitness, Corrective Exercise, and Drug and Alcohol Recovery. She’s also a Wellness Coach, holds an M.A. Physical Education & Health, and is a current doctoral candidate in Health and Human Performance. She is a professional natural bodybuilder, fitness model, and published author.





Healthy Pregnancy Weight Gain Guidelines

One of the most frequent questions pregnant women ask is, “How much weight should I gain during pregnancy?”. This is an important issue, as gaining too much or too little weight can adversely affect fetal growth, birth outcomes and affect the health of the mother.

Research has shown that excessive gestational weight gain can adversely affect fetal growth and increases the risk of cesarean delivery and larger for gestational age births and childhood obesity.  Lack of adequate weight gain can negatively affect fetal growth and development and increase the risk of preterm labor and low birthweight babies. 

The American College of Obstetricians and Gynecologists recommends the following ranges for weight gain during pregnancy. Keep in mind that these are general guidelines; the pregnant client and healthcare provider should determine what’s best for her pregnancy. The health and growth of the fetus may affect what the healthcare provider determines to be a woman’s healthiest weight gain range and that amount can vary as pregnancy progresses.

ACOG Guidelines for Weight Gain During Pregnancy

Pre-Pregnancy BMI  / Recommended Gain 

  • Underweight (Less than 18.5): 28-40 lbs
  • Normal Weight (18.5-24.9): 25-35 lbs
  • Overweight (25-29.9): 15-25 lbs
  • Obese (30 and higher): 11-20 lbs

A pregnant woman’s diet and exercise level play an important role in keeping weight gain within healthy limits.  It’s important to stress that, on average, only 300 extra calories a day are needed to fulfill the energy needs of pregnancy.  If a woman gains in excess of what her healthcare provider recommends, she should keep a food record for several days to see if she’s taking in too many calories. It can be helpful for her to get a referral to a registered dietician to help determine how to maintain a healthy weight gain.

Catherine Cram, MS, is the owner of Comprehensive Fitness Consulting, LLC, a company that provides pre- and postnatal fitness certifications and information to hospitals, health/wellness organizations, and the military. Comprehensive Fitness Consulting offers innovative, evidence-based information to pregnant and postpartum women and their health/fitness providers.



  • BMI Calculator:  https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
  • American College of Obstetricians and Gynecologists Committee Opinion Number 548. January 2013 (Reaffirmed 2020)
  • liu P, Xu L, Wang Y, et al. Association between perinatal outcomes and maternal pre-pregnancy body mass index. Obes Rev 2016;17:1091–102.

Dementia Doesn’t Invalidate Exercise Needs

With careful capability assessment and appropriate program design, exercise regimens can improve walking, balance, and flexibility and reduce falls in patients with dementia.

“Ruth, sit down! Don’t get up on your own.”
Who is that? Why is she yelling at me? I need to get up. My legs are stiff and I want to go for a walk.

“Ruth, stop getting up. You’re going to fall.”
Stop yelling at me. Who are these people? I feel so anxious. All I want to do is go for a walk. Why can’t I just go for a walk? I have walked by myself my whole life.

In working with older adults, many of us have witnessed circumstances similar to this. Often staff wish to maintain the safety and security of individuals living with dementia by limiting their independent mobility and ambulation. But are we truly protecting these individuals who are at risk? What are the ramifications of our actions? Movement and mobility are important foundations to maintaining strength, balance, flexibility, and continence; reducing anxiety and depression; and maintaining social relationships.

To this point, the positive impact of exercise in older adults is well documented in the literature. Exercise programs have been found to result in more favorable physical, social, and emotional health status and fewer activities of daily living impairments in the elderly.(1) These optimistic results provide support for older adults’ exercise groups to improve quality of life and reduce the burden of care for at-risk populations, including those with dementia.

While many focus on the cognitive effects of dementia, the physical aspects are also pronounced. Frequently noted are gait changes including a decrease in step length, step height, and reduction in cadence. These are compounded by balance deficits associated with a reduction in coordination, proprioception, and vision. To further aggravate the situation, the physical effects also can result in expressive and receptive communication deficits. As a result, patients living with dementia can have difficulty communicating these issues, as well as pain.

Effects of Exercise on Individuals With Dementia

Randomized controlled trials of patients with dementia or mild cognitive impairment have indicated improved cognitive scores after six to 12 months of aerobic exercise when compared with a sedentary population.(2) Other benefits associated with aerobic activity include the reduction of osteoporosis and fracture risk,(3) as well as a reduction in mortality risk.(4) Aerobic activity has also been noted to have other beneficial effects on secondary diagnoses associated with dementia including depression,5 anxiety,6 and behavior management.(7)

While the exact causative reasons for these beneficial outcomes are not fully understood, many studies favor the view that the cerebrovascular benefits exercise has on other body systems can be applied to the neurodegenerative process of dementia. Furthermore, evidence exists that aerobic exercise reduces the progression of the neurodegenerative process through facilitation of neuroprotective factors and neuroplasticity.(8)

The positive effects of exercise have also been found in individuals living with dementia who are already experiencing negative physical outcomes. Toulotte et al studied the effects of physical training on frail patients with dementia with a history of falls.(9) The training group was noted to have improved walking, flexibility, and balance, and a reduction in falls. Furthermore, Huusko et al evaluated the impact with hip fracture patients who also had mild/moderate dementia. Those who received intensive rehab were found to have shorter lengths of hospital stay and greater ability to return to the community than those in the control group.(10)

Developing an Exercise Prescription

Regardless of the reasons behind the beneficial effects of exercise on individuals with dementia, it’s necessary to evaluate each patient individually before initiating an exercise program. This includes an interdisciplinary review of an individual’s age, prior exercise involvement, and comorbid medical conditions. Based on the findings, an appropriate exercise program can then be initiated using the American Heart Association’s recommendation of 150 minutes per week of moderately strenuous physical activity.(11) These minutes of exercise can be divided over any number of days per week and with any number of sessions per day. For patient tolerance purposes, these sessions are often kept to between 15 and 30 minutes.

What type of exercise is appropriate for a patient to perform? For individuals with dementia, similar to those without, it is important to focus on their interests. Understanding these interest levels requires investigation. For some patients, this investigation may be complicated by apathy, aggressive behaviors, pain, and communication difficulties.

Depending on the severity of the disease, a focused understanding of a patient’s short- and long-term memory recall is necessary. While older adults without dementia may have a strong recall of their short- and long-term interests, this may not be true of an individual with dementia. Therefore, for those with intact long-term memory, we need to obtain the relevant information. Maybe interests include running, ballroom dancing, bowling, bicycling, gardening, or swimming. If patients can’t physically perform these activities, should we just give up? Of course not. We need to improvise. For example, ballroom dancing may now require walkers, or bicycling may need to be on stationary recumbent bikes with scenery posted around the bicycle.

Case Study

Ms. T is a 53-year-old female who presented to the Hebrew Home at Riverdale skilled nursing facility with a diagnosis including vascular dementia. Prior to initiating a therapy-based warm water program, Ms. T required intermittent assistance walking with a rollator. Her cognition was limited to the point that she could not participate in interviews on the Minimum Data Set (MDS). Despite significant staff efforts to minimize any emotional or environmental disturbances, she experienced periods of agitation. She completed a standardized assessment of her mobility, utilizing the Timed Up and Go (TUG) assessment, completing it in 32 seconds.

At that time, a land- and water-based exercise program with a three-days-per-week frequency was initiated with a physical therapist and dance movement therapist. The hypothesis behind this program was that through the use of multiple therapeutic modalities, gains in strength, balance, cognition, emotional support, and socialization would be achieved. Strength, balance, and functional tasks including ambulation with buoyancy in multiple planes, rotational activities, plyometrics, and resistive activities were implemented. For cognition, behavioral management, and emotional support purposes, music, singing, mental imagery, and floatation were incorporated into individual sessions.

After two months of participating in this innovative program, Ms. T was walking independently without an assistive device. She had also demonstrated an improvement in TUG assessment, completing the test in 10 fewer seconds. Additionally, Ms. T was noted to have experienced an improvement in her cognition, as she was now able to participate in interviews for the MDS. Most meaningful was that Ms. T rediscovered her smile. Tenaya Cowsill, MS, R-DMT, LCAT-P, reported that “this program has been an incredibly meaningful source of joy, autonomy, and pride” for Ms. T.

The Power of Dance

Dance/movement therapy (DMT) is an evidence-based movement approach to psychosocial health and well-being. The American Dance Therapy Association defines DMT as “the psychotherapeutic use of movement to further the emotional, cognitive, physical, and social integration of the individual.”(12) Therapists are board-certified licensed mental health professionals who use movement as a tool to explore, support, and strengthen clients’ emotional needs and coping mechanisms.

DMT can result in both positive physical and emotional outcomes, including a “sense of community, decreasing the experience of emotional isolation, and enriched relational interaction.”(13) Because this modality comprises both verbal and nonverbal interventions, it is especially appropriate for older adults with memory loss who are affected by the expressive and receptive communication difficulties.

The American Dance Therapy Association describes the emotional benefits and processes in treatment for older adults. “Individuals’ capacities and incapacities are explored, and accompanying feelings are expressed. Mourning, frustration, joy, and laughter can be ritualized in group movement, allowing for emotional release and group bonding.”(14)

The physical benefits of exercise and movement have been detailed in previous sections of this article. DMT, which places a focus on mental and emotional health, provides additional benefits as its holistic process includes “physical activity or exercise [and also] … learning, attention, memory, emotion, rhythmic motor coordination, balance, gait, visuospatial ability, acoustic stimulation, imagination, improvisation, and social interaction.”(15)

Older adults, especially those living with memory loss, may struggle with coordinated movement due to changes in brain functioning. Dance therapy welcomes all levels of functioning, encouraging engagement from an individual’s baseline, wherever that may be.

The creative, fluid, psychodynamic process allows for relatedness and engagement with multiple levels of functioning. A primary practice of a dance/movement therapist is one of embodied mirroring defined as the “somatic attunement of the therapist in face-to-face engaged interaction,”(13) which physically communicates to individuals living with memory loss that they are seen and understood. In a time when communication is often impaired, embodied mirroring provides an important tool for validating a patient’s experience.(15) As clinician Kalila B. Homann, MA, LPC-S, BC-DMT, wrote, “Mirroring is practiced by the therapist in DMT as a way to enhance emotional resonance between a therapist and patient … when a therapist mirrors the client’s emotional movements, the therapist is communicating this understanding and acceptance nonverbally.”

On a neurological level this intervention activates the brain’s mirror neuron system. From the neuroscience lens, mirror neurons are thought to be the determining factor in our capacity for empathy and interrelatedness.(13,16) This neurophysiological process “coordinates auditory and visual perception of nonverbal communication by tracking movement and expression in others—replicating the patterns of activation in the brain of the observer.” A resident with memory loss thus experiences validation on a neurobiological level. In dementia, because of the changes in communication that often occur due to brain deterioration, the benefits of emotional attunement from a therapist cannot be overstated. This need for witnessing and validation is a basic human need that does not change with dementia.

Case Study

Ms. M was a 92-year-old woman living in a skilled nursing neighborhood at the Hebrew Home at Riverdale. She carried a diagnosis of mild memory impairment and was a vibrant and active member of the community. She expressed and demonstrated a love for music. She would ambulate throughout the home with her walker, attending a wide variety of programs and actively socializing.

After suffering a stroke, her life shifted. She became reliant on a wheelchair for mobility, and her speech, gait, balance, and cognition were all impaired. This medical event also triggered an exacerbation of major depression, something she had lived with throughout her life. Through working with the rehabilitation team, she demonstrated improvements in functioning; however, major depression remained an impediment to treatment. As her therapy was reaching completion, she was transitioned via a warm handoff to DMT twice weekly from her wheelchair.

During group sessions, she presented with bright affect and eye contact, which was supported and validated by the therapist facilitating the group. In the therapeutic group space, Ms. M was able to both verbally and nonverbally express her grief and frustration with her condition. She spoke about her depression and was able to verbally and physically process her feelings through creative expression within the therapeutic alliance. Ms. M was able to “engage physiological processes related to emotion and make them more available to the conscious mind,” as Homann’s writings suggest. Through increased awareness Ms. M was able to more fully process and express her depressive symptoms, enabling her to further her treatment.

As dance therapy progressed, Ms. M began to increase her interpersonal relatedness, making eye contact with peers, sharing memories and physical gestures of connection. Ali Schechter, LCAT, R-DMT, her dance/movement therapist, states: “[Ms. M’s] movement generates vitality which results in expression.” Through the therapeutic alliance, this expression was validated, supporting Ms. M’s improved mood state.

As her mood state improved through DMT, Ms. M expressed the desire to begin standing and walking again. In addition to mood state support, DMT focused on movement of the spine, core, and hips, aiding in body strengthening for standing. The interdisciplinary team referred her for further physical therapy, and she began standing and, at times, walking with her walker for short periods. She continues to be an active participant in DMT sessions.

Blending Therapy Modalities

Maintaining and improving fitness and well-being remains an important evidence-based practice in our society. This is further magnified for older adults, especially those living with dementia. While the benefits of fitness programs remain the same for this population, the prescription for achievement may require a blended approach. Therapies, inclusive of physical and dance/movement, share many common strengths and goals. Therefore, the ability of these modalities to partner provides opportunities for improved mental, physical, and emotional health. The goal in all treatment is the well-being of residents, and care teams should use interdisciplinary tools and modalities toward that goal.

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This article was featured in Today’s Geriatric Medicine.

Today’s Geriatric Medicine is a bimonthly trade publication offering news and insights for professionals in elder care.

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This article was featured in the March/April 2018 issue of Today’s Geriatric Medicine (Vol. 11 No. 2 P. 14). Written by David Siegelman and Mary Farkas.

 David Siegelman, PT, RAC-CT, is the vice president of rehabilitation at the Hebrew Home at Riverdale in Bronx, New York. In this role he oversees the operation of the short-term rehabilitation units, clinical documentation and reimbursement department, and rehabilitation department. Having entered the field as a physical therapist, he has demonstrated expertise in clinical and systems management in acute care hospitals and skilled nursing facilities over the past 20 years.

Mary Farkas, RDT, LCAT, CDP, is the director of therapeutic arts and enrichment programs at the Hebrew Home at Riverdale. She is a licensed creative arts therapist who specializes in the intersection of dementia, end-of-life care, and mental health.



  1. Hamar B, Coberley CR, Pope JE, Rula EY. Impact of a senior fitness program on measures of physical and emotional health and functioning. Popul Health Manag. 2013;16(6):364-372.
  2. Smith PJ, Blumenthal JA, Hoffman BM, et al. Aerobic exercise and neurocognitive performance: a meta-analytic review of randomized controlled trials. Psychosom Med. 2010;72(3):239-252.
  3. Rizzoli R, Bruyere O, Cannata-Andia JB, et al. Management of osteoporosis in the elderly. Curr Med Res Opin. 2009;25(10):2373-2387.
  4. Lee DC, Artero EG, Sui X, Blair SN. Mortality trends in the general population: the importance of cardiorespiratory fitness. J Psychopharmacol. 2010;24(4 Suppl):27-35.
  5. Conn VS. Depressive symptom outcomes of physical activity interventions: meta-analysis findings. Ann Behav Med. 2010;39(2):128-138.
  6. Dunn AL. Review: exercise programmes reduce anxiety symptoms in sedentary patients with chronic illnesses. Evid Based Ment Health. 2010;13(3):95.
  7. Teri L, Gibbons LE, McCurry SM, et al. Exercise plus behavioral management in patients with Alzheimer disease: a randomized controlled trial. JAMA. 2003;290(15):2015-2022.
  8. Ahlskog JE, Geda YE, Graff-Radford NR, Petersen RC. Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging. Mayo Clin Proc. 2011;86(9):876-884.
  9. Toulotte C, Fabre C, Dangremont B, Lensel G, Thévenon A. Effects of physical training on the physical capacity of frail, demented patients with a history of falling: a randomised controlled trial. Age Aging. 2003;32(1):67-73.
  10. Huusko T, Karppi P, Avikainen V, Kautiainen H, Sulkava R. Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia. BMJ. 2000;321(7269):1107-1111.
  11. Nelson ME, Rejeski WT, Blair SN, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1094-1105.
  12. What is dance/movement therapy? American Dance Therapy Association website. https://adta.org/. Retrieved January 7, 2018.
  13. Homann KB. Embodied concepts of neurobiology in dance/movement therapy practice. Am J Dance Ther. 2010;32(2):80-99.
  14. American Dance Therapy Association. Dance/movement therapy & the older adult. https://adta.org/wp-content/uploads/2015/12/DMT-with-the-Elderly.pdf. Accessed January 7, 2018.
  15. Kshytriya S, Barnstaple R, Rabinovich DB, DeSouza JFX. Dance and aging: a critical review of findings in neuroscience. Am J Dance Ther. 2015;37(2):81-112.
  16. Iacoboni M. Mirroring People: The New Science of How We Connect With Others. New York, NY: Farrar, Strauss and Giroux; 2008.

Youth Obesity: An ounce of prevention is worth a pound of cure

“An ounce of prevention is worth a pound of cure.”

This sentiment from Benjamin Franklin is as true today as ever.  Especially when it comes to fitness and health.  The past 50 years has seen a nearly triple increase in obesity rates for adults and youths.  According to the website USAFACTS.ORG. this costs the American people $147 Billion annually.  They also state that “roughly have of all medical cost associated with obesity are financed by Medicaid and Medicare”.  

Stressed Man Working At Desk In Busy Creative Office

Stress: An Easy Exercise To Help You Deal With It!

Stress. It’s everywhere. If you live and work on this planet it’s almost impossible to avoid. In normal times are stressful enough but this past year we have had to share our lives with Covid 19.

Feeling stressed? Me too!

Today I’m writing about how to reduce stress and suggest some easy ways to get that burden off your back.

Stress has been around since the beginning of time. It started as the fight-or-flight response when early humans confronted a life-threatening situation. In that situation, stress hormones- adrenaline and cortisol- are produced. Your blood vessels constrict, blood pressure goes up, pupils dilate, heart rate quickens, and breathing becomes more rapid. The body is preparing itself to do battle or run. This response is essential in times of acute danger. But problems at work, crying kids, traffic, you name it can trigger the same response.

Given the pressures of daily life, chronic stress itself has become a life-threatening situation. It can cause a host of health problems including headaches, gastrointestinal issues, insomnia, trouble concentrating, anxiety, depression, increased body weight, high blood pressure and heart disease.

We can’t eliminate the stress. But we can relieve the fight-or-flight response that sends our bodies into danger mode. And we can cultivate a relaxation response over time that will reduce our physiological stress reaction.

So what do we do about chronic stress? How do we get rid of it?

How? Relax. That’s what my first yoga teacher used to say when I was all bent up in the pretzel pose with a grimace on my face. Once I was able to relax, I was stress-free even in the pretzel pose.

Seriously, daily conscious relaxation exercises can make a real difference in the way your body responds to stress. Dr. Herbert Benson coined the phrase “relaxation response” in his book by the same name in 1975.

Since then, he and others have conducted numerous studies, including a recent one at the Benson-Henry Institute for Mind/Body Medicine, that have detailed the body’s intricate positive response to conscious relaxation exercises. In a nutshell, the relaxation response has the opposite effect of fight-or-flight. It engages the parasympathetic nervous system to counteract the effects of stress. You experience a feeling of deep relaxation and well-being. And if you practice relaxation regularly, you’ll feel better and help yourself avoid those stress-related health issues. That’s how we get rid of chronic stress.

Meditation is just one of an almost infinite number of ways to consciously relax. Virtually anything that takes your attention away from your daily grind and makes you concentrate on just one thing can work. Doing the dishes, aerobic exercise, yoga, stretching, golf, playing a musical instrument, casting a fishing rod, playing with a cat — almost anything can work if you pay attention to only that and clear your mind. I’m partial to exercise because I get the benefits of a workout as well as the relaxation. It’s my mantra. It’s what I do to get rid of chronic stress.

Dr. Benson suggests you practice some form of conscious relaxation for 10 to 20 minutes every day to get rid of chronic stress in the long term.

But what if you’re pressed for time? (Pressed rhymes with stressed.)

Reduce Chronic Stress with this little exercise. 

Sometimes you only need a few seconds and you feel a lot better.

  • Sit down and close your eyes. (If you’re on the street, duck into a doorway, stand and keep your eyes open and one hand on your purse.)
  • Let your muscles relax. Concentrate on your breathing.
  • Breathe in and hold your breath for one second, count “one, one-hundred-thousand”, and breathe out.
  • Breathe in again a little deeper and hold for two seconds – “one, one-hundred-thousand; two, one-hundred-thousand” — breathe out.
  • Breathe in deeper and hold for three, then four, then five seconds.
  • When you get to around three seconds of breath-holding, your stress level should start to drop and your mind should start to clear itself of thoughts.
  • After five, you should feel pretty good. This works well for me particularly in moments of acute stress.

That one worked too, didn’t it? I hope concentrating on reading this helped you reduce your stress and I hope you’ll make conscious relaxation a part of your life.

It’s a lifestyle change that’s easy to make because it feels so good when you do it.

Check out Mirabai’s video below, guiding you through a short Meditation and Stretch to reduce stress that can be done at work or home.

Mirabai Holland MFA, EP-C, CHC is one of the foremost authorities in the health and fitness industry. Her customer top-rated exercise videos for Health issues like Osteoporosis, Arthritis, Heart Disease, Diabetes & more are available on her website, mirabaiholland.com. Join her NEW Online Workout ClubMirabai offers one-on-on Health Coaching on Skype or Phone. Contact her at askmirabai@movingfree.com


A Pipeline of New Clients Through Physician Exercise Referrals

“I want to know how good the [fitness professional] is at their art and science of progressing people through exercise.” 

These words were spoken by a physician who regularly refers his patients to fitness professionals. In 2019 and 2020, I spent ten months surveying and interviewing physicians and fitness professionals at a New England healthcare organization. This healthcare organization has had an exercise referral network in place for over a decade, and averages about thirty-five exercise referrals per week. 

As part of the exercise referral network, physicians were able to refer patients to community-based fitness centers and professionals, as well as a hospital-affiliated facility. The hospital-affiliated facility has four programs: an 8-week exercise program for post-rehab (muskuloskeletal, cardiac, and pulmonary); a 13-week fitness, nutrition, stress management and behavior modification program; a 12-month weight management program; and a 3-month cancer recovery program. Its program staff were registered dietitians, personal trainers, and health coaches.

The purpose of my research was to understand physicians’ and fitness professionals’ perspectives on physician exercise referrals and the impact on patient behavior change. Not enough physicians provide exercise referrals to their patients, and my research revealed a clear opportunity to address barriers to referral. In addition, physicians are less comfortable referring their patients to community-based fitness facilities and professionals than they are to hospital-based fitness facilities and professionals. Raising physician familiarity with, awareness of, and confidence in fitness professionals can help build physician trust in their capabilities. This is especially true for fitness professionals who have expertise and experience working with special populations, including people with different injuries, disabilities and diagnoses.

Physicians want to know that [their patients] are exercising in a place where, if anything bad or adverse were to happen, they are in good hands.” ​ –Fitness Professional 

Join me for my upcoming webinar with MedFit, where I’ll speak more on this topic as part. I’ll discuss ten steps that fitness professionals can take to become professionals that physicians trust to take good care of their patients. These steps focus on facilitating communication between physicians and fitness professionals about patients’ progress and outcomes, as well as raising physician awareness of the professionals’ capabilities. Join me as I walk through how to develop A Pipeline of New Clients Through Physician Exercise Referrals.


Dr. Amy Bantham has 20 years of experience working in consulting, health & fitness, and healthcare. She is the CEO/Founder of Move to Live®More, a research and consulting firm addressing physical inactivity, obesity, chronic disease, and social determinants of health through cross-sector collaboration and innovation. 

Amy holds a Doctor of Public Health from the Harvard T.H. Chan School of Public Health, with concentrations in Health Communication and Obesity Epidemiology & Prevention. Her doctoral research focused on physician exercise prescriptions/referrals and patient exercise behavior change. She is a certified group exercise instructor, personal trainer, and health & wellness coach. She also holds a Master of Science from Northeastern University, a Master in Public Policy from the Harvard Kennedy School, and a Bachelor of Arts from Yale University.


Closing the Trust Gap: Are personal training certifications failing medical fitness?

For over 30 years, the alphabet soup of letter-bearing personal training certification companies like ACE, NASM, NSCA and ISSA have focused on providing education leading to a fitness certification. While the companies have differing audiences and missions, collectively they have failed to truly make the connection between the fitness industry and the healthcare industry.

Personal trainers tend to be health advocates (and sometimes zealots) who show up as the face of the fitness industry. They tend to actually live and practice the life they espouse. Most leave the industry quickly, but even as they leave personal training and continue throughout their careers they tend to retain their core values around fitness.

Listen to almost any group of personal trainers and you’ll hear them speak passionately about the value of fitness and the ability to help control or eliminate diseases like type 2 diabetes, heart diseases and some forms of cancer. For their more affluent customers, personal trainers are frontline soldiers in a battle for healthier living.

So, how is it that well-intentioned organizations that believe that healthier living improves lives and who have over 350,000 personal trainers working in America alone have been unable to connect those trainers to the next higher level of their mission? What has gone so wrong that the average consumer would more likely connect a personal trainer to an Instagram or social media influencer than to their healthcare provider?

In a recent ISSA survey, personal training buyers were asked what education or qualifications were required to become a personal trainer. Nearly 80% of those surveyed did not know. Fortunately, nearly everyone surveyed believed that some form of education or certification was required. Perhaps consumers would have the same answer if the question was asked regarding nursing or other healthcare positions other than that of a doctor.

In this situation and those like it in America, we are accustomed to trusting the person in the job has the knowledge, skills and abilities to do the job. We may not know how or why, but we have given them the magic ingredient — trust.

In our society, we fundamentally trust that by achieving the title of doctor, the holder will do no harm and will have the secret to curing what ails us. Do we trust that our personal trainer will do no harm and will have the secret to help us achieve our fitness goals? Not so much.

In the same ISSA survey, buyers of personal training were asked if personal trainers could help clients lose weight and 90% answered yes. When asked if personal trainers could help cure type 2 diabetes only 10% answered yes. There was an 80% difference when asked the same question in the context of personal training goals versus medical goals!

It would seem logical that if the same question was asked in the context of knee pain or joint pain and heart disease or blood pressure the results would be the same.

We trust that personal trainers understand how to improve our fitness, but we don’t connect our fitness to our healthcare. This is a trust gap.

This trust gap is the most fundamental issue preventing all of the subsequent steps which need to happen in order for medical fitness to thrive. There can be no insurance reimbursement or physician prescription of exercise as medicine as long as we don’t first believe our health is in our control and that fitness professionals can help their clients achieve results.

Today, even physicians who believe in exercise as medicine are reluctant to refer clients. Despite some of the most forward-looking physicians and groups bringing exercise and personal training into their medical practice, compliance remains spotty and reimbursement varies widely.

A recent study provided insights around prescribing exercise as medicine in the treatment of 26 different diseases: psychiatric diseases (depression, anxiety, stress, schizophrenia); neurological diseases (dementia, Parkinson’s disease, multiple sclerosis); metabolic diseases (obesity, hyperlipidemia, metabolic syndrome, polycystic ovarian syndrome, type 2 diabetes, type 1 diabetes); cardiovascular diseases (hypertension, coronary heart disease, heart failure, cerebral apoplexy, and claudication intermittent); pulmonary diseases (chronic obstructive pulmonary disease, asthma, cystic fibrosis); musculoskeletal disorders (osteoarthritis, osteoporosis, back pain, rheumatoid arthritis); and cancer.

But, how much of this is studied by medical students and applied by physicians? Why does the majority of our society doubt fitness? Is it because we don’t trust fitness professionals? If so, what is the fitness certification world to do?

If we are to close this trust gap, the industry needs to achieve three milestones:

  1. Personal trainers need to have a common standard of professional knowledge and skill
  2. Required continuing education and training must be in place
  3. We need to have standards of care for fitness programming.

This requires that the industry through leadership such as IHRSA combined with companies like ISSA, NASM, ACSM, ACE and others eliminate the need for individual exams and certifications and move to a common standard of excellence for all.

In the absence of the fitness industry creating an environment where all parties can trust their personal trainer to provide safe and effective training programs, none of us can expect medical schools to teach fitness or doctors to prescribe exercise or insurance companies to reimburse for exercise.

COVID-19 created a broad national awareness of the incredible risks of obesity and underlying medical conditions which largely could be controlled through diet and exercise. Now is the time to take action and help a new generation live healthier lives.

Andrew Wyant serves as the President of the International Sports Sciences Association (ISSA) after having helped successfully build and grow a series of businesses in a wide variety of industries. Since becoming ISSA’s leader in 2018, the ISSA has grown by over 400% and has become the No. 1 rated and reviewed personal training company in the world. Andrew is passionate about the potential personal trainers have to help improve our world by reducing the rates of preventable diseases. He has been deeply involved in the health and fitness industry since 2011.

This article was featured in MedFit Professional Magazine. Click here to read past issues or sign up for your free subscription.

Spring into summer salad

The Naturopathic Chef: Spring into Summer Salad

Refresh and revitalize with this bright side dish that’s perfect for any summer table.

The dressing doubles as a versatile marinade, too.


  • 1 Tbls Shallot, minced
  • 1 Tbls Aged Balsamic Vinegar
  • 2 Tbls Fresh Lime Juice
  • 2 tsps Fresh Orange Juice
  • 2 tsps Honey
  • ½ tsp Dry or Dijon Mustard
  • ½ tsp Salt
  • ¼ tsp Pepper
  • ¼ cup Avocado Oil

Stir all ingredients together except avocado oil. Whisk oil into mixture to emulsify. Chill 


  • 2 cups Watermelon, cubed in bite-sized pieces
  • 1 cup Strawberries, sliced
  • 2 small Persian Cucumbers, sliced
  • 8 Mint leaves, chopped
  • 2 Basil leaves, chopped 
  • 2 Tbls Toasted Pistachios, chopped
  • 2 Tbls Feta, crumbled
  • pinch of Salt

Toss ingredients with dressing, top with pistachios and feta.

Phyte Facts

Everything in this salad contributes to proper hydration and mineral balance, making it perfect for warm weather. Both Mint and Basil have cooling properties and keep our thermostats operating at peak performance. Love to hike? This is your perfect companion.

Get more great recipes from Tina Martini — her book, Delicious Medicine: The Healing Power of Food is available to purchase on Amazon. More than a cookbook, combining 20+ years of experience, along with her love of coaching, cooking and teaching, Tina offers unexpected insights into the history and healing power of clean eating, along with recipes to help reduce your risk of disease and improve overall wellness so you can enjoy life!

Affectionately referred to as The Walking Encyclopedia of Human Wellness, Fitness Coach, Strength Competitor and Powerlifting pioneer, Tina “The Medicine Chef” Martini is an internationally recognized Naturopathic Chef and star of the cooking show, Tina’s Ageless Kitchen. Tina’s cooking and lifestyle show has reached millions of food and fitness lovers all over the globe. Over the last 30 years, Tina has assisted celebrities, gold-medal athletes and over-scheduled executives naturally achieve radiant health using The Pyramid of Power: balancing Healthy Nutrition and the healing power of food, with Active Fitness and Body Alignment techniques. Working with those who have late-stage cancer, advanced diabetes, cardiovascular and other illnesses, Tina’s clients are astounded at the ease and speed with which they are able to restore their radiant health. Tina believes that maintaining balance in our diet, physical activity, and in our work and spiritual life is the key to our good health, happiness and overall well being. Visit her website, themedicinechef.com


The Roles of a Medical Fitness Specialist: Scope of practice, prevention and interprofessional collaboration

Physical activity has been demonstrated to positively affect over 30 chronic conditions and is considered the best deterrent of chronic disease in primary and secondary prevention. The main goal of a Medical Fitness Specialist (MFS) in the healthcare continuum is to prevent the onset of chronic disease and bridge the gap between clinical intervention and conventional fitness programs. This is achieved by developing exercise programs for those who have or are at risk for chronic disease or dysfunction, have health conditions that may be mitigated or managed by exercise and activity, are newly diagnosed with a disease and need exercise guidance, or have completed a medically supervised rehabilitation program and need to continue to progress. A fitness professional versed in medical fitness protocols, such as an MFS, can work with those who are at risk for chronic disease.

Scope of Practice

Scope of practice refers to boundaries set by knowledge, skills, and abilities (KSAs), as well as education, experience, and demonstrated competency, such as a program of study, or an exam to measure proficiency. A basic personal training certification suggests the holder can develop exercise programs for apparently healthy clients. Unfortunately, considering the overweight and obesity rate is near 70%, and 50%-60% of the adult U.S. population has at least one chronic disease, adhering to scope of practice becomes increasingly important, yet at the same time many fitness professionals may be providing services outside their scope of practice, and beyond their level of certification. By accepting a client, the trainer is proposing a safe workout will be developed and implemented, and the client will not be at risk of injury. If advice is given that is not within the trainer’s scope of practice, the trainer and the facility may be subjected to a lawsuit.

An MFS who integrates medical fitness into practice has the KSAs, based on education, experience, and demonstrated competency to conduct pre-participation interviews, perform fitness assessments, and design and implement health and fitness programs for disease management to avoid future injury and to improve activities of daily living. Unlike an MFS, unless otherwise educated, a fitness trainer who promotes medical fitness is not a licensed healthcare provider and does not possess the KSAs to diagnose an unknown condition, suggest supplements, design meal plans, physically touch a client or provide behavioral counseling.


In the United States, medical care tends to focus on treatment rather than prevention. Whereas treatment is given for a diagnosed disease or injury, the goal of prevention is to avoid, improve or slow down the progression of a probable or possible disease or injury. Prevention can be categorized as primary, secondary, or tertiary. The goal of primary prevention is to foster a life of wellness and therefore avoid or reduce the chance of disease or dysfunction. Primary prevention includes immunizations, targeted types of exercise, balanced nutrition and wellness, and education programs. Secondary prevention is managing a symptomatic disease in the hopes of slowing down or reversing the progression. Examples include treatment for hypertension, asthma, and some cancer treatments. Tertiary prevention involves the management and treatment of symptomatic disease with the goal of slowing progression and severity, as well as reducing disease-related complications. Tertiary prevention includes treatment for late-stage cancer, coronary heart disease, and some types of rehabilitation to include orthopedic, cardiac, and pulmonary. Physical activity has been demonstrated to effectively treat over 30 chronic conditions, mostly in primary prevention but also in secondary and tertiary, making it the number one intervention against chronic disease.

Interprofessional Collaboration

Due to the growing incidence of obesity and chronic disease, leveraging the skills of various providers who can collaborate to deliver the best possible care, based on clinical needs, is necessary to manage the complex health care demands of a population with an increasing incidence of comorbidities. Due to a worldwide shortage of health workers, in 2010, the World Health Organization (WHO) recognized interprofessional collaboration as means to mitigate the global clinician shortage, strengthen health systems and improve outcomes. Interprofessional collaboration refers to health care teams, made up of trained professionals with various backgrounds, who work alongside patients and their families to provide high-quality care, based on the needs of the patient. Consequently, as medical providers begin to recognize the need to prescribe evidence-based exercise as an intervention in the management of chronic disease, MFSs, who are on the front line of health care, are trained and educated to be part of a clinical team that complements and leverages the strengths of each team member to improve population health. As health science and technology advance, it is imperative for fitness professionals who work with clients who have one or more chronic diseases to remain up-to-date on emerging fitness protocols. An MFS is required to participate in continuing education in areas including cardiopulmonary disease, metabolic disorders, and orthopedic dysfunction.

Although the scope of practice of many allied healthcare fields overlaps, the role of the MFS is to work with the client’s team of other healthcare providers, while staying within the scope of practice, based on KSAs. Regardless of the collaborative health team, the client’s physician is always the center, and as such should be provided regular updates as to the client’s progress.

An MFS is uniquely qualified to work with individuals within the healthcare continuum. Some KSAs associated with MFSs are:

  • Knowledge of basic chronic disease pathophysiology
  • The use and side effects of common medications taken by someone suffering from a chronic disease
  • The knowledge to perform and analyze basic assessments related to movement and anthropometry
  • The knowledge to design a safe and effective workout based on information received via assessment results, and the clinical recommendations from other healthcare providers
  • FITT protocols, exercise progressions, and regressions
  • The implications of exercise and activity for individuals with chronic disease
  • Contraindications of chronic disease, and signs and symptoms of distress related to chronic disease
  • Knowledge of signs and symptoms that require expertise outside of the scope of practice for medical exercise
  • The ability to recognize a medical emergency
  • Current CPR and adult AED are required

Personal Trainers & Fitness Professionals: Prevent & Manage Chronic Disease and Collaborate with Clinicians

Check out MedFit Classroom’s 20-hour online course, Medical Fitness Specialist. This course is designed for fitness and health professionals who want to learn more about using exercise as medicine with clients who suffer from one or more chronic diseases. As a Medical Fitness Specialist, you will be able to prevent and/or manage numerous chronic diseases and collaborate with clinicians.

Dan Mikeska has a doctorate degree in Health Science and a master’s degree in Human Movement, as well as certifications from NASM, ACE, the Cancer Exercise Training Institute and the Exercise Is Medicine credential from ACSM. He currently owns NOVA Medical Exercise and Medical Exercise Academy and is adjunct faculty for A.T. Still University’s Master of Kinesiology program. 

This article was featured in MedFit Professional Magazine. Access past issues or subscribe to read more great content like this!