Williamson, Wendy A. Ph.D.
Positioning exercise professionals to service medical conditions is gaining more attention. The demand is a result of many factors, including increased health care costs, and possibly the reduced allowable visits per insurance coverage, that is, physical therapy. As the skill sets and education of the fitness professional are evaluated, is the average fitness professional prepared and positioned to provide this service? Do fitness professionals have the professional relationships and respect within the medical community to service medical conditions? Can synergy between medical and fitness professionals be created to enhance reciprocation, and can fitness professional skills be advanced to enhance quality service and provide a significant return on investment (ROI)?
Medical exercise servicing (MES) can be defined as a medically approved exercise program for individuals who have been diagnosed with a medical condition (i.e., disease, injury, postsurgery) and now seek further oversight from advanced fitness professionals.
Medical fitness has been around for years. Since 1994, the American Academy of Health, Fitness, and Rehabilitation Professionals (AAHFRP) has offered a medical fitness certification: Medical Exercise Specialist. Michael Jones, Ph.D., PT, and president of AAHFRP indicates that more than 9,000 students have become certified across six continents (Africa, Australia, Africa, Europe, Asia, and North and South America).
According to Dr. Jones, the demand for medical fitness has been growing for years. Why? Several reasons include the fact that the worldwide population is getting older, chronic health conditions are rapidly increasing, and there truly are not enough medical professionals to manage the necessary services for all of these folks. "Everyone is taking advantage of this shift and opportunity," says Dr. Jones (regarding MES).
In the corporate workplace, wellness programs have existed for some time. Currently, nearly two thirds of U.S. companies offer some type of wellness program to lower health insurance costs, combat absenteeism, and boost productivity (6). Is the fitness professional positioned to provide wellness programs?
Amanda Harris, vice president of ACAC Fitness and Wellness Centers, shares the fact that each of their four centers offers a supervised exercise area for members whose physician has highly recommended exercise for their overall health. The ACAC approach for these exercising members is to provide a semiprivate area that introduces basic and simple exercise instructions. Through general supervision, it has served as a springboard for more direct programming for specific needs, whether they are small group sessions or individualized attention.
As a result of programs such as ACAC, fitness professionals can position themselves to help members and address simple lifestyle choices. It is the belief of many adults that U.S. health care dollars should assist in health care. In 2007, the Partnership to Fight Chronic Disease (PFCD) reported that 81% of adults believed that the United States should prioritize health care dollars to "invest more in preventative measures to ensure that diseases are prevented or kept from becoming more serious," whereas 12% say the dollars should be spent "more to treat diseases once they have happened."
In 2007, PFCD also reported that chronic disease represented more than 75% of health care costs and more than 70% of the deaths in the United States. The organization also indicated that more than 133 million Americans have a chronic disease and only 56% of the chronically ill patients receive the recommended health care services (1).
Chronic diseases afflict 100 million Americans, which cause 7 of 10 deaths and consume $2 out of every $3 spent on health care, but much of the burden can be prevented with simple lifestyle choices because a "major contributing factor is physical inactivity" (3).
Table 1 refers to the most common medical categories that may be presented to the fitness professional. These categories and specific conditions are as follows: orthopedic (knee and hip replacements, torn anterior cruciate ligament, meniscus tears, rotary cuff, kyphosis, lordosis), neurological (i.e., spinal cord injuries, strokes, cerebral palsy, Parkinson disease [PD]), cardiovascular (heart attack, heart surgery, elevated cholesterol, high blood pressure), metabolic (obesity, diabetes, thyroid condition), mental disorders (dementia, Alzheimer's), and autoimmune diseases (fibromyalgia, chronic fatigue syndrome, lupus, scleroderma, rheumatoid arthritis).
Specifically looking at PD, in 2006, Crizzle and Newhouse (2) conducted a study to review existing studies evaluating the effectiveness of physical exercise on mortality, strength, balance, mobility, and activities of daily living for patients with PD. Seven studies met the established criteria and were evaluated. The results of the research "up to this time" support the hypothesis that patients with PD improved their physical performance and activities of daily living through exercise (2).
However, is it necessary that each medical condition receive individualized MES? No, it is not necessary in all cases, but many individuals will need initial individualized attention. Depending upon their condition, and as programming develops, specialized fitness groups can be established for accountability, socialization, and the opportunity to create a group setting for similar medical conditions. Small-group fitness programming also can reach more people, enable cost-controlling measures, and still reach fitness goals.
As a result of these conditions, we have an array of medical professionals from which fitness professionals seek direction (Table 2). These professionals include but are not limited to massage therapists, physical therapists, physician assistants, registered dietitians, nurse practitioners, family physicians, sports medicine doctors, and surgeons. Interaction with these professionals is a must but can be challenging. The suggestions below provide the best options for success and collaboration.
As clients present themselves for MES or postrehabilitation, the size of the necessary tool kit for the fitness professional may run large. With rapidly increasing health care conditions in recent years, it has become challenging for a fitness professional to be prepared for all conditions that may be presented. Yet, at the same time, it is the responsibility of the fitness professional to be academically prepared as well as have hands-on experience possibly through an internship.
Programs such as these are delivered in medically integrated health and fitness centers, private residential homes, hospitals, community-based centers, YMCAs, and private fitness facilities. All of these centers provide equipment, classes, and general instruction for exercise. Medically integrated health and fitness centers and some private fitness centers can provide rehabilitation and then continue postrehabilitation with appropriate personnel in-house. For fitness professionals, it has become more common to receive referrals from the medical community, such as physical therapy and sports medicine physicians.
There is an increasing trend toward all-inclusive one-stop medical shopping, especially within the orthopedic specialty. It is becoming more common to find an orthopedic surgeon, along with a physician's assistant, nurse practitioner, physical therapist, and MES all in the same building. Continuation of health care service can be provided from presurgery to complete discharge from one professional to another. This is convenient for the patient/client, and it also creates an advantage for the fitness professional to learn and advance their respective skills under the direction of the medical professionals.
CHARACTERISTICS OF FITNESS PROFESSIONALS
In general terms, the personality of the fitness professional is one of the key ingredients to a successful MES program. The fitness professional needs to be caring and compassionate and able to interact positively and effectively with the client. In the past, a college degree may not have been warranted, but with the complexity of medical conditions, a college degree with appropriate course work is important and increases the credibility of the fitness professional.
Along with the college degree, an approved certification is essential. The National Commission on Certification Agencies http://www.noca.org/NCCAAccreditation/AccreditedCertificationPrograms/tabid/120/Default.aspx is the gatekeeper for the beginning and advanced fitness professional. Criteria must be met to be recognized as an accredited certification association. Currently, the associations include the following advanced personal training certifications: ACSM, Clinical Exercise Physiologist and ACS Certified Cancer Exercise Trainer; ACE, Advanced Health and Fitness Specialist; NASM, Corrective Exercise Specialist; and Training and Wellness Certification Commission, Advanced Certified Personal Trainer. Although this list is used as a determining factor in hiring practices, not all advanced personal training certification programs apply to become accredited.
Within the development of the fitness professional, once the necessary education is acquired and an approved certification is obtained, there may be specialty training or a second certification that is necessary to address medical fitness in a specific population. Specialty study also can be achieved through internships, medical professional observation, and attending local, regional, and national fitness and/or medical seminars.
As a team player, Dr. Jones reports that the fitness professional must understand his or her respective and appropriate role and how to communicate effectively with the medical professional. Communication can often be a challenge, but interacting and networking with the medical staff can often be the best answer. Unfortunately, some medical professionals may not respond to any form of communication (i.e., via letters, phone calls, emails). Regardless, our dialogue with the medical community must reflect professionalism, correct terminology, and confidentiality to achieve respect, reciprocation, and referrals. If the medical condition "homework" is done properly and handled appropriately, the reciprocation will occur and each profession, and ultimately the client, will prosper.
Dr. Jones also reiterates that as fitness professionals, it is important that we have complete understanding of 1. our scope of practice, 2. knowledge of the criteria for postrehabilitation or MES, and 3. recognition of conditions that need immediate follow-up from the referring physician or health care professional.
Perseverance is necessary. For 3 years via telephone calls and formal letters, I attempted, without success, to communicate with a family physician. Eventually, I learned that the nurse working for this respective physician was the daughter of one of my clients. For years, this client, an incomplete paraplegic, had worked with me and once the nurse shared (with the physician) that I was providing MES for her father, the physician began communicating with me. The process was long and difficult, especially seeking medical releases and professional input. Since then, I have continued to provide service to more than a dozen of this physician's patients.
Besides hospital-based wellness centers and private residential homes, are there enough fitness facilities to service MES? What is the current status? The International Health, Recreation, and Sport Association (IHRSA) reported that there were 30,022 fitness facilities within the United States at the end of 2008. However, when reviewing these numbers, Michael Scott Scudder, owner of Club Management Education and Training On-line, stated the following: "I believe the IHRSA numbers were as accurate as could be ascertained at the end of 2008 (30,022 facilities). I also believe there are at least 3,000 other facilities that do not show up on the radar that entertain membership options (i.e., condos, co-ops, gated communities, retirement communities, hotel facilities) (5)."
These data suggest that there are enough facilities, especially in greater metropolitan areas, to service and position fitness professionals to manage postrehabilitation or MES. However, do we have an adequate number of advanced fitness professionals to meet the needs in these facilities? If we look at the most common conditions seen by the advanced fitness professional, it seems that we do not have enough personnel to address MES.
POSITIONING: THE BUSINESS TOOL KIT
As mentioned, establishing relationships, referrals, and reciprocation with the medical community (Table 3) may be difficult; however, it can be done. The fitness professional should always be prepared for the spontaneous interaction that may occur when least expected.
In addition, when corresponding with the medical professional, it is highly recommended to fully understand the medical condition and forward the fitness assessment results and a recommended program design for approval. The signed medical release also is needed at this time. The recommended program design attempts to establish the fitness professional's expertise, research, and thought process regarding the condition and specific needs of the client. Most of the work has been done for the physician. Once received, the medical professional can edit or approve the recommended program design, sign the medical release, and the exercise program can be implemented.
Opportunities also may be extended for the medical professional to serve on the medical advisory team at a medically integrated health and fitness program, general fitness facility, or anywhere MES is provided. This is a great way to assist with the development of medical exercise services at that respective facility. In exchange for the professional's time and expertise, fitness services (i.e., personal training, yoga, Pilates) could be a benefit offered for the medical professional to experience. Often, the medical professional doesn't have a true understanding of fitness programming available until experiencing programs firsthand.
Follow-up correspondence with the medical professional is another key component of the tool kit. This is an effective way to show client progression and an opportunity to illustrate skill sets that will keep the door open with the medical professional. In some cases, the medical professional may provide the fitness professional a summary of a follow-up visit via telephone or email. Keep in mind, the client must have signed the Health Insurance Portability and Accountability Act release for this to occur.
Positioning takes time, energy, and skill. The client who presents for MES wants quality service, to improve their daily activity, and ROI. For every new client, the fitness professional has the opportunity to gain experience, advance skills, improve his/her business, and quite honestly, earn more income.
By maintaining our professionalism, creating relationships with the medical community, and offering quality care and service, the potential is enormous. Positioning the fitness professional requires work, and truthfully, some of the medical community may be skeptical of the potential. Fitness professionals must be willing to put the effort forward to achieve MES or postrehabilitation status. The "fittest" will survive, and the "willing" will be rewarded both professionally and personally. Medical exercise servicing is here to stay, and the fitness professional tool kit must be strategically "packed and prepared" to address the business demand.
CONDENSED VERSION AND BOTTOM LINE
Medical exercise servicing has gained increasing demand and attention as health care costs increase. Through the advanced study and business tool kit preparation, fitness professionals can position themselves for potential specialization and a return on investment. As a result, and via appropriate scope of practice, credentialing, programming, and positioning present vast opportunities for the fitness professional.