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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. 

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The Commodification of Medicine and Fitness: The Good, the Bad, and the Ugly

The need for medical and fitness services/products continues to grow. In the United States, and around the world. The corporate and industrialized delivery of medical and fitness products/ services continues to grow to meet increasing demand. Innovations in medical diagnostic technologies, surgical procedures, biomaterials, and medicines help individuals live longer, and with a higher quality of life. Technology and scientific research are propelling fitness product/service innovation with digital activity monitoring apps . . .

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Interesting Times for Interested People

So, we are all shut in our homes and are not supposed to go to work, movies, or restaurants to dine in, and we can’t even watch live sports on TV. Life is so bad, and unfair… or is it?

I have decided to look at the bright side of this event, and see it as an opportunity. While many are not in my particular position, and are actually out of job and income due to this pandemic, I want you to reframe it. Change the paradigm of this being a negative, to this being a time for catching up, reflecting, and perhaps actually changing yourself.

We all have parts of our lives that need attention. In today’s current society, it is basically impossible to be all things to all people, including ourselves. We must try to balance job, family, social contact, social media, our own diet, hobbies, medical attention, our education — professionally or otherwise, our spirituality, and even our environment. Having balance in a variety of areas is true wellness! We are often so busy teaching and preaching the benefits of fitness and wellness to others, we deny it to ourselves. I remember doing a self-survey several decades ago by some program discussing the “wellness wheel”, which many of you have probably heard of. The survey was showing areas that needed attention. (Back then I had a very lop-sided wheel, and it is not much better now.) The wheel consisted of a mnemonic (6 components. It has shifted slightly in past few decades, but the pneumonic still works well: SPICES.

Old Wellness Areas New Wellness Areas
S-ocial Social – all interactions with people outside of ourselves
P-hysical Physical – our physiological status
I-ntellectual Intellectual – includes cognitive and emotional health
C-ognitive Career – includes educational and skill acquisition and financial health
E-motional Environmental (could include emotional) – clean, organized?
S-piritual Spiritual – interactions with entities beyond people

I want to use this as a time to clean up many things that have been neglected — both around my house and inside “my house”, my physical body and mental space. I may even use this opportunity to shift my professional pursuits away from academic teaching to wellness coaching. Maybe I can chat on the phone more, spend time with my daughter, or spend more time cooking or reading. Whatever it is, start doing it now!

If nothing else, this has opened the world’s eyes to the need to stay healthy. It has shown people the need to be sanitary and practice good old-fashioned health care techniques, like washing hands and not running out of toilet paper! (Sorry, had to throw that one in!)

As an educator in both physical health and medical applications, we are perfectly positioned to show the communities we live in how to harness the power of exercise for both preventative and rehabilitation purposes. I have learned many new applications for teaching online and most people are focused on coming together for the “greater good”, and this is a breath of fresh air.

Good luck and stay healthy as you address the holistic health agenda in our society.


Dr. Mark P. Kelly has been involved with the health and fitness field for more than 30 years. He has been a research scientist for universities and many infomercial projects. He has spoken nationally and internationally on a wide variety of topics and currently speaks on the use of exercise for clinical purposes and exercise’s impact on the brain. Mark is a teacher in colleges and universities in Orange County, CA., where Principle-Centered Health- Corporate Wellness & Safety operates.

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Bridging Rehab with Fitness: Become the Trusted Referral for Rehabilitation Therapists

There are special and unique bonds that are made between clinician and patient in a rehabilitation setting. Many times, rehab patients are at a very difficult time in their lives and through months of daily expert guidance, hard work, education, and often even fun, alongside their rehab team, they make considerable gains back towards independence.

Because of this daily interaction, the rehab team develops a vested interest in the continued progress of their patient. Over the course of many months of the blood, sweat and tears of intensive therapy sessions, a friendship has been formed and considerable progress made together. It’s no wonder that rehab professionals are very selective with the fitness referrals they make once their patients are ready for the post-rehab world.

They are selective because they want the absolute best for their patient; they want someone with an understanding of their patient’s diagnosis; someone who understands medical precautions and contraindications; and someone who can safely continue to progress their patient without putting them at risk for a secondary issue. Though they may be selective with referrals, a trusted source for continuing their patients’ goals is needed.

Here are some ways to bridge the gap and gain the trust of your local rehabilitation professionals:

Require a medical or physical therapy release

Having medical releases before beginning ongoing sessions is an excellent way to open dialog with your client’s doctor or physical therapist and further, ensures that you are programming their fitness plan accordingly. Send your assessment with your client to share in their next appointment along with a simple inquiry form about restrictions or suggestions to use in your program design. This will go a long way in establishing a great level of trust and building a rapport with the clinic.

Volunteer at a rehab clinic

One of the best ways to build a rapport with local rehab professionals and patients is to spend time shadowing/observing or volunteering in a rehab inpatient and/or outpatient clinic. This can be a time-consuming start-up as many rehab clinics will have an orientation process and procedures to allow you to be present in a clinic, but it is definitely worth the time investment. Just being in this environment you can learn a lot about how therapists progress their rehab patients, guard their rehab patients during activity, interact with and educate their patients as they progress them to discharge (the point where you would continue their work). You may also get some valuable opportunities to learn from and build relationships with many therapists in one setting.

Lead warm-ups for local 5K races

There are 3.2-mile run-walk-and-wheels events that take place all over the country. Donating your time to your community Spina Bifida Walk ‘n Roll or Parkinson’s walk is a great way to become visible in your community and demonstrate what you have to offer for all abilities.

Speak at local support groups

Same as with the 5Ks, there are support groups that take place monthly or quarterly for stroke survivors, caregivers, individuals living with Multiple Sclerosis and more. Contacting the organizer of these groups and offering to donate time to speak about the benefits of continued exercise or even providing a no-cost group class during the scheduled talk time is a really good way to connect with both the organizers and their peers and those in attendance who would benefit from a continued exercise program.

Educate yourself on adaptive/medical exercise equipment

Understanding the different options there are for accessories and actual exercise equipment for stroke survivors or those living with spinal cord injury is another great way to demonstrate an understanding of working with a rehab population and continuing to bridge the gap between rehab and fitness. Not all equipment is accessible nor safe, so while thinking outside the box is great, ensuring safety is optimal. Take the time to learn about all the great adaptive equipment that can benefit the population you work with.

Host an open house at your gym

Host regular open house events at your facility and invite any and all rehab professionals, patients, and people from your community. Offer instructional sessions during the open house to demonstrate your adaptive programming/equipment. This is a great way give a sneak peek into what you’re doing to provide a safe environment for patients to continue their progress.

Offer to provide a lunch in-service to rehab staff

Meeting with a clinic full of therapists is an excellent way to educate those therapists that you have done your research, understand your population, and really want to bridge the gap between rehab and fitness. A presentation focused on the population you’re most comfortable working with (Parkinson’s, stroke survivors, etc.), the programs you offer, and pictures or videos of some of the work done in your gym. Bringing food is always a great incentive!

Bridging the gap between rehab and fitness is a process that is long overdue and much needed. By focusing on the points above you will be working towards and moving one step closer to improving the therapist-trainer model, adding a valuable resource to your community and providing a safe environment and safe programming to continue progressing your post-rehab clients.

This article was featured in MedFit Professional Magazine Winter 2020 issue. Subscribe to MedFit Professional Magazine to read more great content like this!


Devon Palermo is a leading authority on Adaptive Fitness for those living with or recovering from a disability. He is the Founder and Principal director of DPI Adaptive Fitness, A company focused on safe and effective adaptive fitness for individuals living with disabilities. With over 15 years of experience in both fitness and rehab, He is the go-to resource for clients, therapists, and doctors in the DC, Maryland and Virginia area looking to maximize the benefits of adaptive exercise to improve strength, balance, function and abilities. dpiadaptivefitness.co

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You Are The Solution

This article is meant to be a wake-up call to the fitness industry. The health of our population and country are at stake. While advancements have extended our country’s overall lifespan, it has occurred primarily through the use of medications and life-saving procedures rather than through lifestyle changes. The stark reality is that the overall health of Americans is declining as evidenced by the $3.5 trillion spent every year on health care expenditures.

Another alarming statistic is that between 1997 and 2016, there were approximately 4.5 billion prescriptions written per year. 70% of Americans take at least one and 20% take five or more prescription medications (Preidt 2017). The majority of these medications were taken to address lifestyle-related diseases and the subsequent impacts of poor nutrition choices and lack of physical activity. Additionally, many prescription and over-the-counter medications are used to treat osteoarthritis, the most common cause of physical disability in the world. While genetics, weight, and age have been considered as underlying factors, the decrease in quantity, as well as quality, of physical activity have been shown to be much greater factors to the onset and prevalence of osteoarthritis in modern society (Wallace 2017, Osar 2018).

While often attributed to causes outside one’s control (i.e. genetics), the fact is that the diseases contributing to the greatest number of deaths (heart disease, cancer, and Type 2 diabetes) and disability (osteoarthritis) are directly related to controllable factors. While each has a genetic component, lifestyle has a much greater impact on the incidence and prevalence of these diseases. One of most important and underappreciated components in the overall decline in one’s physical, physiological, and cognitive health, is the lack of physical activity. Less than 20% of the population meet the daily physical activity guidelines and less than 5% of the adult population participates in 30 minutes of physical activity. Even more disturbing is that more than 78 million U.S. adults and 12 million children are obese.

Dr. Caldwell Esselstyn has been attributed with the quote, “Genetics loads the gun, lifestyle pulls the trigger.” This suggests that lifestyle is as important as genetics in the expression of many chronic diseases. This sentiment is reiterated in a recent study from Bodai et. al (2018). “Epidemiological, ecologic, and interventional studies have repeatedly indicated that most chronic illness, including cardiovascular disease, cancer, and type 2 diabetes, are the results of lifestyles fueled by poor nutrition and physical inactivity.”

The health of our population and country is at stake. This is a call for fitness professionals to step up and recognize that you are the first line of defense against the deleterious impacts of lifestyle diseases. It is your responsibility to educate your communities that lifestyle changes, incorporating proper nutrition as well as increased physical and cognitive exercise, should be the first step in addressing chronic lifestyle diseases. You can continue to change the health of our nation by implementing evidence-based nutrition, exercise, and cognitive training programs. Be the solution your clients, your community, and our country needs by investing in advanced education in nutrition, exercise, movement, and cognitive training. Create relationships with allied health professionals so that we can collectively educate, collaborate, and coordinate the changing of our nation’s health care system.

This article was featured in MedFit Professional Magazine Winter 2020 issue. Subscribe to MedFit Professional Magazine to read more great content like this!


Dr. Evan Osar, an internationally recognized speaker, author, and expert on assessment, corrective exercise, and functional movement. Dr. Osar is committed to educating and empowering fitness professionals while helping them develop relationships with allied health professionals. He is author of the Corrective Exercise Solutions to Common Hip and Shoulder Dysfunction and has developed the industry’s most complete training certification, the Integrative Movement Specialist™. With his wife Jenice Mattek, he created the online educational resource. For more info, visit IIHFE.com

References

Bodai, B. I., Nakata, T. E., Wong, W. T., Clark, D. R., Lawenda, S., Tsou, C., … Campbell, T. M. (2018). Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival. The Permanente journal22, 17–025. doi:10.7812/TPP/17-025

Centers for Disease Control and Prevention. Osteoarthritis. Retrieved from https://www.cdc.gov/arthritis/basics/osteoarthritis.htm

Centers for Disease Control and Prevention. Leading Causes of Death. Retrieved from https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

Centers for Medicare & Medicaid Services. National Health Expenditure Data. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html

Osar, E. (2018). The Fundamentals for Training the Older Client with Osteoarthritis. Retrieved from https://www.ptonthenet.com/remote-learning

Preidt, R. (2017). Americans Taking More Prescription Drugs Than Ever. https://www.webmd.com/drug-medication/news/20170803/americans-taking-more-prescription-drugs-than-ever-survey

U.S. Department of Health & Human Services. Facts and Statistics. Retrieved from https://www.hhs.gov/fitness/resource-center/facts-and-statistics/index.html

Wallace, IJ., Worthington, S., Felson, DT., Jurmain, RD., Wren, KT., Maijanen, H. Woods, RJ., Lieberman, DE. (2017). PNAS. 114(35): 9332-9336.

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Healthcare Through Fitness

A discussion of medical fitness is rooted in an understanding of the health benefits of fitness and exercise. The documented benefits are endless and include management of chronic disease, management and prevention of osteoporosis, improved mood and sleep disorders, stress relief, management and prevention of obesity.

Health agencies across the spectrum of public health and disease-specific organizations recognize and promote exercise and fitness as an integral part of the management of chronic disease; diseases that include diabetes, cardiovascular disease, Parkinson’s, depression, multiple sclerosis, and arthritis, among others.

If fitness and exercise are well accepted as part of the management strategy for multiple diseases, why is it that access to organized exercise plans, and fitness professionals who can help implement those plans, are not a standard part of the medical treatment paradigm? Why is it not a standard benefit covered by common medical insurance policies?

The reasons are multifactorial and a reflection of the overall healthcare conundrum in our country today. Let’s focus, however, on how to make a change. We need to focus on how to integrate fitness professionals into the medical paradigm. A perfect model for this is an integrative medical fitness center.

What is a medical fitness center? It is a fitness facility with a multidisciplinary staffing approach and has the following characteristics:

  • Regular medical oversight by a medical director
  • Practitioners with nationally-recognized certifications and training in the care of chronic disease
  • Comprehensive health assessments and exercise prescription
  • Exercise classes geared toward specific medical conditions

These centers bring together credentialed staff in a collaborative way to provide exercise prescription plans specific to the needs of an individual with chronic disease.

The concept of the medical fitness center is not new; many currently exist in communities throughout the United States. However, an understanding of their importance in the context of the current healthcare environment has grown. The idea of creating “medical homes” that are collaborative across disciplines and provide a comprehensive healthcare approach is now being recognized to provide a high standard of care while simultaneously decreasing overall healthcare costs. This is true specifically for high-risk individuals who suffer from chronic disease.

Further integration of medical fitness centers, and broad access to exercise and fitness resources, will hopefully become standard of care and widely accessible to all individuals, especially those with chronic disease. This integration will inherently bring fitness professionals into the paradigm of healthcare and promote healthcare through fitness.

This article was featured in MedFit Professional Magazine fall 2019 issue.

Subscribe to MedFit Professional Magazine to read more great content like this!


Dr. David Kruse attended medical school at UC San Diego, after graduating from UC Berkeley. He holds board certifications in family and sports medicine. He practices sports medicine with the Orthopaedic Specialty Institute, in Orange, CA. Dr. Kruse is the Chief Medical Officer for the MedFit Network and on the Medical Advisory Board for the MedFit Education Foundation. He is currently a Team Physician for USA Gymnastics, Orange County Soccer Club, and Biola University. Visit his website, krusesportsmd.com

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The Lumbar Spine: Understanding the Science Behind Both Movement and Dysfunction

The spine is a complex structure, comprised of nerves, connective tissue, bones, discs, muscles and other essential integrative components. Whether it getting out of a chair or car, lifting or carrying items, some 29 muscles around the pelvic girdle and lumbar spine, provide stability. In this article, we will review the anatomy of the spine, common injuries to the lumbar spine, functional assessments and training strategies to work with clients with previous injuries.

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?”