What Is Health?

Consistent with the tenets of Hippocrates to which all health care professions aspire—“rst do no harm” and “the function of protecting and developing health must rank even above that of restoring it when it is impaired”—the primary objective of health care is to promote health and wellness, to prevent illness and disability and, in the event that these occur, to exploit the least invasive interventions.

The World Health Organization (WHO) defines health as “a complete state of physical, emotional and social well-being”—not merely the absence of disease and impairment.³ Although physical well-being contributes to health in the other dimensions, it does not ensure health. Thus emotional and social well-being should be assessed as systematically as is physical well-being in a model of care based on health. Collectively, these domains of health translate into an individual’s capacity to perform activities that enable him or her to participate fully in life.⁴ The WHO’s definition of health has not been amended since 1948. Although having withstood time, this definition has failed to be incorporated as the primary goal of contemporary health care.

Over the past century, the primary determinants of improved health have been the provision of clean water, sanitation, basic nutrition, shelter, and security, rather than biomedical advances (other than mass vaccination programs). In addition, education and socioeconomic and employment status are independent determinants of health. Biomedical care has had particular success in controlling infection, providing symptomatic relief of acute problems, and providing emergency care. Such care, however, has not had the impact on health that the primary determinants of health have had overall, nor has biomedical care achieved major success in preventing, reversing, and managing chronic lifestyle-related conditions.

By the time an individual has entered the biomedical system, health care in its truest sense has failed. Without question, the need exists for invasive care (drugs and surgery), well-equipped hospitals, and highly qualified health care professionals. On the other hand, as practitioners committed to noninvasive care, physical therapists have the capacity to promote health and well-being in their practices, with the global goals of reducing the number of patients and minimizing the need for invasive care. The role of physical therapists in preventing and managing chronic lifestyle-related conditions is essential.

Because of widespread immigration, the cultural and ethnic demographic profiles of high-income countries such as those in North America and Europe are changing rapidly. Beliefs, attitudes, values, cultures, ethnicity, and traditions affect health, ill health, and their interactions, including how often individuals seek health care. For example, Asian immigrants to the United States report fewer stress-related and psychological problems than do non-Hispanic Caucasians.⁵ With increasing time in the United States, however, reports of stress increase for Asian Americans. This may reflect a number of factors: cultural differences in the acceptability of reporting psychological distress (leading to underreporting by members of some cultural groups), sensitization to the definition and the awareness of stress with increasing duration of residence, or the compounding effect of increasing stress in the new culture. How best to reduce racial and ethnic disparities through culturally competent health care is a matter of debate and requires such outcomes as client satisfaction, improved health status, and culturally appropriate management and delivery across racial and ethnic groups.^6,7

Since the psychobiological adaptation model was posited over 25 years ago,⁸ the few models of physical therapy practice that have been reported have included psychosocial and other nonphysiological components.^9–11 Psychosocial components include health belief, self-efficacy, and perceived control. The Health Belief Model is useful in appreciating the ways in which belief may affect health, illness, and the responses and reactions to them (Table 1-1).¹² Assessment of self-efficacy provides an index of an individual’s sense of mastery over his or her health and well-being. These concepts can be used in a clinician’s practice setting. A few questions can help assess a patient’s perception of susceptibility to risk or a condition. These concepts can provide a basis for health education that includes increasing the patient’s awareness of the effects of lifestyle factors on health and of their consequences. The action necessary to avoid the condition or minimize its risk can be selectively targeted for each individual when the individual’s context is known.

The International Classification of Functioning, Disability and Health advocated by the WHO interrelates body functions and structures, activity, and participation in life.⁴ The biomedical model focuses on impairment (i.e., body functions and structures), with less attention to health and wellness, sickness impact, life satisfaction, and quality of life, which reflects an individual’s participation in life and associated activities. One problem that occurs when the primary focus is on the remediation of limitations of function and structure in managing the leading health care priorities of our day (i.e., chronic lifestyle-related conditions) is that such limitations do not necessarily affect activity and participation—the essence of a meaningful life. These relationships need to be evaluated in each case rather than assumed.

The integration of health belief and motivational models has been a means of incorporating psychosocial dimensions of care, interventions, and outcomes so as to directly focus on an individual’s limitations of activity and participation. As a result of this paradigm shift, an increasing number of measurement tools are available to assess the dimensions of health. These tools can be categorized as generic, as having general application across individuals and conditions, or as having specific application to a cohort of individuals, based on age, condition, or some other variable (see examples in Chapter 17). Many of these scales have been validated on a subset of these cohort groups. Physical therapists need to be able to use these tools knowledgeably and specifically to assess outcomes in their practices, just as they use conventional tools to assess and evaluate anatomic structure and physiological function. One such measure is the Short Form-36, which evaluates health-related quality of life and has become an established tool for general use and has been adapted cross-culturally.^13,14 Such tools can be used to evaluate the individual’s perception of health improvement, which supplements conventional objective clinical measures.

Lifestyle-Related Conditions

Poor nutritional choices and sedentary lifestyles combined with tobacco use, excessive alcohol consumption, and stress underpin chronic lifestyle-related conditions in high-income countries, and they pose the greatest threats to public health.23–25 Eight major risk factors related to lifestyle and their documented impacts on health appear in Table 1-2. This trend has given rise to dramatic increases in a relatively newly defined condition, metabolic syndrome, which includes insulin resistance, high blood pressure, elevated triglycerides and cholesterol, and obesity. With industrialization and technological advances, lifestyle-related conditions are on the rise in low- and middle-income countries as well.^26,27 Despite their prevalence, however, the WHO has long proclaimed that lifestyle-related conditions are largely preventable.²⁸

Atherosclerosis is the major common denominator and contributor to lifestyle-related conditions, including ischemic heart disease (IHD), hypertension, and stroke. Factor analysis supports a two-factor solution for heart disease and possibly for other lifestyle-related conditions: family history (factor 1) and lifestyle factors such as smoking, serum cholesterol, blood pressure, nutrition, exercise, and weight control (factor 2).²⁹ At the population level, choosing health—which includes smoking abstinence along with optimal nutrition and exercise throughout life—can enhance the quality of life, decrease the prevalence of chronic lifestyle-related conditions, and reduce the burden of these conditions on individuals, families, communities, and countries, including suffering and health care costs.^30–32

Life Cycle and Lifestyle-Related Conditions

Lifestyle-related conditions have their foundation in childhood because their associated underlying health behaviors are rooted during this critical period. The latency period before developing significant signs and symptoms can be decades.

IHD secondary to atherosclerosis continues to be the leading cause of premature mortality and disability in industrialized countries. The prevention and management of risk factors of systemic atherosclerosis should be a primary target of contemporary care for children as well as for adults.33–35 Ischemic cerebrovascular, coronary, and peripheral vascular conditions are manifestations of the same underlying pathological process, blood vessel narrowing caused by atherosclerosis and thrombosis. Smoking, a high-fat diet, and inactivity can precipitate damage to the endothelium and fat deposition within arterial walls. This common pathway has been associated with increased fibrinogen and C-reactive protein, markers of inflammation.³⁶ The focus of biomedical research has shifted to the role of inflammatory mediators and the contribution of low-density lipoproteins to atherosclerosis and away from the concept of degenerative vessel disease. Fibrinogen is an inflammation mediator and a clotting factor. People with cardiovascular disease have high fibrinogen levels, which further increase the risk for thrombosis and manifestations of circulatory disease. Inflammation has been implicated in a growing number of chronic conditions, such as IHD, stroke, asthma, gastrointestinal ulcers, cirrhosis of the liver, Alzheimer disease, cancer, and autoimmune conditions.^37,38 Unhealthy lifestyle choices have been thought to contribute to a proinflammatory state, giving rise to low-grade infection in various organ systems and leading to the signs and symptoms associated with various chronic degenerative processes.³⁹ Although this is an important finding, a proinflammatory milieu and inflammation are not the causes of the chronic conditions with which they have been associated but, rather, are precipitating effects of traumas resulting from lifestyle.

Promotion of a healthy lifestyle early in life transfers responsibility to the individual as much as possible and away from some inherent pathophysiological cause. Although conventional invasive biomedical care with medications and surgery may provide symptomatic relief, only fundamental changes in lifestyle can address the root cause in the majority of cases of chronic lifestyle-related conditions. The physical therapist as a contemporary health care provider can serve as an effective health coach in the care of children and adults.

Lifestyle-related conditions can no longer be considered adult conditions or age-related conditions. Children are exhibiting signs of cardiovascular disease, including arterial atherosclerotic streaking, hypertension, type 2 diabetes mellitus, and obesity.⁴⁰ Forty years ago, these conditions manifested in adults. With sedentary lifestyles, low activity, and poor nutrition, children are showing the results of accumulated injury to blood vessels and larger body frames and weights. As a consequence, children today are manifesting lifestyle-related conditions earlier than previous generations and are thus expected to die prematurely from these conditions and to have shorter life expectancies than their parents. Throughout their lives, these individuals can expect to have prolonged morbidity associated with these conditions, the secondary complications of these conditions, associated adverse responses to other health complaints, and increased iatrogenic problems (secondary to drugs and surgery).^41,42 Health promotion strategies directed toward parents and young children will help to offset the population’s health threat of lifestyle-related conditions.

Life expectancy has almost doubled since 1900. The post–World War II baby-boom generation characterizes the demographics of many industrialized countries. This cohort has lived in prosperous times and up to that time was the longest living generation in history. Despite the prosperity seen by the baby boomers, this era was associated with more sedentary lifestyles and access to food products low in nutritional value. Although the manifestations of lifestyle-related conditions are associated with aging, they are not necessary consequences of aging. This is based on cross-cultural comparison studies. Optimal nutrition, exercise, stress control, smoking abstinence, and moderate alcohol consumption, if any, are central to reducing the probability of chronic lifestyle-related conditions and associated disability and maximizing quality of life as people age.⁴³ In particular, increased quality of life with a higher threshold for chronic lifestyle-related conditions and less morbidity toward the end of life is the objective. Figure 1-1 shows the theoretical increase in the threshold of these conditions with healthy lifestyle choices (i.e., not smoking, optimal nutrition and weight control, regular physical activity and exercise, optimal sleep, and reduced stress) and reduced rate of progression of chronic conditions. Ostensibly, the net result is more “life to years” as well as more “years to life.”

“First Do No Harm”

As primarily a noninvasive health care profession, physical therapy is uniquely positioned to have a primary role in promoting health and wellness, while also preventing, managing, and in some cases, reversing these pandemic lifestyle-related conditions, objectives that commonly coexist because they share a common pathway.⁴⁴ Integrating health promotion into practice would directly address the ultimate knowledge translation gap in health care (with respect to the benefits of healthy living).⁴⁵ Indeed, focusing on health promotion, in addition to directly addressing the risk factors and/or manifestations of secondary lifestyle-related conditions, may result in more favorable outcomes for a patient’s presenting problem. Triage of individuals by both noninvasive practitioners and invasive practitioners would constitute a bold initiative in health care. Such triage could establish whether a patient’s complaint is best managed in the short and long term wholly noninvasively, wholly invasively, or by some combination, with a view to weaning the patient off medications or minimizing the medication. Similarly, every effort should be made to avoid surgical intervention and its risks whenever possible (i.e., surgical intervention as a last resort rather than a first resort) by exploiting noninvasive interventions and strategies to restore health and promote lifelong health. When an individual enters the health care delivery system, her or his receptivity to health information is likely to be high. This is a prime opportunity to evaluate risk factors and prescribe a lifelong health plan.

The effectiveness of nonpharmacological treatments in the management of chronic lifestyle-related conditions has been well documented, but implementation has been poor.46–48 As noninvasive practitioners, physical therapists have a primary role on the health team, which may include physicians and surgeons (i.e., invasive practitioners), nurses, nutritionists, pharmacists, social workers, psychologists, respiratory therapists, spiritual leaders, and others, depending on the requirements of each case. On a broader level, physical therapists can serve in a multisector capacity as consultants and work alongside health care policy makers, corporate business people, urban planners, and architects in developing healthy and safe homes, workplaces, recreational facilities, and communities. The role of the physical therapist clinician is shifting from hospital-based acute care and private practice to the community, schools, industry, home, workplace, and playing field.

Biomedical research that evaluates drugs and surgery often lacks control groups that are otherwise healthy or a comparative group in the research design that includes a potentially superior, noninvasively managed group where feasible. For example, a 12-month exercise program involving selected individuals with stable coronary artery disease has shown superior event-free survival and exercise capacity when compared with individuals who received percutaneous coronary intervention.⁴⁹ In another study, the mortality rate of individuals with heart disease has been estimated to be reduced by 20% to 25% with cardiac rehabilitation, which is comparable to the results of established therapies such as beta blockers.⁵⁰ Cardiac rehabilitation is noninvasive; thus it is cheaper and has few side effects. Management is focused on changing negative health behaviors and maximizing lifelong health rather than on simply altering a sign or a symptom.

Changing one’s lifestyle can be more challenging than taking a drug or undergoing surgery. In both cases, the patient is a passive recipient of treatment. Being an effective agent of change and promoting active participation by clients in their own health are fundamental to the expertise of the physical therapist who specializes in noninvasive, long-term health and care. In societies with open and free marketplaces (such as in North American and European countries), people are presented with seemingly endless choices, many of which can be injurious to lifelong health. Thus physical therapists need superior skills in educating people regarding their lifestyle choices and promotion of health.

In contrast to biomedical advances, progress in these noninvasive yet high-impact interventions receives much less coverage and attention as lead articles in peer-reviewed medical journals or by the popular press. Yet these noninvasive advances show significant promise for having a major impact on the population’s health and well-being, including increased probability of lifelong health at minimal cost, compared with the results of invasive interventions, which frequently do not address the causes or contributing factors. Such findings need to be integrated into contemporary practice to ensure that individuals are not subjected unnecessarily to the risks associated with prolonged courses of medication and invasive procedures, along with the high probability of repeated invasive procedures. Noninvasive interventions have a distinct advantage over drugs and surgery—they empower individuals to manage their own long-term health by learning skills that will change deleterious lifestyle habits and reduce the risks and costs of hospitalization and its recurrence. Considering the risks and costs of an invasive procedure such as revascularization, the advantages of noninvasive interventions are worthy of much greater attention.

Physical therapists treat individuals with chronic lifestyle-related conditions as either primary or secondary diagnoses. Smoking is currently the leading cause and contributor to chronic conditions and premature death in the United States, with poor diet and sedentary lifestyle anticipated soon to overtake tobacco use.⁵¹ Television viewing, an indicator of sedentary living, is associated with obesity and is a marker of cardiovascular disease independent of total reported physical activity.⁵¹ As noninvasive practitioners, physical therapists have a responsibility to manage these conditions and their risk factors in all patients so as to prevent or control their physical, psychosocial, economic, and societal impact and to promote health in their practices. By prioritizing health and addressing suboptimal health behaviors, regardless of a patient’s primary complaint, the complaint may be mitigated, the rate and quality of recovery potentially improved, and the potential for recurrence reduced.

Hypertension and Stroke

Stroke is a preventable tragedy for nearly 750,000 people in the United States annually; hypertension is the most common risk factor.¹¹³ Although lowering blood pressure below 130/85 mm Hg is well accepted across ages, the success of blood pressure control has been reported to be less than 25% in the hypertensive population.¹¹⁴ Stroke risk is far from being well controlled despite considerable understanding of its causes, and it remains a major health threat. Risk factors for stroke include previous stroke, hypertension, IHD, atrial fibrillation, hyperlipidemia, diabetes, abnormal ankle-to-brachial pressure index, reduced exercise endurance, retinopathy, albuminuria, autonomic neuropathy, smoking, alcohol consumption, and lack of exercise.^{113,115–119}

Risk factors for hypertension and stroke can be accentuated by smoking, elevated cholesterol, glucose intolerance, inactivity, and obesity.¹²⁰ In addition to stroke, serious consequences of hypertension include hypertension heart disease and renal disease. Implicated as a cause of stroke is increased sympathetic reactivity.¹²¹

In the adult population between 60 and 74 years of age, almost 75% of African Americans and 50% of Caucasians have high blood pressure.¹²² As with IHD, risk factors for high blood pressure consist of nonmodifiable and modifiable risk factors. Nonmodifiable risk factors include age, sex, race, and other genetic factors. Modifiable risk factors include diets high in sodium and low in potassium, alcohol consumption, reduced physical activity, and being overweight.¹²³ Obesity is a strong predictor of hypertension.¹²⁴ Although significant reduction of hypertension has been attributed to low-dose thiazide diuretics and beta blockers, the first line of defense to prevent high blood pressure and normalize blood pressure should be nutritional approaches, weight reduction, and regular physical activity and exercise.¹²⁵ In individuals whose hypertension is controlled, the combination of a Mediterranean diet and physical activity can reduce health risk substantially.¹²⁶ Like other lifestyle-related conditions, hypertension is increasingly common in American children; thus screening should be included in routine pediatric assessments.¹²⁷

With respect to nutrition, high sodium and low potassium have been implicated in hypertension and stroke, as have lipids. The National Academy of Science has recently announced that reducing added salt by as little as one-third would reduce hypertension in the United States by 25% (11 million fewer cases). Low plasma vitamin C is associated with a several-fold increased risk for stroke, particularly in men who are overweight and hypertensive.¹²⁸ A minimal reduction in diastolic blood pressure (5 to 6 mm Hg) reduces the risk for stroke by 35% to 40%.⁸³ Thus weight control; regular exercise; a diet rich in fruits, vegetables, and whole-grain cereals; smoking cessation; and blood pressure control are central to stroke prevention, as well as to the comprehensive management of stroke.

Although weight reduction is an essential component of hypertension prevention and management, the protective effect of physical activity may be unrelated to the degree of obesity.¹²⁹ A 4% to 8% reduction in body weight can reduce blood pressure by 3 mm Hg, and physical activity can reduce blood pressure by 5/3 mm Hg.¹³⁰

In normotensive African American men, aerobic exercise can attenuate an exaggerated blood pressure response.¹³¹ Similarly, normotensive fit African American women have blunted blood pressure responses to experimental stressors.¹³² One study reported no relationship between physical activity and hypertension, flow-mediated dilation of the brachial artery, or an index of angiogenesis assessed with plasma vascular endothelial growth factor (the latter two being indicators of endothelial dysfunction).¹³³ In this study, however, physical activity was based on self-report in a questionnaire rather than on fitness outcomes, so the results of the study are difficult to interpret.

Physical activity and optimal nutrition can reduce the risk for early atherosclerosis, a precursor to stroke, in lifelong nonsmokers.¹³⁴ Smokers benefit less from this protective effect. Physical activity seems not only to reduce the risk for stroke but also to provide a potent prophylactic strategy for increasing blood flow and reducing brain injury during cerebral ischemia.¹³⁵ A possible mechanism is augmented endothelium-dependent vasodilation via up-regulation of endothelial nitric oxide synthase throughout the vasculature. Aerobic exercise three times a week reduces cerebral infarct size and functional deficits in a mouse model and improves endothelium-dependent vasorelaxation.¹³⁵

Assessment of risk for hypertension is an important component of each patient’s assessment. The management strategy should be based on an analysis of the overall risk assessment rather than on blood pressure alone. The prevention of hypertension requires more than normalizing blood pressure if the deadly manifestations of high blood pressure including IHD are to be avoided. Because of the dire consequences of hypertension, the American Heart Association advocates stringent blood pressure limits—specifically, below 130/85 mm Hg, regardless of age.¹³⁶ Recommendations by the American Heart Association concerning physical activity and exercise guidelines for survivors of stroke concur that physical conditioning is a primary goal in these individuals, who must contend with both the pathological effects of stroke and the effects of deconditioning.¹³⁷ Walking as little as 2 hours a week can reduce the risk for stroke by 50%.¹³⁰ Improved conditioning may help to reduce limitations of activity and participation and hence improve quality of life. The burden of disease and disability and their risk factors may be correspondingly reduced.

To affect the health of the population, stroke prevention depends on the dissemination of these well-established and widely available interventions to a large number of people through public health policy. Advice given by a health provider to individuals with stroke for the purpose of prevention of a second stroke can have significant impact. In one study, individuals were simply advised to eat fewer high-fat and high-cholesterol foods and to exercise more.¹³⁸ Compared with a control group that received no advice, those receiving advice reported fewer days with limited activity, fewer days that “were not good physically,” and more “healthy” days. The results of this study are compelling in that even simple advice by a health care provider can have a major impact on important health behaviors and on potential health outcomes.

Type 2 Diabetes Mellitus and Metabolic Syndrome

Type 2 diabetes mellitus is a serious multisystem condition that has rapidly become pandemic in Western countries and some other countries where its incidence was previously minimal. In addition to the serious physical and functional consequences of this condition, perceived health status and quality of life are also compromised.¹³⁹ By 2010, an estimated 250 million people will be affected worldwide.¹⁴⁰ Formerly known as adult-onset diabetes, type 2 diabetes mellitus is now being diagnosed in children, predisposing them to blindness, IHD, stroke, renal disease, peripheral neuropathies, vascular insufficiency, and amputations.^141,142 Inositol acts as a poison on the membranes of cells in the presence of high blood sugar, and it has been implicated in the deadly systemic consequences of diabetes. The primary consequences include pathological changes to the macro- and microvasculature and to the nerve endings. Impaired glucose tolerance is a marker of vascular complications in the large and small blood vessels, independent of an individual’s progression to diabetes. Early detection of glucose intolerance allows intensive dietary and exercise modifications, which have been shown to be more effective than drug therapy in normalizing postprandial glucose and inhibiting progression to diabetes.¹⁴³ Diabetic autonomic neuropathy as an independent risk factor for stroke may reflect increased vascular damage and effect on the regulation of cerebral blood flow in individuals with diabetes.¹¹⁵

Individuals with type 2 diabetes mellitus have increased risk for cardiovascular disease compared with individuals without diabetes, so strict control is essential. Moderate physical activity (such as brisk walking¹⁴⁴) along with weight loss is a powerful combination to reduce the risk for type 2 diabetes mellitus, as well as to reverse it. These interventions combined with a balanced diet can reduce the risk for developing diabetes among those who are at high risk by 50% to 60%.⁸⁶ Cigarette smoking is an independent risk factor for type 2 diabetes mellitus¹⁴⁵ and is particularly dangerous for individuals who already have diabetes.¹⁴¹

Metabolic syndrome refers to a virulent and lethal group of atherosclerotic risk factors, including dyslipidemia, obesity, hypertension, and insulin resistance, and it affects some 47 million people in the United States.¹⁴⁶ The incidence of the syndrome is increasing and warrants aggressive noninvasive management. Insulin sensitivity is predicted primarily by body mass index, smoking, age, and daily physical activity. Weight reduction counters the effects of metabolic syndrome and may counter the associated hypertension and dyslipidemia as well. Diet and exercise are primary components of the multifactorial approach to preventing and managing this lethal condition.

Obesity

Obesity has been increasing exponentially over recent decades; currently, 61% of the American population is overweight.¹⁴⁷ Obesity is becoming a global pandemic that rivals malnutrition as a health priority in some low-income countries,¹⁴⁸ and it contributes to health risks for all lifestyle-related conditions. The complications and risks for which each patient should be assessed include IHD, cardiac myopathy, and chronic heart and lung dysfunction; hypertension and stroke; some cancers; insulin insensitivity and type 2 diabetes mellitus; gallbladder disease; dyslipidemia; osteoarthritis and gout; and pulmonary conditions, including alveolar hypoventilation and sleep apnea.^149–153 With each kilogram of weight above normal, the risk for hypertension, IHD, and type 2 diabetes mellitus increases proportionately. Obesity is commonly linked with insulin resistance and high blood pressure, which may reflect reduced activity and exercise. Reduced physical activity is a predictor of obesity.¹⁵⁴ Insulin resistance associated with lack of exercise in people who are overweight may be further compounded by insulin resistance associated with chronic inflammation observed in fat cells.¹⁵⁵ Abdominal obesity, lipid metabolism, and insulin resistance are interrelated markers for coronary artery disease.¹⁵⁶ In addition to cardiovascular and general health risk, being overweight affects quality of life.^157,158

Comprehensive management of an individual who is overweight and has abnormal blood glucose levels includes normalizing blood glucose (with recommendations for low-glycemic foods and small, frequent snacks rather than infrequent large meals), weight reduction, restricted intake of trans fats and saturated fats, strict blood pressure and lipid control, regular physical activity and exercise, and avoidance of tobacco.¹⁵⁹

Nutritional habits during childhood are associated with lifestyle-related conditions in adulthood.¹⁶⁰ Obesity in children is associated with parental obesity.⁷⁹ Maintaining weight within a healthy body mass index range throughout life is recommended for optimal health. Although body mass index may be limited with respect to assessing adiposity because it fails to discriminate between muscle and fat and identify regional adipose depositions, it remains a useful supplementary clinical index.¹⁶¹ Physical therapy has a primary role in preventing and managing overweight and obesity in every client or patient, regardless of age, given obesity’s serious multisystem consequences, psychosocial sequelae, and threat to life participation and satisfaction.¹⁶²

Cancer

The risk factors for cancer are well documented and include environmental and behavioral factors such as nutrition (fats and refined foods), inactivity, poor air quality and smoking, psychological factors, and ingestion of and exposure to chemicals. Cancer, hallmarked by an overgrowth of cells, eventually compromises normal organ function.

Cancers associated with the highest mortality rates include lung, colorectal, and pancreatic cancer.¹⁶³ Smoking has been implicated as a risk factor for many cancers, not only those involving the respiratory tract. The role of lifestyle factors in cancer remission has not been studied in detail.

Cancer prevention and rehabilitation have become a specialty area, requiring an integrated knowledge of pathophysiology, psychosocial implications, and management interventions.164,165 Routine assessment of health behaviors and risk factors and healthy living recommendations may help avert the diagnosis of many cancers or mitigate their effects. To date, evidence that walking is an effective strategy to prevent cancer has been best established for colon cancer,⁸⁶ although breast cancer and prostate cancer have also been reported to be positively affected by regular aerobic exercise including walking.^166,167

Musculoskeletal Health

Osteoporosis and arthritis contribute to considerable morbidity and secondarily to mortality. Because both of these conditions have lifestyle components, a lifestyle risk factor review should be included in every initial assessment to establish a baseline of musculoskeletal health. Moderate levels of physical activity, including walking, are associated with a substantially lower risk for hip fractures in postmenopausal women.¹⁶⁸ Thus assessment of both nonmodifiable and modifiable risks is a major component of the health assessment as a means of minimizing morbidity and potential mortality.⁹ Osteoporosis and associated morbidity, particularly in older age groups, is a serious health issue that warrants monitoring. Establishing baseline information on bone health in every patient is prudent, given the relationship between bone health and lifestyle behaviors (e.g., activity and nutrition—smoking and heavy consumption of meat, alcohol, and coffee). Although older, postmenopausal women have been the focus of bone health studies, other groups are also at risk for osteoporosis and should not be overlooked: older men; inactive children, particularly girls; and individuals with chronic conditions who may be less able to undertake weight-bearing activities and physical activity. In a study of the development of bone mass and strength in girls and young women, only exercise (not daily calcium intake) was associated with bone density and strength.¹⁶⁹ This finding stresses the singular importance of bone building in young people to help offset osteoporosis later in life and associated decrement in quality of life.

Psychological Health

Mental health problems and depression are prevalent in Western society despite its affluence. Based on one descriptive study, individuals with mental health conditions such as schizophrenia tend to have poor physical health and die prematurely from cardiovascular disease.¹⁷⁰ Compared with women who have schizophrenia, men with the condition consumed less fruit, vegetables, whole grains, and rice than recommended. Further, the incidence of smoking and obesity in both sexes was higher than in the general population. Cholesterol levels were high and activity levels low. This study suggested cause for concern about both the physical and psychological well-being of individuals with mental health conditions and indicated the need for further investigation of the physical health and well-being of people with mental challenges.

Dementia and Alzheimer disease appear to be increasing. Aging has been countered as a primary argument for this trend in favor of lifestyle-related influences including nutrition, specifically, processed meat consumption. Recently, Alzheimer disease has been associated with the consumption of meat from animals that have been fed nonnatural foods. This has been thought to lead to misfolding of DNA, thus affecting cognitive function in people who have consumed such products over many years.¹⁷¹ Other factors that have been associated with the condition include decreased cerebral blood flow.¹⁷² Understanding the vascular component of this condition along with food-related explanations will be an important advance in its prevention and management. In a cohort of older African Caribbean individuals, vascular risk has been associated with cognitive impairment and physical activity is inversely related to impaired cognition.¹⁷³ Exercise training has been reported to improve physical health and depression in individuals with Alzheimer disease.¹⁷⁴ Whether this reflects a vascular component of the pathogenesis of the disease that is offset by exercise warrants elucidation.

Dental Health

Periodontitis, characterized by low-grade infection of the gums, is widespread and may be associated with serious systemic health problems. In a study of 39,461 men, periodontitis risk decreased with increased physical activity, independent of such risk factors as age, smoking, diabetes, body mass index, alcohol consumption, and total calories.¹⁷⁵ Inactivity and the typical Western diet have been described as proinflammatory. Whether the benefits of a physically active lifestyle and an optimal diet can extend to dental health warrants investigation.

Promoting Healthy Living: The Contemporary Physical Therapist’s Role

Assessment of health behaviors and recommendations for healthy living can be put into practice in every patient interaction¹⁷⁶ and, in turn, help reduce the population’s health risk and mitigate the economic cost of lifestyle-related conditions.¹⁷⁷ Increased consumption of meat, fat, and sugar has contributed to the increased prevalence of lifestyle-related conditions in low- and middle-income countries, as well as in high-income countries.¹⁷⁸ An associated increase in the prevalence of insulin-resistance syndromes is further increasing the incidence of cardiovascular disease.¹⁷⁹ Anthropologists have argued that food abundance and inactivity may be altering evolutionary processes and that these factors contribute to the current pandemic of chronic conditions.¹⁸⁰ Attitudes toward factors contributing to lifestyle-related conditions reflect the values and behaviors of society. Optimal control will be achieved only with widespread public health policy, social action involving health care providers, and an increase in individual responsibility.

Why Physical Therapists Need to Understand and Advocate Optimal Nutrition

Physical therapists use exercise as a primary intervention to prevent, remediate, or mitigate the effects of disease and disability. As clinical exercise physiologists, they need substantial understanding of healthy nutrition, nutritional assessment, and nutritional regimens that will maximize human performance in patient populations. Such populations are comparable to athletes in that they need to meet the metabolic demands of their day (or event), as well as maximizing their health overall. Without such knowledge, assessment and exercise prescription are suboptimal and, in turn, therapeutic outcomes are suboptimal.

Given that an association has been established between diet and chronic lifestyle-related conditions, the question of what is the optimal nutritional regimen for humans has been widely debated. Of note is that the anatomic structure and physiological (endocrine) function of humans are consistent with an organism designed for a largely plant-based diet—that is, having hands rather than claws, a particular tooth type and skin type, salivary glands, acidity in the saliva, ptyalin in the saliva, a specific level of hydrochloric acid in the stomach, and an intestinal tract of a certain length.¹⁸¹

Cultures that consume a diet based primarily on plants tend to have superior health outcomes. The diets of octogenarians in Asia and of centenarians in general tend to be high in fiber and low in saturated and trans fats, refined sugar, and salt compared with the typical diet of Western people.¹⁸² The Mediterranean diet, which includes plentiful fruits, vegetables, fish, and vegetable oil, has shown health benefits and is associated with lower incidence of chronic disability and premature death compared with the typical Western diet.^87,126 Cultures in the Mediterranean region also tend to have higher activity levels, which influences metabolism and physiological responses to food.

Weight-loss diets are a multibillion-dollar industry in Western cultures. Many of these diets are unsubstantiated or may theoretically work but are not well balanced in terms of the macro- and micronutrients needed daily for optimal health. Low-carbohydrate diets have been popular, but weight loss associated with these diets results from calorie restriction and the duration of the diet rather than from a reduction in carbohydrate consumption.¹⁸³ Weight control is achieved by the balance between optimal caloric and nutrient content consumed and optimal energy expenditure. Given the pandemic of obesity in industrialized countries, physical therapists need to understand the normal physiological adaptations to poor food choices and sedentary lifestyles—weight distribution, endocrine changes, cardiovascular and pulmonary changes, and musculoskeletal changes—in order to prescribe the best lifelong management programs.

Overweight and obesity constitute a life-threatening pandemic that warrants management before the manifestation of one or more of its life-threatening consequences, in addition to its associated psychosocial and economic consequences. Along with obesity, glucose intolerance may complicate the picture, or the patient may have subclinical intolerance. Central adiposity, in particular, has been associated with a high incidence of insulin resistance, which may explain the high rates of dyslipidemia, hypertension, and type 2 diabetes mellitus in these individuals.¹⁸⁴ Thus the physical therapist has a primary role in basic nutrition counseling, commensurate with the promotion of optimal health, and in providing information about nutrition (related to exercise energetics and glucose control) to support a prescribed dosage of regular exercise and physical activity. A nutritionist may need to be consulted to provide nutrition counseling beyond fundamental needs, especially in complicated cases.

Nutrition guidelines have been revised by the U.S. Department of Health and Human Services¹⁸⁵ and Health Canada.¹⁸⁶ Compared with previous versions, the revisions appear to be better aligned with the literature than with the interests of lobby groups from the food industry and producers of so-called nutritional supplements. Some authorities have argued that the current pandemic of lifestyle-related conditions reflects adherence to guidelines over which food-industry lobbyists had influence, rather than lack of adherence by consumers. Current consumption of fats, refined foods, and vegetables in North America, for example, has failed to meet the recommended revised guidelines. Diets high in salt, saturated fat, and refined foods, and low in servings of vegetables and fruit have been implicated in lifestyle-related conditions.

The revised guidelines are more evidence based and have been designed to optimize health and reduce the risk for chronic conditions. Earlier guidelines fell short with respect to this objective. Adherence to established dietary guidelines for Americans as assessed by the healthy eating index was only weakly associated with risk for major chronic conditions in men¹⁸⁷ and was not associated at all with risk for major chronic conditions in women.¹⁸⁸ Thus dietary guidelines and the healthy eating index require refining to achieve more favorable outcomes and to allow them to be assessed.

An optimal food pyramid, on which the revised nutrition guidelines are based, is shown in Figure 1-2, A. The pyramid illustrates general guidelines for maximizing health in the general public, and these guidelines have been shown to offset lifestyle-related conditions.¹⁸⁹ Each individual’s diet should conform with these guidelines for optimal lifelong health. The nutrition food pyramid emphasizes abundant servings of vegetables at the base; followed by vegetable or lean-meat protein sources and dairy; beans, lentils, and whole grains; and low-glycemic foods. Red meat and eggs, positioned at the top of the pyramid, are to be consumed most sparingly. The typical Western diet is short on vegetables, fruits, and fiber (particularly insoluble fiber)^190–192 and includes excess salt, sugar, highly refined foods, and saturated and trans fats.¹⁹³ Diets high in grain-based foods are associated with reduced cardiovascular risk, independent of other behaviors.^193,194 The food pyramid has recently been revised as a plate icon where 2-3 servings of vegetables cover half the plate, a quarter carbohydrates (multigrains) and the remaining quarter vegetable protein or animal protein Figure1-2, B. Unless a person has an objectively identified deficit, there is no evidence that nutrient supplementation adds benefit to a daily nutritious diet.

Attention to nutrition is important not only in relation to body weight. Cholesterol and triglycerides are risk factors for IHD.¹⁹⁵ To address this major health threat, lipid-lowering drugs have glutted the pharmaceutical market and one-stop coronary cholesterol clinics have been advertised. However, a cardioprotective diet, which has been well described in the literature, should be the goal, in conjunction with lipid-lowering agents in selected cases. Even when medications are used, weaning individuals off them as lipids and cholesterol are lowered by noninvasive means is an important goal of physical therapy, in conjunction with a lifelong program of exercise, good nutrition, no smoking, moderate alcohol consumption, and stress management.

With respect to body mass, risk factors increase as body mass increases beyond a healthy range. Studies recommend that a healthy waist girth (low risk) is <84 cm (33 in) for women and <89 cm (35 in) for men.¹⁹⁶ Further, waist-to-hip ratio has been shown to be a better predictor of myocardial risk than body weight alone.¹⁹⁷ Thus measures of height and weight to calculate body mass index, as well as waist and hip girth, are simple standardized assessment tools and outcomes that can be used diagnostically and as tools to evaluate response to interventions such as dietary education and exercise to achieve optimal weight.

Finally, Western diets have excessive salt content—hence the pandemic of hypertension. Measures need to be taken to legislate the salt added in food production and processing. An overriding simple solution at the individual level is restricting added salt to foods. A one-third reduction of salt intake by the average American (from 3400 mg to 2300 mg daily) would reduce cases of hypertension (the second-leading cause of death in the United States), by 11 million and would lower health care costs by $17.8 billion.¹⁹⁸

Why Physical Therapists Need to Understand Ethnic and Cultural Differences

Industrialized countries are becoming increasingly ethnically and culturally diverse as people migrate around the globe, particularly to high-income countries where lifestyle-related conditions are prevalent. With birth rates on the decline in these countries, immigration is being encouraged. Thus it is important to understand the role and impact of ethnicity and culture as important factors influencing health, ill health, use of health care services, the types of health education that are needed, and the ways in which they should be disseminated.²¹⁴

The prevalence of COPD and its associated mortality increase with age, rates being higher in Caucasians than in other ethnic groups in North America.²¹¹ Among people with advanced COPD, however, African Americans and women are more prone than other groups to the adverse effects of tobacco. Cardiovascular disease in Mexican Americans and Native Americans is a particular concern and has implications for optimal care and service delivery.^54,215,216 Obesity, hypertension, and metabolic syndrome are also more prevalent in these groups, so their special needs should be recognized by physical therapists. Currently, Eastern Europe, the Middle East, and Asia have the highest smoking prevalence in the world.

The health advantages that people of other cultures enjoy in their homelands (Asians, for example) are compromised when they immigrate to Western countries and adopt Western dietary and exercise habits.67,217,218 Although they may benefit from improved health services and access, lifestyle-related conditions exact more of a toll on new immigrants with each passing year. The physical therapist has a unique role as health educator in promoting optimal lifestyle practices in new immigrants, as well as in long-term residents.

People from Utah, 72% of whom are Mormon by faith and follow a strict lifestyle code, have among the best health indexes in the country and some of the lowest rates of chronic disease,⁵⁷ but ethnic minorities in Utah are at increased risk for heart disease and stroke, among other conditions. Designing preventive and management strategies requires responding to the needs of different groups. A training program designed specifically for African Americans with stroke and complex comorbidities can be highly effective in improving fitness and reducing risk for further disease and disability.²¹⁹ Racial differences have been documented with respect to the interactions of obesity, hypertension, and diabetes between African American and European American women.²²⁰ Greater emphasis needs to be placed on targeting risk factors in various ethnic and cultural groups. For example, alcohol consumption in Caucasian Americans and weight control in African Americans and Caribbean groups are among the targeted priorities.²²¹ For each individual, the severity of the problem, the risks, and the willingness to change needs to be assessed to effectively target management strategies. Sensitivity to cultural, as well as to individual, differences when designing health-education strategies is essential to the long-term success of the intervention.

Cultural differences in self-reports of body functioning have been reported.²²² These differences, along with low education status, are thought to explain the overrating of functional status in self-reports as compared with objective measures of performance. These observations support the need for greater cultural sensitivity and awareness in the clinic, particularly when the patient belongs to a minority group and the physical therapist is part of the dominant Caucasian American group. These findings support the need for objective functional assessment in addition to self-reported functional status.

Another important cultural factor in health care is the reporting of exertion, discomfort, and pain, which affect activity and participation. Studies have examined the expression of pain and the responses of health care providers to the pain expressed by people from cultures different from those of the health care provider. In addition to cultural differences in pain expression, patients from cultures that are highly expressive in expressing discomfort and pain have been reported to receive less medication and fewer pain control interventions than individuals who are less expressive, a characteristic consistent with the dominant culture.223,224

Physical Therapists as Drivers of Change in Health Behaviors

Direct patient access is fast becoming a reality for physical therapists worldwide. With this trend comes the additional responsibility of knowing whom not to treat as well as whom to treat. The physical therapist may be the entry to health care for many patients, so she or he needs to consider the patient’s overall health and risk factors in addition to focusing on the specific physical problem that brought the patient to physical therapy. Even if the patient has been referred for physical therapy, the therapist has a responsibility to ensure that the patient’s health status is optimal so as to maximize the patient’s response to treatment and to address factors contributing to the patient’s other complaints, which may be the more serious and important considerations. In a direct-access model of health care delivery, the physical therapist needs to know what is not amenable to noninvasive physical therapy management and, in such cases, have the patient referred to or managed concurrently with an invasive medical care practitioner.

Based on the discordance between the extant knowledge of lifestyle-related conditions and health-promoting lifestyles, health care has failed to significantly reduce the prevalence of these diseases and their risk factors. The issue of why people do not always make appropriate lifestyle choices is of central importance to their health and to the practice of the health care provider. Patients may be more inclined to make follow-up visits to their health care providers than to change their lifestyles.²²⁵ One explanation for the failure of conventional models of health education^226–232 is that traditionally they have been based on a unidirectional model of information delivery—that is, from the health care provider (a dominant person) to the individual or patient (a subordinate person) in the form of brochures, books, videos, magazine articles, and television and radio announcements. These formats typically are not well targeted to a specific demographic or to the needs of the learner. Smoking cessation programs, for example, have been reported to be more effective when targeted to the specific needs of middle-aged men, including resources that promote a perceived sense of control over health behavior.²³³ Changes in behavior are effected most successfully in a personal, bidirectional model, including rapport building, trust, commitment, and follow-up. Other important factors include receptivity, susceptibility, beliefs, timing, message delivery, barriers, reinforcers, and external stimulus-control factors.²³⁴ Such a strategy is the so-called AIM approach: Assess the learner, Identify barriers to learning, and Motivate the individual to make change.²³⁵

Cardiovascular disease is the leading cause of death in women, particularly those over 60 years of age. This cohort of women believes they are at low risk for heart attack, yet 82% of coronary events in women are explained by the absence of a low-risk lifestyle.²³⁶ Although women may respond favorably to risk-reduction initiatives, their awareness of risk factors and prevention strategies may be poor.²³⁷ When health information (with respect to a low-fat plant-based diet, exercise, smoking cessation, and stress management) is delivered in a supportive group environment, in innovative multiple formats (e.g., a retreat and group meetings), people make sustainable lifestyle changes that reduce health-risk factors, decrease the need for medication, and improve their quality of life.^238,239 Furthermore, health education is more effective when cultural differences that affect health beliefs, attitudes, and behaviors are considered.^240–242

Understanding poor adherence to health behavior change is as important as understanding the factors contributing to good adherence. In healthy middle-aged men at risk for IHD, for example, poor adherence to the recommendation to increase dietary fiber is related to smoking, hostility, perception of barriers to diet change, and poor knowledge of risk factors.²⁴³ Poor adherence to following a low-fat diet is related to smoking, young age, and having no family members or friends with IHD. Poor adherence to an exercise program is associated with young age and having young children at home. Such information for various target groups is important in planning effective health-education interventions. The results of studies, however, are based on group outcomes. Individual assessments are needed to determine the barriers to and facilitators of learning for each person. The physical therapist needs to anticipate that these may change for an individual over time.

Education is a common component of the management of every patient with the exception of those who are unconscious, severely mentally challenged, or cognitively incapable of responding to the information. Even in these cases, education of the attending health care providers and caregivers can be the priority. The success of health education reflects the individual’s expectations.²⁴⁴ Most physical therapists and other health care providers have little background in assessing expectations. Physical therapists would benefit from formal education in assessing the learners’ needs and wants, expectations, and readiness to learn and implement positive changes in their behaviors. Varying expectations may be particularly important when the patient is from a culture different from that of the physical therapist.

Various theories have been proposed to explain people’s health choices and to promote improved choices. One such theory is that of reasoned action or planned behavior.²⁴⁵ Based on this theory, an individual’s decision to engage in a healthy behavior such as exercise is based on his or her intention. Intention is a function of the person’s attitudes, perceived control and self-efficacy, and social factors. The elements of the McEwen model of health motivation are comparable and have been used, for example, to effect positive lifestyle changes in individuals participating in cardiac rehabilitation.²⁴⁶ The assessment includes the individual’s current knowledge, perceived severity, perceived susceptibility, perceived value of action, background variables, internal and external aids and hindrances, and the catalyst factors. Understanding the factors that affect an individual’s lifestyle choices is vital for targeting health education so as to produce sustained outcomes.

The transtheoretical model of “readiness to change behavior”²⁴⁷ outlines several behavioral-change stages, including precontemplative, contemplative, preparation, action, and maintenance. In designing health promotion education programs, this model helps to identify the stage of readiness to change, so that interventions can be tailored to and timed with an individual’s readiness to interact with the information, thereby enhancing outcomes. The five stages of change are shown in Box 1-1. Key questions can be asked to establish an individual’s stage of readiness to change (Box 1-2).

A study of change in exercise behavior employing the transtheoretical model in sedentary women compared psychological variables and the capacity for a moderate or vigorous exercise program, either at home or at a center, to effect change in their exercise habits over 18 months.²⁴⁸ Self-efficacy for exercise competence increased as women moved from the contemplative to the action stage and was particularly marked in the groups involved in vigorous exercise. Almost half of the women shifted from the action stage to the maintenance stage. The intervention was effective regardless of the setting and the intensity of the exercise program.

When patients are in the preparation and action stages, the physical therapist can teach a range of self-monitoring skills and recording strategies along with information about circulatory and heart conditions, risk factors, and prevention. Blood pressure self-monitoring can be taught, provided the equipment is calibrated and checked by the physical therapist, standardized procedures are used, and the patient’s measurement proficiency is evaluated.²⁴⁹

Psychological principles, including cognitive and behavior-modification strategies, are central to behavior change; they include the stimulus environment and events before the behavior, the reinforcement of the behavior, and consequent events.²⁵⁰ Shaping, feedback, and reinforcement schedules are powerful strategies. Complex behaviors such as lifestyle behaviors may be shaped by the introduction of small, progressive, easily achievable steps toward a larger goal, a process comparable to the integrated stepwise approach used to improve dietary habits.⁹⁶ These principles can be incorporated into a model of lifestyle modification that incorporates factors such as culture.^234,250

Education and effecting change in health behaviors are perhaps the most important components of the physical therapist’s expertise because such change dramatically affects the lifelong health of each individual patient. Preventive health messages stated by a health care provider can be powerful, and they are a strong predictor of change in health behaviors.230,251–253 However, preventive health messages are delivered to a relatively small number of patients by their health care providers. Thus lifestyle recommendations should be delivered as a holistic management priority to every patient, in a structured, conscious manner comparable to the rigor and precision of a prescribed treatment program. The cumulative time the physical therapist spends with each patient over days, weeks, and years translates into numerous teachable moments. Multiplying this time spent annually in teachable moments by the number of physical therapists in the world indicates that the potential for having a societal impact and making a global assault on lifestyle-related conditions is enormous.

Sending a patient home with a brochure on exercise or telling a patient not to smoke has a low probability of producing lasting results—or any results at all. The educational needs of the patient, in terms of receptivity to new information and to the styles of teaching and learning that are being used, need to be established; otherwise, both the clinician and the patient are wasting their time. Educational needs are multifactorial; they include health beliefs, self-efficacy, readiness to change, and motivation. The transtheoretical model²⁴⁷ of readiness to change (see Boxes 1-1 and 1-2) is valuable in demonstrating how to determine the patient’s stage through appropriate questions and how to devise strategies for moving a patient from one stage to the next in a progression toward preparation, action, and maintenance. Self-efficacy is an important determinant of readiness to change and of one’s capacity to effect and maintain a behavioral change.²⁵⁴ If the stage of readiness to change is considered when promoting healthy lifestyles, health coaching can be successful even if brief.²⁵⁵ The level of importance a person ascribes to a behavior and that person’s sense of confidence that she or he can effect the change are the main determinants in whether the person will achieve the threshold level and make the change. Factors that contribute to this decision should be integral components of the assessment; they can be examined systematically, as outlined in Table 1-5. The individual is asked to weigh the benefits and costs of changing a given lifestyle behavior as opposed to not changing that behavior at that point in time. Decision balance analysis involves having the patient identify the benefits and costs of making a lifestyle change and of not making the change. This information is useful to the practitioner in directing and planning interventions that will effect changes in health behavior in an individual.

People in need of care such as hospitalized patients are a receptive and captive audience. They present prime opportunities for identifying teachable moments. Even if older, these individuals are motivated to better understand their risk factors and to change their lifestyles.²⁵⁶

The impact of the physical therapist as a driver of change may reflect her or his capacity to serve as a role model. Physicians who exercise, for example, are more likely to advise that their patients exercise, as well as to advocate other positive health behaviors.257,258 Thus as a health care professional, practicing what one preaches may have a powerful effect on patient adherence to lifestyle change and health recommendations.

Evidence-Based Practice

Evidence-based practice has become a major thrust in the physical therapy profession; it ensures that our practice has both a physiological and a scientific basis. An important source of evidence that has shaped cardiovascular and pulmonary physical therapy over the past 50 years has been systematic, methodologically rigorous studies in the physiological and clinical sciences.

Physical Therapists as Drivers of Change

Physical therapists are health care professionals well qualified to bridge the gap between knowledge and practice in health care and its delivery. Our role is to increase the number of people at low risk for lifestyle-related conditions rather than focus primarily on high-risk individuals. The biomedical model is being replaced by a broader health model that views the individual in the context of his or her life and culture.

Strategies of behavioral change such as the transtheoretical model²⁶¹ are being adopted with increasing frequency for the purpose of promoting healthy lifestyle change. Implementation of such a program in the workplace has been shown to increase physical activity in previously sedentary adults, to reduce the number of reported barriers to such activity, and to increase muscle endurance, predicted , and flexibility.²⁶²

Every Patient Is a Case Study

The randomized controlled clinical trial (RCCT) has become the gold standard for evaluating clinical interventions. Despite the scientific rigor involved, the limitations of the RCCT need to be appreciated by clinicians. Because of these limitations, Simon²⁷⁵ has argued that the clinical relevance of the RCCT may be overestimated and would be better described as a “silver standard.” The designs of RCCTs and their statistical analyses are based on probability theory. Because of this, results can be generalized only to comparable groups, not to an individual—the focus of the clinical situation. The results of RCCTs homogenize the outcomes for individuals who responded to treatment, failed to respond, or had negative outcomes. As clinical practitioners, we are interested in knowing how a particular individual with a given presentation will respond to a given treatment. The clinician needs to exercise a high level of clinical reasoning and judgment in determining the probability of a favorable response to a given treatment regimen in a given individual, based on studies of groups. Thus the physical therapist needs to understand the differences between the responders (favorable and unfavorable) in an RCCT and the nonresponders. This information is seldom detailed in published articles.

Another limitation of RCCTs is that in the real world, individuals seen by physical therapists have multiple comorbidities. In the interest of experimental control, conditions that confound the patient’s presentation and treatment response are selectively eliminated, or the groups are randomized so that they are relatively equivalent in this dimension. Rarely can the findings of a study that compares groups be applied perfectly to a given clinical situation.

The clinical decision-making process is iterative and time limited.⁹ Physical therapy diagnoses are derived from detailed histories and assessments. Clinical hypotheses are formulated, and the physical therapist systematically evaluates them to establish the cause of the complaints and factors that contribute to them. The physical therapist selects valid and reliable measures and outcomes and conducts them in a standardized manner. The patient’s treatment response and prognosis are predicted so as to establish a timeline for treatment. Based on the assessment, each treatment intervention is prescribed (e.g., with respect to exercise, the type, intensity, duration, frequency, and course). Periodic reevaluation with established standardized outcomes measures are conducted to determine whether the patient has achieved the treatment objective and may be discharged or whether the prescriptions need to be modified and, if so, in what way. The relevant outcomes and outcome measures are identified at the start of treatment, and the treatment responses are evaluated over time until the predetermined outcomes are achieved within the predetermined time frame.

Aligning practice with research requires that the physical therapist apply research tools in practice, or at least have an understanding of them and their impact on drawing conclusions about the effect of treatment. For example, patients often improve spontaneously with time. This phenomenon is called “regression toward the mean.” Physical therapy often involves an eclectic treatment approach involving multiple interventions. Because of this, individual treatment effects cannot be isolated. Rather, the physical therapist has to conclude that treatments A, B, and C may have resulted in some improvement; however, the effect of spontaneous improvement with time can be determined only in a controlled clinical trial or on the basis of a prolonged unchanging baseline in the patient’s symptoms. Confounding variables such as medications and improvement with time need to be isolated so that it is possible to say that they may have contributed to the outcome, even if they cannot be ruled out. Confounding variables, which result from inadequate experimental control, cloud the interpretation of cardiovascular and pulmonary physical therapy studies.²⁷⁶ The effect of placebo also plays a major role in treatment outcome. This effect reflects such factors as patient expectancy. Once maligned and considered a characteristic of the hypochondriac, the placebo effect is now known to be a potent and clinically important self-healing effect that warrants being promoted. To date, there is little scientific evidence about how to exploit the power of the placebo effect systematically to promote self-healing.

A typical example of an individual with comorbidities seen by the physical therapist is the person with acute back pain who is also overweight, has high blood pressure, and has a family history of IHD. In such cases, the physical therapist may have to introduce interventions in a stepwise manner. Even though immediate relief needs to be provided for the acute back discomfort, the comorbidities, as well as the low back pain, contribute significantly to the state of the individual’s health and well-being at present and figure importantly in the future (with respect to prolonged morbidity and premature death). Thus for maximal and sustainable health, a lifelong health program needs to be implemented. To do this effectively, the practitioner needs a stepwise, paced approach that engages other members of the health care team as needed. The first goal is to provide physical relief of acute pain. Then a weight-reduction and exercise program plan is introduced commensurate with the individual’s needs and wants. A nutritionist may need to be consulted not only to assist with weight loss but also to educate the patient about dietary principles to address hypertension (e.g., salt restriction) and minimize the risk for type 2 diabetes mellitus. Weight reduction, improved core and general strength, and aerobic conditioning may eliminate the cause of the low back pain or may attenuate it significantly over the long term. These interventions can also reduce blood pressure and help maintain blood glucose levels within normal limits, considering that the patient is at risk for diabetes. Follow-up is implemented to monitor progress and maintain psychosocial supports so as to ensure the long-term sustainability and success of the lifestyle changes. Such a regimen overcomes the limitations of a conventional course of analgesia and musculoskeletal physical therapy. Although the latter may produce short-term results, it does not necessarily address the underlying problem or eliminate the likelihood of recurrence of the primary problem and related health-behavior risks over time.

Health promotion practice needs to be modified to the needs of a patient based on his or her cultural background and affiliation. Cultural competence in practice is geared toward augmenting clinical outcomes by adapting communication style, assessments, and treatments. Differences in people with respect to culture, traditions, and religion or faith can affect health, illness, health reporting, beliefs, and expectations about treatment intervention, as well as adherence to the treatment program. For example, the holy month of Ramadan requires creativity in managing the needs of Muslims. During Ramadan, Muslims fast from dawn to dusk, and the fast may include abstinence from water as well as from food. Sedentary people show greater adverse physiological effects during this period, both when at rest and during exercise, than do active people.²⁷⁷ Body weight drops in a predictable manner. The respiratory exchange ratio decreases during exercise, reflecting increased fat metabolism. Serum iron and platelets decrease, particularly in sedentary people, and fluid balance is better maintained in active people. Exercise, particularly whole-body exercise, may have to be curtailed or modified during fasting. This is especially true when Ramadan falls during the hot summer months.

Adapting lifestyle and treatment recommendations to the needs of the people physical therapists serve is fundamental to a successful outcome. The parameters of exercise prescription for optimal health benefits have been well documented (see Chapter 18). Prolonged adherence to physical activity and exercise programs, however, is poor. Understanding the factors that sustain health behaviors is as critical as the physiological basis for them. One study compared the effects of conventional aerobic training with the effects of a program designed to increase strength, endurance, and mind-body coordination but designed also for “comfort,” so that the program would be more appealing to people unused to exercise. After training, participants in the latter group had superior endurance compared with those in the conventional group, and they reported more comfort and less exertion. This preliminary study supported the idea that an exercise program modified for comfort and enjoyment still resulted in a greater capacity to adapt to increased physiological demands. Such programs should be extended so that adherence over time can be evaluated. In addition, readiness to change as described in the transtheoretical model needs to be considered in studies of long-term lifestyle change.²⁷⁸

The Magic Bullet and the Fountain of Youth

A “magic bullet” and a “fountain of youth” are not just myths. They exist, but they are not to be found in a pill or in surgery. For almost a century of documented physical therapy practice, education and exercise have been the hallmarks of the profession292–294 and the elixirs that add years to life and life to years. These “drugs” have been at the core of the practice of the physical therapist, who is distinguished from invasive-medicine practitioners primarily by the use of noninvasive “drugs” as opposed to the invasive interventions of pharmacotherapy and surgery. In addition to providing preventive health benefits, lifestyle changes such as smoking cessation, optimal nutrition, and exercise can enhance the quality of life²⁹⁵ and increase the probability of long-term health.

Given the epidemiological changes in global health, this is physical therapy’s moment on the world health care stage, a time to promote health and wellness in every patient and to prevent, manage, and in some cases, reverse lifestyle-related conditions that are contributing to enormous social and economic burdens globally. The profession is uniquely and strategically positioned to lead the assault on lifestyle-related conditions by integrating health promotion into practice. The benefits of noninvasive strategies such as physical activity and exercise and healthy living are clear. If a drug could offer these same benefits and similarly improve public health, it would be heralded as nothing short of a miracle remedy. Although public perception of the benefits of noninvasive intervention is on the rise, much work remains to be done. The role of health coach for every patient could be one of the most rewarding competencies for physical therapists of the 21st century as they strive to make a positive impact on public health, one patient at a time.

Summary

This chapter describes the pivotal role of the noninvasive practitioner—namely, the physical therapist—within the contemporary framework of health in the 21st century. With the pandemic of lifestyle-related conditions, physical therapists need to consider the underlying risk factors for these conditions in every individual, regardless of the physical therapist’s particular specialties or areas of practice and regardless of the patient’s primary reasons for the consultation. A patient’s low back pain or tennis elbow, for example, may be mere inconvenience compared with his or her smoking, excessive body weight, inactivity, high blood pressure, high cholesterol, or abnormal blood sugar. Physical therapists are uniquely qualified professionally and are strategically well positioned to address the leading health priorities of our time by using the profession’s primary “drugs”—education and exercise—in diverse settings, one individual at a time or in groups. In addition, physical therapists need to identify risk factors in all patients, irrespective of presenting problems and diagnoses, so that they can prescribe optimal treatment, including exercise, to address lifestyle risk factors and monitor the patient for therapeutic and safety reasons. Physical therapists pride themselves on their communication skills, which are fundamental to building rapport with people and effecting lifelong behavior change. This expertise can be exploited because physical therapists not only spend more time with people during visits than most health professionals, but also see them over repeated visits. As effective drivers of change, physical therapists can exert considerable influence on their patients over time, given the potential teachable moments through the course of care. In the 21st century, physical therapy’s impact will be reflected in outcomes associated with prevention, potential reversal, and management of lifestyle-related conditions, over and above the conventional practice of physical therapists across clinical areas and settings.