Writing the Preface for a book or its revision is an opportunity to pause and reflect. As we take a collective breath seeing the next edition become an entity, we inevitably reflect on our vision for this edition, and the degree to which we have achieved this.
Our vision has always been an ambitious one. This is appropriate given the power of nondrug and nonsurgical approaches to health promotion and remediation of chronic conditions injury and illness. In this fifth edition, specifically, we have revised the title fur ther to reflect changes in theory and practice, and knowledge translation. In the fourth edition, we changed the title from “Cardiopulmonary Physical Therapy: Evidence and Practice” to “Cardiovascular and Pulmonary Physical Therapy: Evidence and Practice” to align the title with the change in the name of the Cardiovascular and Pulmonary Section of the American Physical Therapy Association. In this revised edition, our intention was to fur ther link evidence and practice with a minor yet important change, i.e., the replacement of “evidence and practice” with “evidence to practice”; thus, the revised title is now “Cardiovascular and Pulmonary Physical Therapy: Evidence to Practice.”
The merits of the structure of the book and the interrelationship of its Parts and component chapters have held up well with intense scrutiny by external reviewers and users of the book. Therefore, we have concentrated on strengthening the emphasis on the epidemiological basis for content and lifestyle-related conditions given that most patients today have risk factors or manifestations of these conditions, and, in turn, these conditions invariably impact the cardiovascular and pulmonary systems either primarily or secondarily. In addition, contributors were committed to reporting the highest level of physiological and scientific evidence for overall management approaches and treatment interventions. Because of the international appeal of the book over its multiple editions, we remain committed to using boxes, tables, figures, appendices, and pictures as strategically and selectively as possible to best illustrate concepts, ideas, and management considerations. We have paid par ticular attention to these materials to ensure they reinforce the information in the text to the utmost degree. We take the book’s reputation most seriously; therefore we have attempted to incorporate changes that meet the needs of as many stakeholders as possible including students, educators, clinicians across specialties and areas of care, specialists, and other health professionals. We are most appreciative of these stakeholders who have taken time to advise us in this revision.
In ensuring the appeal of the book to users, we have made several changes. First, we have fur ther improved chapter flow and the consistency of their information with additional cross referencing. To enhance the learning experience for students we have contextualized the academic content wherever possible into a clinical framework, which in turn is fur ther
reinforced in the cases in the accompanying online Clinical Case Study Guide. Throughout editions, the book has been acknowledged for its user-friendly approach and continues to be a primary textbook in the field. Consistent with the needs in health care this century, we have attempted to broadly consider the impact of multisystem influences on the cardiovascular and pulmonary systems across the continuum of health and dysfunction (consistent with the International Classification of Functioning, Disability and Health [World Health Organization]). Our commitment to the content being both evidence-informed and evidence-based has led us to consider this perspective, in the selection of invited contributors and in the case examples in the accompanying online Clinical Case Study Guide. Each chapter has key terms and review questions to guide the reader in grasping central concepts and translating these into practice. In addition, to serve as an authoritative resource to colleagues developing specific programs such as pulmonary rehabilitation and cardiac rehabilitation that have established international standards, we have outlined the standards for these programs in an easy to use format in appendices for handy reference.
To meet the needs of busy faculty and instructors who need to keep up to date, we provide learning resources and outlines, PowerPoint slides for lectures, and review questions for group work. These resources complement the online Clinical Case Study Guide that accompanies the text. We have fur ther responded to clinicians who need updated information on examination, evaluation, interventions, and outcomes for patients with cardiovascular and pulmonary limitations. In the literature, examination and evaluation tools focus increasingly on the use of standardized outcome measures and professional associations are increasingly encouraging clinicians and students to use these measures routinely and systematically. This is considered essential in contemporary practice to evaluate patients’ progress objectively and in a clinically relevant manner. Further, such practice provides an indicator in deciding whether to treat a patient, for changing interventions or their parameters, and as a basis for discontinuing treatment or discharging the patient.
It has been a pleasure for us to reflect on our vision for this edition and how well we have achieved our goals. We sincerely hope the fifth edition meets and surpasses your expectations. With years in the field, we appreciate more than ever that “every patient is a cardiovascular and pulmonary patient” and hope that the information in the book will help ensure health is promoted in every patient, and also ensure we provide “the right treatment, for the right patient, at the right time” in pursuit of the best physical therapy outcomes based on best practice.
We very much look forward to your feedback and welcome suggestions for the sixth edition at any time.
Acknowledgments
The tenets of Hippocrates of “first do no harm” and “the function of protecting and developing health must rank even above that of restoring it when it is impaired” have provided an overarching philosophy and context of practice for this book. It is this perspective that I believe has largely distinguished its contribution and ongoing favorable reception by students, clinicians, and educators worldwide. Over the years, I have often reflected on the wisdom of Hippocrates and cite him frequently. It therefore seems fitting that I formally acknowledge him and his seminal work. The tenets of Hippocrates are as relevant today as they were more than two millennia ago in providing a context in which to address the pandemic of lifestyle-related conditions today. This vision has become blurred in a care arena with competing interests, e.g., a disproportionate emphasis on illness care than on health care and the lens of illness care as a lucrative business. We have attempted to do justice to the ideas and wisdom of Hippocrates in the context of today’s health-care needs and priorities. In fact, as one of the leading established health professions and, of these, the primary profession committed to non invasive approaches, physical therapy is in a strategic position to lead in the pursuit of “health and par ticipation for all.”
As yet another edition of the book goes to press, I reflect on how we arrived here. No foreword material would be complete without primary acknowledgment of my long-time colleague and friend, the primary co-editor of the book, Donna Frownfelter. I think back to her first edition of the book, a best-seller in the field in North America. I continue to mar vel at Donna’s unwavering commitment to her original vision through each edition of the book, yet her ever willingness to adapt and change as the world and the needs of the profession evolve along with the demand for evidence-based practice. Thank you, Donna, for the opportunity to be on this journey with you. It has been a phenomenal one.
Few words can express my appreciation to my family, more recently new husband Lawrence Aronsen, and friends for your unending support, inquiries, and quality time. During book
revisions, my conversation becomes rather single focused when asked “how are things?” Thank you for your forbearance and understanding and in seeing this project through once again. And, Lawrence, yourself having been through this process several times, your quiet implicit understanding and no-explanation-needed support were invaluable to me in moving things along each day.
My sincere appreciation to the Elsevier team. There are many people behind the scenes in a major undertaking such as the fifth edition of a major textbook. You have contributed in many ways to this new and improved edition. In par ticular, I would like to thank Kathy Falk, Megan Fennell, and Celeste Clingan. In each of your roles, I thank you for your commitment, support, and adaptability during this revision. You have added to its quality while supporting us and our vision.
Finally, I would like to express my gratitude to the international physical therapy community and my colleagues around the world for your insights and shared vision. In the preface of the fourth edition, I had said that “…by the fifth edition, physical therapists around the world will have increasingly made their mark as primary health care professionals and leaders in the assault on the diseases of civilization by being effective agents of change.” Based on multiple international visits since that time, I am hear tened to see the groundswell of change taking place in several countries at the levels of our professional bodies, entry-level physical therapy programs, educators, researchers, and clinicians, and their emerging impact on policy makers and ministries of health. By the sixth edition, I look forward to this groundswell becoming a tsunami with physical therapists making major inroads across all of these levels and collectively impacting global health.
I continue to look forward to working with international colleagues toward a shared vision of “health and participation for all.” By collectively translating our substantial knowledge base to address the world’s leading health-care challenges, we shall make a difference.
Elizabeth
Dean, PT, PhD
Part I
Cardiovascular and Pulmonary Function in Health and Disease
1
Epidemiology as a Basis for Informing Contemporary Physical Therapy Practice 2
Elizabeth Dean
2 Oxygen Transport: The Basis of Cardiovascular and Pulmonary Physical Therapy 32
Elizabeth Dean
3 Cardiovascular and Pulmonary Anatomy 45
4
5
6
Elizabeth Dean
Cardiovascular and Pulmonary Physiology 65
Elizabeth Dean
Cardiovascular and Pulmonary Pathophysiology 77
Elizabeth Dean
Cardiovascular and Pulmonary Manifestations of Systemic Conditions 103
Elizabeth Dean
Part II
Cardiovascular and Pulmonary Physical Therapy: Assessment
7 Measurement and Documentation 115
Claire Peel, John D Lowman, and Diane Clark
8 History 125
Willy E. Hammon III and Elizabeth Dean
9 Pulmonary Function Tests 137
Donna Frownfelter
10 Arterial Blood Gases 143
Donna Frownfelter
11 Imaging of the Chest 151
Myriam Riboh and Patrick Knott
12 Electrocardiogram Identification 158
Christian Evans and Gary Brooks
13 Multisystem Assessment and Laboratory Investigations 175
Elizabeth Dean
14 Special Tests 181
Gail M. Huber
15 Clinical Evaluation and Assessment of the Cardiovascular and Pulmonary System 198
Donna Frownfelter and Susan M. Butler McNamara
16 Monitoring Systems, Catheters, and Devices in the Intensive Care Unit 214
Elizabeth Dean and Christiane Perme
Part III
Cardiovascular and Pulmonary Physical Therapy: Interventions
17 Maximizing Outcomes: Relating Interventions to an Individual’s Needs 229
Elizabeth Dean and Donna Frownfelter
18 Mobilization and Exercise: Physiological Basis for Assessment, Evaluation, and Training 244
Elizabeth Dean and Scotty Butcher 19 Mobilization and Exercise: Testing and Training 273
Elizabeth Dean and Scotty Butcher
Body Positioning 293 Elizabeth Dean
Airway Clearance Techniques 309
Anne Mejia-Downs 22 Facilitating Airway Clearance with Coughing Techniques 337
Donna Frownfelter and Mary Massery 23 Facilitating Ventilation Patterns and Breathing Strategies 352
Donna Frownfelter 24 Exercise Testing and Training: Primary Cardiovascular and Pulmonary Dysfunction 377
Elizabeth Dean, Donna Frownfelter, and Eduard Gappmaier 25 Exercise Testing and Training: Secondary Cardiovascular and Pulmonary Dysfunction 409
Elizabeth Dean, Donna Frownfelter, and Eduard Gappmaier
Respiratory Muscle Training 419
Rik Gosselink and Simone Dal Corso
Complementary Therapies as Cardiovascular and Pulmonary Physical Therapy Interventions 431
Meryl I. Cohen and Carol M. Davis
Patient Education 457
Kelly Hawthorne, Katherine Ennis, and Alexandia J. Sciaky Part IV Cardiovascular and Pulmonary Physical Therapy: Acute Conditions
Part V
Cardiovascular and Pulmonary Physical Therapy: Chronic Conditions
31 Individuals with Chronic Primary Cardiovascular and Pulmonary Dysfunction 502
Elizabeth Dean and Donna Frownfelter
32 Individuals with Chronic Secondary Cardiovascular and Pulmonary Dysfunction 522
Elizabeth Dean and Donna Frownfelter
Part VI
Cardiovascular and Pulmonary Physical Therapy: Intensive Care
33 Comprehensive Management of Individuals in the Intensive Care Unit 544
Elizabeth Dean and Christiane Perme
34 Intensive Care Management of Individuals with Primary Cardiovascular and Pulmonary Dysfunction 558
Elizabeth Dean and Christiane Perme
35 Intensive Care Management of Individuals with Secondary Cardiovascular and Pulmonary Dysfunction 572
Elizabeth Dean and Christiane Perme
36 Intensive Care Management of Medical and Surgical Complications 584
Elizabeth Dean and Christiane Perme
Part VII
Cardiovascular and Pulmonary Physical Therapy: Special Cases
37 Infants and Children with Cardiovascular and Pulmonary Dysfunction 600
Mary Rahlin and Victoria A. Moerchen
38 The Aging Patient 625
Elizabeth J. Protas
39 Multisystem Clinical Implications of Impaired Breathing Mechanics and Postural Control 633
Mary Massery
40 The Transplant Patient 654
Susan A. Scherer
41 The Patient in the Community 668
Donna Frownfelter and Jennifer M Ryan
Part VIII
Related Aspects of Cardiovascular and Pulmonary Physical Therapy
42 Body Mechanics: Positioning and Moving Patients 681
BJ Lehecka, Donna Frownfelter, and Mary Massery
43 Respiratory Care Practice Review 690
Donna Frownfelter
44 Care of the Patient with an Artificial Airway 703
Donna Frownfelter and Lisa Sigg Mendelson
45 Respiratory and Cardiovascular Drug Actions 712
Stacy J. Laack and Arthur V. Prancan
Appendix A Elements of International Standards for a Cardiac Rehabilitation Program 724
Appendix B Elements of International Standards for a Pulmonary Rehabilitation Program 728
Appendix C Exercise Testing and Prescription Considerations for People with Primary Cardiovascular, Pulmonary, and Endocrine Conditions 732
Appendix D Exercise Testing and Prescription Considerations for People with Nonprimary Heart, Lung, and Endocrine Conditions 748
Appendix E Common Complementary Therapies 764
Glossary 768
Index 776
Part I
Cardiovascular and Pulmonary Function in Health and Disease
1
Epidemiology as a Basis for Informing Contemporary Physical Therapy Practice
Elizabeth Dean
KEY TERMS
Building healthy communities
Epidemiology
Global health
Healthy people
CHAPTER OU TLINE
What Is Health? 2
The Paradox 4
Lifestyle-Related Conditions 4
International Classification of Functioning, Disability and Health
Lifestyle-related conditions
Magic bullet
Life Cycle and Lifestyle-Related Conditions 5
“First Do No Harm” 6
Evidence-Informed Practice 6
Addressing the Health Care Priorities of the Day 6
Our Village 7
Principles of Evidence-Informed Practice 8
The Priorities of Our Village 8
Promoting Healthy Living: The Contemporary Physical Therapist’s Role 13
Evidence-Based Practice 19
Knowledge into Action 19
Physical Therapists as Drivers of Change 20
Refocusing and Expanding the Clinical Repertoire of Physical Therapists 20
Continuing Professional Education 21
Every Patient Is a Case Study 21
Physical Therapy’s Role: Participation in Health Promotion Practice 23
Physical Therapy’s Role: Participation in Population-Wide Health Initiatives 23
Implications of Epidemiology and Health Care Trends for Physical Therapy Practice 24
Implications of Epidemiology and Health Care Trends for Physical Therapy Professional Education 24
The Magic Bullet and the Fountain of Youth 25
Summary 25
Review Questions 25
References 25
Noninvasive practitioner
Our village Paradigm shift
World Health Organization
This past century, health care priorities have shifted from the prevention and management of acute infectious diseases to the prevention and management of lifestyle-related conditions. These include ischemic heart disease (IHD), smokingrelated conditions (including chronic obstructive pulmonary disease [COPD]), hypertension and stroke, diabetes, obesity, and cancer. Not only have the morbidity and mortality resulting from these conditions escalated to their current pandemic proportions, but the probability that an individual (child or adult) has at least one risk factor is high.
To address the gap between lifestyle practices and the body of knowledge on the relationship between lifestyle choices and health,1 a societal commitment to reducing the number of patients rather than increasing the focus on biomedical care (drugs and surgery) has never been more urgent. Physical therapists are uniquely qualified and strategically positioned as health care professionals to lead in the translation of this well-established body of knowledge into daily practice.2 A consideration of the risks of lifestyle-related conditions in every individual is consistent with a comprehensive model of best practice in the context of epidemiological trends—that is, evidence-based practice in the context of practice priorities that are themselves informed by evidence. This chapter expands these concepts and outlines principles for applying them proactively and as a priority in the health care of every patient. Physical therapists can have a major impact on the leading priorities of health care, one individual at a time.
What Is Health?
Consistent with the tenets of Hippocrates to which all health care professions aspire—“first 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 wellbeing”—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
Table 1-1 Concepts of the Health Belief Model
Concept Definition Application
Perceived susceptibility
Perceived severity
Perceived benefits
One’s belief of the chances of getting a condition
Define the population(s) at risk and their risk levels
Personalize risk based on a person’s traits or behaviors
Heighten perceived susceptibility if too low
One’s belief of the seriousness of a condition and its consequences
One’s belief in the efficacy of the advised action to reduce risk or seriousness of impact
Perceived barriers
Cues to action
Self-efficacy
One’s belief in the tangible and psychological costs of the advised behavior
Strategies to activate “readiness”
Confidence in one’s ability to take action
Specify and describe consequences of the risk and the condition
Define action to take—how, where, when
Clarify the expected positive effects
Describe evidence of effectiveness
Identify and reduce barriers through reassurance, incentives, and assistance
Provide how-to information
Promote awareness
Provide reminders
Provide training, guidance, and positive reinforcement
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,
From Stretcher VJR, Rosenstock IM: The health belief model. In Glanz K, Lewis FM, Rimer BK, editors: Health behavior and health education: theory, research and practice, San Francisco, 1977, Jossey-Bass.
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.
The Paradox
People living in high-income countries (e.g., countries in North America and Europe, and some Asian countries) and, increasingly, in countries whose economies are growing are experiencing a paradox: an increase in the negative impact of a more Western lifestyle combined with an increase in advances in biomedicine. Technological and economic advances have
been proposed as factors contributing to an obesity-conducive environment.15 The effects of low activity (hypokinesis) and poor nutritional choices on health in Western countries have been reported to be synergistic and partially additive,16 although a potent interaction may exist. The power of nonpharmacological interventions and solutions to affect global health priorities related to chronic lifestyle-related conditions can no longer be considered secondary to pharmacological solutions.17,18 Rather, they may need to be considered foremost.
A nationwide, population-based strategy to improve lifestyle is the primary means of improving a country’s overall health and minimizing morbidity and premature mortality from chronic lifestyle-related conditions with the least risk and cost.19-21 Even a modest reduction in cardiac risk factors, for example, could save approximately three times as many life-years as invasive interventions.22 Preserving and maximizing health in the most cost-effective, low-risk, and ethical manner warrant being universal health care priorities in the 21st century to stem the tide of chronic lifestyle-related conditions.
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
Table 1-2 Major Modifiable Risk Factors for Lifestyle-related Conditions
*An increased risk of all-cause cancer. Smoking is not only related to cancer of the nose, mouth, airways, and lungs; smoking increases the risk of all-cause cancer.
†Partially saturated, saturated, and trans fats are the most injurious to health.
‡Alcohol can be protective in moderate quantities, red wine in particular.
Modified from the Heart and Stroke Foundation of Canada, 2003; Bradberry JC: Peripheral arterial disease: pathophysiology, risk factors, and role of antithrombotic therapy, Journal of the American Pharmacy Association 44(2 Suppl 1):S37–S44, 2004; Charkoudian N, Joyner MJ: Physiologic considerations for exercise performance in women, Clinics in Chest Medicine 25:247–255, 2004.
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 lifestylerelated 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,
Extent to which the body is affected by lifestyle-related conditions
Fig. 1-1
Higher threshold for condition
Lower threshold for condition
Rate of progression of condition in a typical individual
01020304050
60 Age (years)
Rate of progression of condition in a healthy individual
Theoretical relationship between the threshold of lifestylerelated conditions and their rate of progression over the life cycle. (From Dean E, Lomi C, Bruno S, et al: Addressing the common pathway underlying hypertension and diabetes in people who are obese: the ultimate knowledge translation gap, International Journal of Hypertension [in press].)
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.
Evidence-Informed Practice
Addressing the Health Care Priorities of the Day
Physical therapists treat individuals with chronic lifestylerelated 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.
Our Village
Fundamental to the principle of evidence-informed practice is the fact that health care providers respond to epidemiological indicators and an understanding of the changing demographics and face of our “village.” Lifestyle-related conditions are the leading killers in our village. Men can expect to live 75 years; women, 82 years.52 Functional capacity, however, is estimated to decrease 10% per decade, and half of this decrement is due to sedentary living. Raising children to be healthy and physically active will promote a generation of healthy adults and will thereby delay their physical dependence by 10 to 20 years.
Health care workers with international health organizations are trained to manage the unique needs of their villages. This entails knowing the health priorities of the village and making decisions that positively affect the problems and reduce their impact on the community as a whole. In some parts of the world, a health care worker who focuses on malaria when intestinal parasites are the priority is a hindrance, rather than a help, to that village. Similarly, in our health care climate, physical therapists need to make it a priority to meet the leading needs of their “villages.” Smoking abstinence, good nutrition, weight control, exercise, and stress management are evidence-based noninvasive interventions consistent with the needs of contemporary physical therapy practice; the therapeutic potential and impact of those elements on the health of our village are enormous. For example, each kilogram of weight loss has a dose-dependent effect on health outcomes. Further, as little as 30 minutes of moderately intense activity on most days of the week offsets the deleterious effects of sedentary living.53 With the aging of the people of our village and the signs of lifestyle-related conditions now evident in children and young people, the burden of chronic conditions will be prolonged, particularly as individuals approach the end of life. It has been suggested that life expectancy will plateau or even decrease as a result.42
Indigenous peoples in North America and Australasia have unique health challenges and needs. They tend to be less well educated than the dominant culture, have fewer employment opportunities, experience more violent injuries and deaths, and have poorer health and shorter lives. They have significant health risks because of sociocultural factors and genetic predisposition, such as higher rates of IHD, stroke, type 2 diabetes mellitus, obesity, hypertension, tobacco use, and alcoholism. Large-scale intervention programs are needed for the Native American population based on studies of the health of its children.54 The past few generations have witnessed a shift from indigenous foods to refined grains and foods high in fat and sugar and from active to inactive lifestyles. These trends have exacted an enormous toll in terms of personal and social health indicators.
As individuals age in industrialized countries, their activity levels tend to decline. With relatively long life expectancy in these countries, sedentary lifestyles may prolong end-of-life morbidity. A study of individuals who adhered to exercise programs and those who did not revealed the importance of variables such as self-efficacy, perceived fitness, social support, and enjoyment.55 The results of this study have important implications for urban planning; they can inform the design of healthy communities, as well as individual activity and exercise programs.
A study of black Seventh-day Adventists has provided a unique opportunity to isolate the effects of lifestyle on African Americans. Seventh-day Adventists promote spiritual wellbeing and a healthy diet and lifestyle. As a result, the health of black Seventh-day Adventists is better and the incidence of chronic lifestyle-related conditions is lower than that of African Americans who are not Seventh-day Adventists.56 In addition, based on the results of a study of a large cohort, Mormons tend to be fitter and have fewer risk factors for IHD than do other Americans.57
The physical activity profiles of African American women have been compared with recommendations for moderate levels of activity.58 In this study, findings showed that few subjects met the recommended levels of daily physical activity. Exercise was performed on fewer than the recommended number of days per week and for less than the recommended 8 to 10 minutes per session. Attention to frequency and duration may be particularly important when counseling African American women about regular physical activity.
African American women have a higher risk for cardiovascular disease and stroke than do Caucasian American women.59 Based on a cross-sectional study of 399 urban African American women, correlates of physical activity within this cohort were identified. Programs to promote physical activity should address the safety of the physical environment and psychosocial factors. Inactive women with less than a high school education and those who perceive themselves to be in poor health should be considered special target groups.
Latina women have a higher risk for cardiovascular disease and stroke than do Caucasian American women; this has been attributed to the higher incidence of obesity and type 2 diabetes mellitus among Latinas.60 The facilitators and barriers to exercising in this cultural cohort have been examined in a cross-sectional study of 300 Latinas. Physical activity has been reported to be higher in younger women, in married women, and in women who had confidence that they could become more active, who saw people exercising in the neighborhood, and who attended religious services.60 The church was recommended as a suitable community setting for initiating programs that provide women with the knowledge, skills, and motivation to become more active and to transmit this information to others in the community through their families.
The impact of gender is being increasingly appreciated in terms of health affliction, access to health care, and physiological responses and psychological reactions to illness.61,62 In a Swedish cohort of older adult individuals, obesity-related health indicators and risk factors were reported to differ in men and women and also to differ on the basis of socioeconomic status.63 In response to cardiac rehabilitation, genderspecific effects on high-density lipoprotein cholesterol have been documented.64 Women demonstrate greater improvement in high-density lipoprotein than do men.
Urbanization, modernization, and immigration are affecting global health. Within industrialized countries, indigenous people are moving from rural to urban areas; this is occurring in the United States, Canada, Australia, New Zealand, and many African countries. Rather than seeing improvements in their health overall, relocated rural people are succumbing to lifestyle-related conditions. Middle-aged black men who move to urban areas from rural South Africa, for example, increase
their risk for IHD and stroke.65 One explanation for this observation is increased autonomic reactivity to the stress of relocation; however, other lifestyle factors may be implicated. These patterns have been reported for other groups as well; for example, Mexicans and Asians who move to affluent industrialized countries.66 The typical health advantage for people who move to the West from certain Asian countries, such as Japan, is lost with increasing numbers of years in the new culture.67
Principles of Evidence-Informed Practice
The efficacy of the quick fix (drugs and surgery) in the management of chronic conditions, particularly lifestyle-related conditions, is being seriously questioned. With respect to long-term outcomes, noninvasive interventions may often be more successful.68 Premature mortality can be significantly reduced with regular physical activity, optimal nutrition and weight control, and avoidance of smoking.69 Relative to invasive care, noninvasive interventions associated with physical therapy (health education and exercise) are low in cost; yet access to these noninvasive measures is commonly more limited than access to invasive care.
The Priorities of Our Village
Health risks and the causes of premature death today are largely related to lifestyle-related conditions, namely:
n Ischemic heart conditions
n Smoking-related conditions, including COPD
n Hypertension and stroke
n Type 2 diabetes mellitus, obesity and metabolic syndrome
n Cancers
These conditions are frequently either the primary or the secondary diagnoses of the patients treated by physical therapists. This positions physical therapists favorably to make direct assaults on the risk factors of lifestyle-related conditions, as well as on their manifestations in patients. Physical therapists have the advantage of prolonged patient contact during treatments compared with other health care providers, and such contact can be exploited in targeting teachable moments and health education opportunities.
Although most people are aware of the positive benefits of healthy choices, what is less apparent to them is that small changes in health behaviors can result in major effect sizes. These effect sizes most often surpass those of medications targeted at a single sign or symptom. In a study of over 23,000 people between 35 and 65 years old, for example, Ford and his colleagues70 showed that over an 8-year period, people who did not smoke, had a body mass index under 30, were physically active for at least 3.5 hours a week, and followed healthy nutritional principles had a 78% lower risk for developing a chronic lifestyle-related condition. Specifically, the risk for type 2 diabetes mellitus was reduced by 93%, myocardial infarction by 81%, stroke by 50%, and cancer by 36%. Even if not all four of these health factors were present, the risk for developing one or more chronic lifestyle-related conditions decreased commensurate with an increase in the number of positive lifestyle factors. Should a medication be found to have such potent benefits, it would be hailed as nothing short as miraculous.
The goal in health care is to exploit the benefits of lifestyle modification and supplement those benefits with medication only if necessary,71 rather than the other way around (supplementing medication with lifestyle modification). A healthy lifestyle is the treatment of choice for lifestyle-related conditions; it is also the primary intervention for their prevention.72 The translation of these research findings into health care practice is a priority.
Ischemic Heart Disease
The risk factors for IHD are well established.73 They contribute to atherosclerotic deposits not only throughout coronary vessels but throughout the systemic arterial vasculature.74 Nonmodifiable risk factors include age, sex, family history, and past history. Modifiable risk factors include increased cholesterol, increased homocysteine, smoking, inactivity, high blood pressure, diabetes, weight, and stress.75-77 Less commonly acknowledged risk factors include elevated C-reactive proteins (markers of inflammation37), sharing a lifestyle with someone who has IHD,78 and having overweight parents.79 Further, a shared lifestyle confers increased evidence of IHD in and health risk for children.80 Other emerging risk factors include passive smoking, level of education, depression, anger coupled with hostility, and social isolation.81,82
Based on epidemiological evidence, a 1% decrease in cholesterol reduces the risk for IHD by 3%, and a long-term reduction in diastolic blood pressure of 5 to 6 mm Hg reduces the risk by 20% to 25%.83 Thus even modest changes can have a sizable impact on health. Most risk factors are associated with behavior choices and can be substantially modified.84
Risk factors for IHD are prevalent in the general population. When a cross section of people in their later middle-age years was screened, atherosclerosis involving the femoral artery affected two-thirds of them.85 Further, a direct relationship existed between the degree of atherosclerosis and cardiovascular and general circulatory health. Individuals with peripheral artery disease have a several-fold increased risk for IHD; thus peripheral artery disease can be considered a marker of systemic atherosclerosis. It is estimated that optimal lifestyle could reduce cardiac events related to atherosclerosis by 70% to 80%. Regular walking has a significant effect on reducing the risk for IHD, as has vigorous activity.86 In men with left ventricular hypertrophy, moderate physical activity reduces the risk for stroke by 49% compared with sedentary men who do not have left ventricular hypertrophy.87 Type 2 diabetes mellitus has been reported to be a strong risk factor (and hypertension a less strong risk factor) for IHD in women when compared with men.88
Self-reported fitness has been reported to be independently related to fewer risk factors for IHD and angiographic evidence of IHD in women undergoing coronary angiography for suspected ischemia.89 Measures of obesity are not independently associated with these outcomes. Thus fitness appears to be more important than body weight for cardiovascular risk in women. Physical activity and fitness warrant detailed assessment. They should be an integral part of the cardiovascular risk-factor stratification, and interventions should aim at long-term increases in physical activity and fitness. Assessment of physical activity and exercise programs should be included in the management of all people, particularly in women and those at risk for IHD.
Nutrition is a well-established determinant of health and an independent risk factor for lifestyle-related conditions and other chronic conditions. The average North American diet, which tends to be monotonous and unbalanced, has been thought to be a primary contributor to the prevalence of lifestyle-related conditions. Despite its unhealthy characteristics, the North American diet is increasingly being emulated in other parts of the world.
Mediterranean-type diets have been increasingly shown to have multiple health benefits and are superior to the North American diet in terms of food diversity and healthfulness. These diets are high in fish, fresh fruit and vegetables, and multigrains. Mediterranean-type diets are also low in added sugar and salt, and they favor unsaturated vegetable oil over saturated animal fats. When diet-related studies are evaluated, people who consume fish twice a week have a 47% reduced risk for cardiac mortality compared with those who eat fish less than once a month.90 Cereal fiber (two whole-grain slices of bread daily) is associated with a 14% reduced risk for myocardial infarction or stroke. Cereal fiber consumption even later in life is associated with a reduced incidence of cardiovascular disease.91 One alcoholic drink a day is associated with the least number of cerebrovascular abnormalities. Moderately and highly physically intense leisure-time activities predict 28% and 44% lower mortality rates, respectively, compared with little activity. Low, moderate, and high levels of exercise are associated with 30%, 37%, and 53% more years of healthy life, respectively. Aerobic training can reduce serum lipids even in older individuals; high-density lipoproteins increase and low-density lipoproteins decrease.92 With lifestyle change, atherosclerosis can regress and associated cardiac events can be minimized.93-96
Psychosocial factors have been identified as risk factors for IHD. Difficulty in managing anger and hostility is one such risk factor, regardless of whether a person has a type A or a type B personality.97 Stress is a risk factor that can be classified as minor daily hassles or as major negative events. Lipoprotein levels increase with both levels; however, coping style and subjective appraisal of stressors are powerful mitigating factors.98 Cumulative daily hassles may be underestimated in terms of their impact on health compared with major life stressors. After an individual’s first coronary event, avoidance strategies are inversely associated with healthy lifestyles, whereas positive reappraisal and problem solving are directly associated.99 Positive reappraisal and problem solving, program participation, rather than adopting distancing and escape strategies predict a person’s capacity to change lifestyle after a coronary episode. Stress management should consider the type of stressor and help to modify the individual’s coping strategies and interpretation of stressors.
The risk for a cardiac event after the first one is high.100,101 Thus there is a high prevalence of repeated revascularization procedures and the prescription of more drugs with increased potency to help offset worsening pathophysiological changes. Ornish102 reported that 194 individuals with previous revascularization procedures avoided repeat procedures for at least 3 years (the duration of follow-up in the study) when they participated in a comprehensive lifestyle-change program. Compared with individuals who also had had a previous revascularization procedure but did not participate in the lifestyle-change program, those who did participate reported a level of angina comparable to that experienced with
revascularization. The effects of noninvasive intervention can be considered long term, given their multisystem benefits. Revascularization focuses on the repair of an impairment and does not provide the additional multisystem benefits of the lifestyle-change program.
To date, efforts to champion aggressive modification of risk factors have been modestly successful. Optimal control of modifiable risk factors for coronary atherosclerosis, including cigarette smoking, dyslipidemia, hypertension, and sedentary lifestyle are well known to reduce the incidence of IHD and, in turn, revascularization procedures and health care utilization.103 Our major health crisis can be addressed only by means of a system of care committed to health, wellness, aggressive risk-factor prevention, and lifestyle modification.
Smoking-Related Conditions
Smoking is the leading cause of preventable death in the United States, as well as the rest of the world.51 Despite the well-documented health hazards, smoking remains prevalent in industrialized and nonindustrialized countries and is estimated to shorten life by 11 minutes for each cigarette smoked.104 Thus smoking cessation is a primary health care goal, as well as a professional goal. (In 1996, the APTA adopted guidelines from the Agency for Health Care Policy and Research [AHCPR], which have subsequently been revised.105) The danger of smoking extends beyond COPD and cancer. Overall morbidity and all-cause mortality, including cancer of organs other than the respiratory tract, are higher in smokers. Of the leading causes of mortality worldwide, COPD is typically among the top killers and is associated with the loss of a million years of life each year.106 In the United States, COPD ranks fourth behind IHD, cancer, and stroke. Longterm smokers have higher incidences of all-cause morbidity and mortality ( Table 1-3); thus smoking leads to lifethreatening conditions that are systemic and are related not just to the respiratory tract.90 Former and current smokers have 25% and 44% fewer healthy years of life, respectively, compared with lifelong nonsmokers. Smoking cessation is a priority for all individuals, not only those with lung disease, regardless of disease severity.107 Smoking by children is highly associated with parental smoking; thus smoking by adults with young families has become a primary focus of public health initiatives.79 Smoking is the single most important preventable cause of illness and death.
Pulmonary rehabilitation has demonstrated sustainability of smoking cessation and other health benefits in individuals with COPD;108 thus its use is warranted as a preventive measure, as well as for the remediation and management of disease.109 Rehabilitation programs have proven efficacy, independent of pharmacotherapy, so they should be considered primary interventions rather than priorities after conventional expensive medical care has failed.110 Only with health coaching and follow-up can these individuals effect lifelong health behavior change to minimize exacerbations, reduce doctor and hospital visits, continue working, and reduce overall morbidity. Innovative smoking cessation programs warrant development so that they have maximal impact in the most significant window of opportunity and stage of readiness of a smoker to quit. One such program consisted of 5 weeks of counseling.111 The mean time to deliver the intervention was 44 minutes. At 1 month, 70% of participants had
Table 1-3 Tobacco Facts and Multisystem Consequences of Smoking
Type/Area of Effects
Effects and Conditions That Are More Common in Smokers
Mortality from smoking Tobacco causes 30% of all deaths of people between 35 and 69 years of age
Tobacco reduces a person’s life as follows:
Ages 35 to 59 years: Those killed by tobacco lose about 27 years of life
Ages 60 to 69 years: Those killed by tobacco lose about 16 years of life
Brain Stroke
Mouth Lip and oral cancers
Pharynx and larynx
ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage,112 as well as for IHD. The risk is directly proportional to the amount smoked. Risk factor detection and management are the cornerstones of high-impact and high-quality care of cardiovascular disease.
Hypertension and Stroke
Cancers of the pharynx and larynx
Esophagus Cancer of the esophagus
Lungs Cancer of the lungs
Heart Ischemic heart disease, hypertension, and circulatory diseases
Chronic lung disease
Gastric and duodenal ulcers
Bladder and kidney cancers
Bone
Bronchitis and emphysema; 90% of deaths from chronic lung disease attributable to smoking
Upper respiratory tract infections and increased days of absenteeism
Higher risk in smokers
Higher risk in smokers
Postmenopausal women who smoke have reduced bone density compared with nonsmokers
Increased risk of bone fractures and delayed healing
Fertility and Pregnancy Infertility
Increased risk for spontaneous abortions, still births, pre-term deliveries, low-birth-weight babies, and sudden infant death syndrome
Potential developmental and learning delays in children
Data from National Cancer Institute: Cancer Facts, 2010; U.S. Department of Health and Human Services: The health consequences of smoking: a report of the Surgeon General, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004; Peto R, Lopez AD, Boreham J, et al: Mortality from tobacco in developed countries: indirect estimation based on national vital statistics, Lancet 339:1268–1278, 1992; Twardella D, Kupper-Nybelen J, Rothenbacher D, et al: Short-term benefit of smoking cessation in patients with coronary artery disease: estimates based on self-reported smoking data and serum cotinine measurements, European Heart Journal 25:2101–2108, 2004.
continued to abstain. The mean cost of the intervention was approximately $50 for each person.
Smoking cessation is the most cost-effective intervention for smokers with heart disease in terms of health protection and risk reduction. Further, treatment of hyperlipidemia and referral to cardiac rehabilitation are highly cost-effective per quality-adjusted life-year and are relatively cost-effective per year of life saved. Smoking is an established risk factor for
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-tobrachial 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 endotheliumdependent 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 endotheliumdependent 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 lowglycemic 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 lowglycemic 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 lipidlowering 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 Exercise in the Context of Population Health
The physical activity and exercise pyramid is illustrated in Figure 1-2, B. This pyramid shows a physically active lifestyle at the base, followed by aerobic exercise three to five times a week, followed by strengthening exercise and flexibility, with rest and inactivity at the top.
Sedentary behavior has been a recent focus of study with the recognition that reducing sedentary behavior is not necessarily synonymous with increasing physical activity. The literature supports that prolonged periods of being sedentary are associated with greater health risk than multiple short periods of sedentary behavior (i.e., breaks in sedentary time).199,200 Sedentary activity is common today; people often sit for long periods in front of a television or computer, and children and adolescents are increasingly consumed with screen-based activities. Recommendations for breaks in sedentary behavior are complementary to those for increasing physical activity. Sedentary behavior in early childhood is associated with such behavior in adolescence and adulthood.201 Encouraging physical activity in adults and children regularly throughout the day requires not only individualized education about exercise, but structuring neighborhoods, transportation systems, recreational facilities, homes, and workplaces that are health promoting.
The physical activity pyramid, like the food pyramid, is a reminder of the importance of lifestyle choices for optimal health.202 Generally, walking 10,000 steps a day is consistent with an active lifestyle and good health in an adult,203 whereas fewer than 5000 steps a day would be considered a sedentary lifestyle. Walking 7500 to 9999 steps a day is consistent with a somewhat active lifestyle, and more than 12,500 steps a day would be consistent with a highly active lifestyle.
With increased physical activity, the risks for IHD, stroke, and colon cancer are reduced. The precise dosage-response relationships between physical activity and health and between physical fitness and health have yet to be clarified and may differ among people.204 Moderate physical activity, which does not have to be strenuous or prolonged, includes leisure activities such as walking and gardening and is associated with marked health benefits.145 Even light to moderate physical activity in middle and old age confers marked benefit to cardiovascular health and is protective against all-cause mortality.205 The U.S. Surgeon General recommends 30 minutes of moderately intense exercise on most days, with an accumulated duration of 180 minutes a week.206
Exercise has a profound effect on the endothelial function of blood, which has been implicated in atherosclerosis, IHD, cerebrovascular disease, and gastrointestinal conditions, and could explain exercise’s multisystem benefits. Moderate levels of physical activity reduce the risk for stroke, independent of other factors.207 In addition to dietary habits, reduced physical activity has been implicated in most lifestyle-related conditions including osteoporosis, and exercise is recognized as an essential component in the primary prevention of these conditions. Even mild physical activity has an important role in the primary prevention of type 2 diabetes mellitus through its
Red meat, butter
White rice, white bread, white pasta, potatoes, soda, and sweets
Use sparingly
Dairy or calcium supplement, 1-2 times/day
Fig. 1-2 Nutrition and activity pyramid guides. A, An alternative Food Guide Pyramid based on the latest research on optimal nutrition. B, The Activity Pyramid. (A from Clayton BD: Basic Pharmacology for Nurses, ed 15, St Louis, 2010, Mosby. B from Park Nicollet Health Source Institute for Research and Education, Minneapolis, Minn.)
Fish, poultry, eggs, 0-2 times/day
Multiple vitamins for most
Alcohol in moderation (if appropriate)
Nuts, legumes, 1-3 times/day
Vegetables (in abundance)
Fruits, 2-3 times/day
Whole grain foods (at most meals)
Plant oils (olive, canola, soy, corn, sunflower, peanut, and other vegetable oils)
Daily exercise and weight control
direct effect on increased tissue sensitivity to insulin.208 Nonpharmacological interventions for preventing and managing hypertension have been strongly advocated to maximize their therapeutic benefit and minimize the risks associated with medications.209 Furthermore, in older people, regular physical activity has an important role in preventing chronic conditions and prolonged end-of-life suffering.210
Why Physical Therapists Should Promote Smoking Cessation
Smoking is the leading cause of premature death. It results in premature death and higher rates of all-cause death.50 Although Caucasian Americans have a higher rate of smoking than do African Americans, African Americans and women who smoke have respiratory problems at a younger age, despite having started smoking later and having a lower overall packyear smoking history.211 Men with a strong intention to quit have been reported to have a more favorable attitude toward quitting and a stronger sense of perceived control than those with a less strong intention to quit. In addition, men who have a strong intention to quit smoking have greater success.212 With a view to promoting lifelong health, advocating smoking reduction and cessation is an important responsibility of the physical therapist regardless of the patient’s problems. Over time, smoking cessation can reverse many of the lethal effects of smoking ( Table 1-4; also see Table 1-3). For smokers unable to quit, advocating “competing” health strategies has been proposed.213 Improved diets and increased physical activity and exercise, however, do not counter the negative effects of smoking.134
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
Table 1-4 Health Benefits of Quitting Smoking
Benefits
Immediate Benefits Family: Quitting smoking removes harmful environmental tobacco smoke that pollutes nonsmokers’ breathing space
Individual: Your body starts to heal itself; the levels of carbon monoxide and nicotine in your system decline rapidly; heart rate and blood pressure drop quickly; peripheral circulation improves
Benefits after 1 Year Increased risk for ischemic heart disease decreases 50%
Benefits after 3 Years Risk for heart disease declines to levels similar to those of lifelong nonsmokers
Benefits after 5 Years
Risk for cancers of the oral cavity and esophagus reduced by 50%
Risk for bladder cancer reduced by about 50%
Risk for stroke can return to levels similar to those of nonsmokers
Risk for cervical cancer is significantly reduced
Benefits after 10 Years
Benefits after 15 Years
Risk for lung cancer decreases 50% to 70%
Risk for ischemic heart disease is similar to that of lifelong nonsmokers
Risk for death is similar to that of lifelong nonsmokers
Data from the American Cancer Society, 2004; U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004; American Lung Association. www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b= 22938; Manson JE, Tosteson H, Ridker PM, et al: The primary prevention of myocardial infarction, New England Journal of Medicine 326:1406–1416, 1992.
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 education226-232 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
Box 1-1 Prochaska’s Stages of Readiness to Change*
Precontemplation
n Not currently engaged in the target behavior
n Not seriously thinking of change in the next 6 months
n Unaware of the need to change or denies the need to change Contemplation
n Not currently engaged in the behavior
n Seriously considering making a change within the next 6 months
n Acknowledges that the behavior is unhealthy
n Seeks out information regarding the pros and cons of changing
Preparation
n Planning to change within the next 30 days
n Has attempted to change in the previous year
n On the verge of taking action to change behavior
n Begins to reevaluate self in light of the new behavior Action
n Engaged in the desired behavior
n Has implemented the change only in the past 6 months
n Tries the behavior but is at high risk for relapse
Maintenance
n Has maintained the behavior for 6 months
*An individual can be at different stages for different health behaviors. From Prochaska JJ, Spring B, Nigg CR: Multiple health behavior change research: an introduction and an overview, Preventive Medicine 46:181–188, 2008.
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 behaviormodification 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
Box 1-2 Assessing Readiness to Change by Using a Quiz
The Stages of Readiness to Change model is designed to help people adopt new health behaviors. Knowing where you are in the stages of readiness to change helps you to understand the steps you should take to move to subsequent stages to achieve lifelong sustainable health behaviors.
Circle a response to each question using the “Y” or the “N.”
Y = Yes, I meet my health objective on this question.
N = For each “N” you circle, circle the readiness-to-change number that applies:
1 = Not thinking about change at this time (precontemplative)
2 = Thinking about change (contemplative)
3 = Preparing to change (preparation)
Readiness to Change Checklist Response
Do you exercise moderately intensely at least 3 times a week for 20 to 40 minutes?
Are you physically active during your average day (walk, walk briskly, take stairs)?
Is your weight within normal range?
Do you eat at least 5 servings of fruit and vegetables daily?
Do you minimize the trans and saturated fats in your diet?
Do you minimize highly refined carbohydrates in your diet (sugar and white flour)?
Do you drink alcohol less often than 5 times a week?
Are you generally relaxed during your day and do you feel in control?
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
Modified from Rollnick S, Mason P, Butler C: Health behavior change: a guide for practitioners, Philadelphia, 2002, Churchill Livingstone.
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.
Knowledge into Action
With the advent of Sackett’s rules of evidence259 and schemes for grading the quality of scientific studies and criticalappraisal topics,260 physical therapists have had to learn to be discriminating consumers of research. In addition, systematic reviews and metaanalyses have emerged to examine areas of practice where there are discrepancies in the literature regarding a treatment’s effect and to answer specific clinical questions. The levels of evidence and the grading recommendations for the quality of studies are shown in Table 1-6.
In becoming an evidence-based practitioner, the physical therapist needs to know what is not known in the field, as well as what is known. The therapist should distinguish this knowledge from what is known inconclusively and from areas in which no studies have been done. The physical therapist needs to be comfortable with uncertainty when applying interventions and receptive to integrating new information as it emerges.
