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

Physical activity is any bodily movement produced by voluntarily contracting skeletal muscle that results in energy expenditure above a basal level. 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 Practitioner (MFP) 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 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 MFP, 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 heathy 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 MFP 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 to design and implement health and fitness programs for disease management to avoid future injury and to improve activities of daily living. Unlike an MFP, 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.

Prevention

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, MFPs, 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 disease to remain up-to-date on emerging fitness protocols. An MFP 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 overlap, the role of the MFP 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 MFP is uniquely qualified to work with individuals within the healthcare continuum. Some KSAs associated with MFPs 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

This article was featured in the summer 2020 issue of MedFit Professional Magazine. Click to read the latest issue and get your free subscription.


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. Dan’s mission is to improve population health and to increase the quality of life by connecting education, medicine and fitness. 

Physical therapist gesturing thumbs up besides senior woman on yoga ball

Medical Fitness – A Win for Professional and Patient

Medical Fitness is a growing trend in health care. Medical Fitness helps extend basic healthcare from the classic and formal model of a person being a patient, receiving treatment and being discharged entirely, to after care professional services. Medical Fitness is the integration of ongoing fitness, wellness and preventive care under the supervision of health professionals such as, physical therapists, exercise physiologists, personal trainers, nutritionists, acupuncturists, chiropractors, massage therapists, mental health practitioners, health and wellness coaches, yoga professionals and more.

Physical therapist gesturing thumbs up besides senior woman on yoga ballMedical Fitness is appropriate for many types of conditions such as arthritis, diabetes, orthopedic conditions, pre and post natal, heart disease, fibromyalgia, stroke, cancer, mental disorders,  and others. When properly implemented, Medical Fitness is a win-win for both patient and health professional.

Medical Fitness Advantages for the Patient

First, after discharge from the formal healthcare world, the patient can be referred to a variety of health professionals educated in the patient’s condition, providing both a continuum of care and a multi-discipline approach. For example, a person discharged from physical therapy after a total knee replacement might be referred to a certified personal trainer facility educated in post-rehabilitation of a total knee to continue to make further functional gains and improvements. If that person needed help with weight loss, perhaps a referral to a nutritionist would be included. If they also had issues with coping with their diminished function, a consult with a specialist in mental health might be provided as well.

Second, many times the medical facility in which care was provided will have a Medical Fitness component associated with it. Direct referral to this type of facility can provide the patient with security and confidence, being familiar with the facility and with the knowledge that the new health professional is familiar with their condition and diagnosis.

Medical Fitness Advantages for the Health Professional

First, by being part of a Medical Fitness community the health professional can refer a discharged patient for follow up care, secure in the knowledge that their patient will be cared for by an ancillary care professional who is trained and certified to provide a proper continuity of care plan along with the appropriate goals and treatments.

senior man with trainerSecond, by referring to a Medical Fitness multi-discipline team, the health professional receives security that if their patient has any other issues, those concerns will be addressed. For instance with the example of the total knee replacement patient needing assistance with weight loss or nutrition consults, (treatments that don’t fall under the umbrella of physical therapy), the physical therapist is assured their patient will be helped to achieve a better transition back into their “non patient” status.

Third, when the health professional refers their patient into a Medical Fitness wellness and preventative care environment, the chance for overall improved outcomes is increased. Patients learn better self-confidence in caring for themselves, taking charge of their own health and lifestyle. If a patient’s condition begins to backslide, the wellness program professionals can help make sure the patient gets referred back to the health professional in a timely manner.

In conclusion, Medical Fitness benefits all involved. Quality of care is improved. Patients receive access to multi- discipline care and can learn to take charge of their life. Health professionals receive security of proper continuity of care and gain improved patient outcomes.


Douglas Feick, PT is a licensed physical therapist in Texas, with emphasis in orthopedics for over 15 years. He is President of BioEx Systems Inc, a software company providing software solutions for physical therapists, athletic trainers, chiropractors, dietitians and personal trainers. His hobbies include scuba diving, raising bees and he is an avid skydiver.

BORRELIA-bacteria

Another MAJOR Mental Health Hidden Stressor…. BORRELIA!

Lyme disease is caused by the spirochete bacteria, borrelia (strains vary by region). The borrelia bacteria has the crazy capability of altering its genome in order to change its exterior shell antigens in order to avoid being detected by the host’s immune system. These modified surface proteins can trigger autoimmunity in the host.

Borrelia infection in the blood

16 proteins on the borrelia bacteria have been shown to cross-react with thyroid tissue, thereby triggering thyroid autoimmunity, such as Grave’s or Hashimoto’s thyroiditis. Lyme can also trigger chronic inflammatory response syndrome, or CIRS.

The bacteria also produce protein “cocoons” called biofilms that protect the bacteria from antibiotic treatment and immune system defense mechanisms. The bacteria will secrete enzymes to digest and steal nutrients from the host. These little bastards will burrow into tissues across the body, such as the joint tissue (joint pain?), or even central nervous system (can mimic neurological conditions). Lyme often comes with co-infections like babesia and bartonella.

Testing for Lyme can be tricky and antibiotics are not always effective by themselves. Therefore using a functional approach (in conjunction with antibiotics, only when absolutely necessary) yields superior outcomes.

Learn more about this topic… join Brendan for his upcoming webinar, Integrative Therapeutics for Lyme and Coinfections.


Brendan Vermeire is an Integrative Clinician and Functional Diagnostic Nutrition Practitioner specializing in complex chronic illness. He began his career as a personal trainer and nutrition coach at the age of 19. After being exposed to the power of functional lab testing in the start of his career, he began intensely pursuing that as a career path which has lead him to being the current Director of the Association of Functional Diagnostic Nutrition Practitioners, the owner/founder of the Premier Virtual Integrative Health Clinic, Metabolic Solutions, and a Clinical Educator for Bio-Botanical Research.

Prescription for good health diet and exercise flat lay overhead with copyspace.

A New Era Begins

The rallying cry is, “Let’s change healthcare!” From all corners of the medical universe, there is agreement that change is necessary. The biggest questions are, “What is the change?” and, “Who will make it happen?”

mold

Is Mold Your Root Cause?

Once upon a time I was engaged. I was 21 years old and more in love than I had ever been, and perhaps more than I have even to this day as I sit here writing this at 6 am on a calm Summer morning.  I lived with my fiancé and her children. Although life was a bit nutty at times. We had something. Something good. For a moment there, it was permanent…

Prescription for good health diet and exercise flat lay overhead with copyspace.

Medical & Fitness Integration… a HEALTH-E-FIT!

Year after year, the IHRSA Trend Report continues to state that there will be an increase of trillions of spending cost in healthcare spending, with aging Baby Boomers contributing heavily to the total over the next decade. At least 50% of adults between 50-64 years of age live with at least one chronic condition. More than 44% of US consumers take at least one prescription medication daily, and the 50+ age group accounts for nearly 3/4 of spending on prescription drugs. The most commonly prescribed drugs for 40- to 60-year-old adults are for high cholesterol, gastrointestinal disorders, diabetes and hypertension.

As more individuals who actively participate in the US healthcare system seek solutions, the more we need to do for positioning our programs and facilities to address their non-traditional needs. As with any other business, we must change, modify and refocus our service delivery system as our client profile and the associated service needs change.

In April 2017, I made the decision to solely focus on developing a Medical Fitness Service to champion the Exercise is Medicine® (EIM) initiative through HEALTHEFIT. Despite being created in 2007, EIM remains an untapped service that has not only been ignored by fitness professionals but also by healthcare as well. Exercise is Medicine®, a global health initiative managed by the American College of Sports Medicine (ACSM), encourages primary care physicians and other health care providers to include physical activity when designing treatment plans and to refer patients to evidence-based exercise programs and qualified exercise professionals, especially those with the Exercise is Medicine credential.

In reviewing the multiple areas that we could contribute positive health outcomes, we decided to focus on the following:

1. Orthopedic Pathology

  • Acute Low Back Pain, Low Back Pain and Sciatica, Shoulder Impingement Syndrome, Rotator Cuff Pathology, Hip Replacement, Full Knee Replacement, ACL, Meniscus Pathology, Patella-Femoral Syndrome, Osteoporosis

2. Cardiovascular Disease

  • Hypertension, Coronary Artery Disease, Peripheral Vascular Disease, Alular Heart Disease

3. Pulmonary Disease

  • Chronic Obstructive Pulmonary Disease [COPD], Asthma, Bronchitis, Emphysema

4. Metabolic Disease

  • Diabetes Mellitus, Obesity, Blood Lipid Disorders

HEALTHEFIT’s medical fitness services incorporate a Triangle Treatment Protocol® including: EIM, DNA based nutrition, and Behavioral Medicine. Depending on an individual’s employer benefits plans and/or health insurance, either all or part of these medically directed services can potentially be reimbursable. Creditability is very important to the medical industry therefore we had to ensure that we differentiate our staff from the everyday personal trainer.

While credentials are indeed important, the ability to translate this knowledge into patient specific program design and treatment progression processes is the real professional test. Our medical fitness providers are fitness professionals who have a comprehensive knowledge of special populations. I have been able to create a new professional that is gaining the trust of physicians and health insurance. Our recruiting, orientation, and onboarding process has been the difference in separating HEALTHEFIT from other programs and gaining acceptance with Virginia Premier as their exclusive in-network medical fitness provider and out-of-network
status with Anthem and Cigna.

Want to learn more? Join David for his upcoming MedFit webinar on this topic:


David Rachal III is the founder and CEO of HEALTH-E-FIT, a medical fitness based facility in Chester, VA, where he’s created a scalable system that engages, educates, and empowers physicians and medical fitness providers to work together. His facility uses exercise and nutrition as medicine making prevention, treatment, and long-term management accessible for all. David’s contributions to the fitness industry also include training hundreds of private clients to success and educating over 1,000 trainers in the past eight years as a Fitness Presenter and Certification Specialist with nationally recognized organizations. David holds an MBA with a focus in Healthcare Management. He holds many specialty training certifications, including the ACSM ‘Exercise is Medicine’ credential, the FMS Functional Movement Specialist, and NSCA Tactical Strength and Conditioning Facilitator.

doctor-health

Adaptive Health Paradigm: A Principle-Centered Perspective for Medical Fitness

I hope to give you some insights to both how the human body works as well as why medically-based fitness is not only valid, but absolutely necessary to reverse, assist, or prevent various chronic and acute disease conditions.  Wow, that is a “mouthful” to say the least. I feel so strongly about this perspective that I hope to create the Adaptive Health Model as a major “brand” of fitness. My company (Principle-Centered Health) for the past couple of decades has always had a systems-based approach to health and fitness. This approach ties a lot of different facts into a common theme, usually called a theory in science. Even my dissertation looked at how people adapted to the physical, mental and social issues in their lives using exercise, self-efficacy, and social support, respectively, and levels of strain and burnout. How humans adapt to the stresses put on them is very specific and can go in good or bad directions.

What is the Adaptive Health Paradigm?

Like most theories, paradigms or what people consider “original thought”, this “adaptive” paradigm builds on the “regenerative medicine” framework, and some disease models; thus, is not original at all. What may be new, or unique about the adaptive perspective is taking the old phrase from physicist Isaac Newton and his third law of motion, “for every action there is an equal and opposite reaction.” The body will respond to stresses by reacting in a “defensive” manner. If we break something down, the body builds it up (opposite reaction). If we are too low or too high in some function, the body will try to correct this. This negative feedback loop controls most systems in our bodies. I have often described our bodies as fragile but resilient. It is our fragility that signals the resilience to kick into gear!

Luckily for us, fitness is based on this exact principle. If we do endurance training, we are going into a lower oxygen state and there are many mechanisms or functions that kick in (sympathetic nervous system) when we push or stress our bodies. The body is responding to what is known as an “acute insult” by increasing the ability to transport and use oxygen, so that this “insult” doesn’t hurt us next time. The same “specificity of training principle” occurs with resistance training. We breakdown muscle and the body builds it back stronger to tolerate that “insult” the next time. When multiple acute exercise stresses are added up, the body changes and we call this “training”.

If stresses are really high, either too intense, too long, or too often, the body gets injured due to this overload, or it needs a lot more time to heal back up. This is why overload needs to be done gradually and progressively. Even our brains use this idea as a guiding principle. We push our mental capacities to learn more, but if we stress it too much, it will repress memories or shut down (burnout).

This same principle applies when we give our body bad things, or a lack of good things, it adapts with a dysfunctional state or disease state. Chronic inflammatory diseases, diabetes, metabolic syndrome, coronary artery disease, emphysema and heart disease are just a few of the examples of how the “garbage in and garbage out”, or “use it or lose it” works. If we sit and work at the computer too much we develop dysfunctional postures and upper cross syndrome may develop. If we do not constantly stress some system, it reverses the training changes, and goes into the “default” state, which is untrained and unable to respond to daily stresses. We simply need to obey our bodily blueprints, we need to constantly use our bodies to maintain function, and overload it to improve function. We need to have the right nutrients in place to allow this to happen, and then basically – get out of the way!

Intelligence in the Body – Applications the Adaptive Health Paradigm

The perspective being proposed in this article shares much with the more holistic medical practices. The human body is really good at healing itself when is it given the right factors to do so, and when we “get out of the way” for it to do so. I know many people who strongly believe in using alkaline water to “cure their ills”. They believe that the body does not know how to regulate itself with its own pH.  Most of these same people don’t know what pH even stands for! They don’t know that it is actually the inverse log of the hydrogen ion concentration relative to the hydroxide ions, and that the respiratory system and renal system will go into action as soon as blood pH goes 0.05 pH units high or low!

In other words, these people believe their own bodies are naïve or incapable of curing itself, and like a young child or baby, their body needs constant care and guidance. Most people are so stressed about “taking care” of their bodies that they are doing more harm than good via the stress hormones, especially cortisol being constantly secreted and their adrenal gland is getting fatigued. In reality, the body is really good at healing itself, when we keep it strong and in good operating condition (via exercise and movement) and when we give it the right components to do the healing (via nutrition), and we get out of the way of the immune system (by managing our daily stress levels).

The mind works very much like a muscle. It must be trained and kept strong and when injured it will react in dysfunctional ways, and fight to protect itself. I recently heard an expert in human behavior change speak on how to keep a resolution. He said, we can’t keep a resolution without changing the underlying behaviors which caused the bad habit or lack of a good habit in the first place. By changing the way we think, we change the way we act, and changing our actions will change the way we think!

“What goes Around, Comes Around”

The quote often stated by Thomas Edison in 1903, which was to give rise to the HMO concept, “The doctor of the future will give no medicine, but will interest his patient in the care of the human frame, in diet and in the cause and prevention of disease.” Medical doctors (M.D.s) upon completing medical school and prior to practicing take the Hippocratic Oath, which is to do no harm. Even back in Ancient Rome, Hippocrates understood the importance of individualized medicine and the power to “get out of the way” (#5) and give the body what it needs to take care of itself. He had five rules that are still relevant in today’s medical practices.

  1. Walking Is Man’s Best Medicine.
  2. Know What Person the Disease Has Rather Than What Disease the Person Has.
  3. Let Food Be Thy Medicine.
  4. Everything in Moderation.
  5. To Do Nothing Is Also a Good Remedy.

Integrative and Functional Medicine – Highly Inclusive and Holistic Perspectives

A philosophy of practice using these practices is integrative medicine. A brand of medicine created or at least popularized by Andrew Weil. The University of Arizona has this “brand” of medical school. Again, the academic requirements are similar to the M.D. and D.O. but expands its scope to other areas. From the website, Integrative Medicine (IM) is defined as a “healing-oriented medicine that takes account of the whole person, including all aspects of lifestyle. It emphasizes the therapeutic relationship between practitioner and patient, is informed by evidence, and makes use of all appropriate therapies. many different ways in the patient.
A new type of medicine is emerging from this Functional perspective which is called personalized medicine. Again, the two are basically two sides of the same coin.

Figure 1: A diagram above showing the greater scope of each medical perspective- Integrative and Functional medicines are close in their holistic perspectives, with differing points of emphasis


What is going on within the individual to cause the disease or prolong its existence?

Sometimes disease hits simply because we were genetically predisposed to get it. However, very often if our system is strong and in good operating condition, we resist it from every occurring or overcome it quite quickly. Cancer is a prime example of this. We all have cancers in our bodies all the time. It is the strong immune system that fights it off. This is amongst the reasons that many, many chronic diseases hit us when we are old. The various system have lost their capacity to fight the dysfunction off, or recover from its destruction. Soon cell death (necrosis or apoptosis) or neoplastic (cancer) growth kicks in.

Harnessing the Power of Exercise and Diet to Fight Chronic Disease

Many, many chronic conditions that the MedFit Education Foundation/MedFit Network addresses are helped by exercise and diet because the ability of body to adapt and regenerate itself is enhanced. Most systems in our body fall under the “use it or lose it” scenario. High sugar, alcohol, smoking, and lack of movement are culprits in our health. Our body is not designed for an overload of these factors and across time, many different symptoms will develop because our body can no longer compensate or regenerate.

It is important for the medical fitness professional to understand the power of exercise and nutrition, and the proper application of these tools given the client’s or patient’s current condition. The field of physical therapy developed because many musculoskeletal conditions are helped by movement therapy or exercise. Many chiropractors believe that proper spinal alignment delivers proper neural signals throughout the body, which allows the body to optimize its regenerative capacity.  Thus, an expert in medical uses of exercise to combat disease is critical to a healthcare team.

Join Dr. Mark Kelly at the Medical Fitness Tour in Irvine, CA! Dr. Kelly will be a presenter for the Aging Stronger pre-conference workshop on Friday, February 8, and the session Using Exercise and Diet to Fight Alzheimer’s during the main conference on Sunday, February 10. Click for Event Details


Dr. Mark Kelly Ph.D., CSCS, FAS, CPT has been actively involved in the fitness industry spanning 30 years as a teacher of exercise physiology at academic institutions such as California State University, Fullerton, Louisiana State University, Health Science Center, Tulane University and Biola. He was an exercise physiologist for the American Council on Exercise, a corporate wellness director, boot camp company owner and master fitness trainer.

References

Center for Integrative Medicine, Univ. of Arizona (n.d.). What is IM/IH? Retrieved from: https://integrativemedicine.arizona.edu/about/definition.html

Science Daily (n.d.). Personalized medicine. Retrieved from: https://www.sciencedaily.com/terms/personalized_medicine.htm

Good Reads (n.d.). Retreived from: https://www.goodreads.com/quotes/13639-the-doctor-of-the-future-will-give-no-medication-but

Kalish, N. (2018). Hippocrates’ Diet and Health Rules Everyone Should Follow. Reader’s Digest. Retrieved from: https://www.rd.com/health/wellness/hippocrates-diet/