1. Health Promotion for
Physical Therapists:
Concepts and Practical
Applications
Julie Gahimer PT, HSD
Associate Professor
Krannert School of Physical Therapy
University of Indianapolis
November 8, 2010

2. ObjectivesObjectives
 6 Dimensions of Health
 Blue Zones- Dan Buettner
 Health Issues in America
 Obesity and overweight, smoking, diabetes
 How Healthy Is Indiana?
 Health Risk Appraisals
 Human Kinetics Senior Fitness Test
 Real Age
 Healthy People 2010/2020
 Role of the APTA
 Role of the Physical Therapist
 Fitness Following Disability

3. 6 Dimensions of Wellness

4. The Six Dimensions of Health

5. My Six Dimensions of Health

6. My Six Dimensions of Health
1. Physical
2. Emotional
3. Spiritual
4. Intellectual
5. Psychological
6. Social

8. Physical
Exercise/fitness
Weight/body fat
Diet
Cardiovascular/strength training
Disease prevention
Lifestyle: active vs sedentary
Prevention and safety: helmets,
seatbelts, smoking, safe sex, drugs,
alcohol

10. Emotional
Stress management
Depression
Relaxation time
Outlets
Self-esteem
Support of loved ones
Worrying about things you cannot control
Learn from mistakes, not dwelling on them
Control of anxiety

12. Spiritual
Faith
Values
Morals
Beliefs

14. Intellectual
Job/school fulfillment or success
Stress
Relationships with co-workers, clients,
employer
Job safety
Good attitude
Motivation
Financial security

16. Psychological
Stress management
Self esteem
Social interaction
Attitude
Organization
Environment

18. Social
Interaction and relationships with
friends, family, significant others
Communication- both verbal and
non-verbal
Extracurricular activities
Activities and events

21. Why Is Health Promotion SoWhy Is Health Promotion So
Important in Our Nation Today?Important in Our Nation Today?
 Historical Movement from
Infectious Disease to
Chronic Diseases
 30 year increase life
expectancy since 1900’s
 Diseases of longevity,
lifestyle, & health
behaviors
 More people living longer
with chronic disease
associated pain &
disability

23. 10 Leading Causes of Death
(increased longevity & lifestyle)
 Heart disease (decreased)
 Malignant neoplasms
 Cerebrovascular disease
 COPD
 Accidents (including
MVA)
 Pneumonia & Influenza
 Diabetes
 Suicide
 Nephritis/Nephrosis
 Chronic Liver & Cirrhosis
Shift from
curative measures
to preventative measures
Increased emphasis on personal
responsibility for health

24. Obesity and OverweightObesity and Overweight
61% adults in
U.S. are
overweight or
obese (BMI>25)
13% children
aged 6-11 years
14% adolescents
aged 12-19 years
National Health Interview Survey, National Center for
Health Statistics, Health U.S. 2006

25. Obesity and Overweight
 Increase the risk of
morbidity from:
 Hypertension
 Dyslipidemia
 Type 2 diabetes
 Coronary heart
disease
 Stroke
 Gallbladder disease
 Osteoarthritis
 Sleep apnea and
respiratory problems
 Endometrial, breast,
prostate, and colon
cancers.
National Heart, Blood, & Lung Institute, Clinical Guidelines: Obesity
An estimated total cost of obesity in U.S. in 2000 was about $117 billion.

26. Obesity Trends* Among U.S. Adults
BRFSS, 1990
No Data <10% 10%–14%
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
Source: Behavioral Risk Factor Surveillance System, CDC

27. Obesity Trends* Among U.S. Adults
BRFSS, 1995
No Data <10% 10%–14% 15%–19%
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
Source: Behavioral Risk Factor Surveillance System, CDC

28. Obesity Trends* Among U.S. Adults
BRFSS, 2000
No Data <10% 10%–14% 15%–19% ≥20
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
Source: Behavioral Risk Factor Surveillance System, CDC

29. Obesity Trends* Among U.S. Adults
BRFSS, 2001
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
Source: Behavioral Risk Factor Surveillance System, CDC

30. Obesity* Trends Among U.S. Adults
BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Source: Behavioral Risk Factor Surveillance System, CDC

32. Source: Behavioral Risk Factor Surveillance System, CDC

33. Childhood Overweight/ObesityChildhood Overweight/Obesity
 In the U.S., the prevalence of childhoodIn the U.S., the prevalence of childhood
overweight tripled between 1980 & 2000.overweight tripled between 1980 & 2000.
Circulation: Journal of the AHA downloaded 7/15/07

34. The State of Our Nation:The State of Our Nation:
Trends in Health StatusTrends in Health Status
 Nearly 30% of adultsNearly 30% of adults
18-75 years old are18-75 years old are
classified asclassified as
“inactive”“inactive”
 Report no leisure-Report no leisure-
time physicaltime physical
activity (vigorous oractivity (vigorous or
light/moderate) of atlight/moderate) of at
least 10 minutesleast 10 minutes
durationduration
National Health Interview Survey, National Center for
Health Statistics, Health U.S. 2006
 Nearly 50%Nearly 50%
American adults doAmerican adults do
not get enoughnot get enough
physical activity tophysical activity to
provide healthprovide health
benefitsbenefits

35. Most Recent CDC-ACSM Guidelines
 All adults perform 30 or more minutes ofAll adults perform 30 or more minutes of
moderate-intensity physical activity on most,moderate-intensity physical activity on most,
and preferably all, days---and preferably all, days---eithereither in a singlein a single
session orsession or “accumulated” in multiple bouts“accumulated” in multiple bouts,,
each lasting at least 8-10 minutes.each lasting at least 8-10 minutes.
 Or at least 3 days a week for 20 minutes a dayOr at least 3 days a week for 20 minutes a day
of vigorous intensity activityof vigorous intensity activity
 All adults perform 30 or more minutes ofAll adults perform 30 or more minutes of
moderate-intensity physical activity on most,moderate-intensity physical activity on most,
and preferably all, days---and preferably all, days---eithereither in a singlein a single
session orsession or “accumulated” in multiple bouts“accumulated” in multiple bouts,,
each lasting at least 8-10 minutes.each lasting at least 8-10 minutes.
 Or at least 3 days a week for 20 minutes a dayOr at least 3 days a week for 20 minutes a day
of vigorous intensity activityof vigorous intensity activity

38. National Center Health Statistics. Health, 2004
The State of Our Nation:
Trends in Health Status
 19% adult women
and 23% men current
smokers in 2004,
strongly associated
with educational
level
 22% high school
students reported
smoking, slight
decline in upward
trend began in 1990’s

40. Source: Behavioral Risk Factor Surveillance System,CDC
2006 Nationwide Data shows Tobacco Use: 20% yes; 80% no

41. The State of Our Nation:The State of Our Nation:
Trends in Health StatusTrends in Health Status
 Adults aged 65 to 74 years
(2001-2004):
17% elevated cholesterol
30% hypertension
 Diagnosed or undiagnosed
Diabetes (FBG of 126 mg/dl
or over)
 10% persons 20 yrs of age
and older
 20% of the U.S. Population,
aged 60 years and older
National Center Health Statistics. Health, 2006

42. Native
Hawaiian/
Pacific Islander
Am. Indian/
Alaska Native
I = 95% confidence interval. *Data are statistically unreliable and are suppressed. NOTE: Data are for adults aged 18-84 years and
are age-adjusted to the 2000 standard population. The black and white categories exclude persons of Hispanic origin. Persons of
Hispanic origin may be any race. For data prior to 1999, respondents reported one or more races and identified one race as best
representing their race. For 1999 and later years, respondents were asked to select one or more races. Data for the single race
categories shown are for persons who reported only one racial group. SOURCE: National Health Interview Survey (NHIS), NCHS,
White BlackAsian Hispanic
*
Total
Age-adjusted rate
per 1,000 population 1997-99 2000-02 2003-05
2010 Target: 3.8
*
Decrease
desired
5
10
15
0
20
Total White Hispanic Black
Female 7.4 (0.4) 6.3 (0.5) 12.1 (1.1) 10.8 (1.3)
Male 7.5 (0.5) 7.0 (0.5) 7.4 (1.1) 9.7 (1.7)
Obj. 5-2
New Cases of Diabetes, Among Adults

43. Percentage of Adults Who Reported
Eating fewer Than Five Servings of
Fruits and Vegetables a Day,
by Sex, 2002
The State of Our Nation: TrendsThe State of Our Nation: Trends
in Health Behaviorsin Health Behaviors
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Men
Women
Total
0%
Dietary Factors Associated
4 of the 10 leading causes
of death:
- CHD
- Cancer
- Stroke
- DM II
Source: CDC, At A Glance: Phys. Activity & Good Nutrition

44. Why Is Health Promotion SoWhy Is Health Promotion So
Important in Our Nation Today?Important in Our Nation Today?
 95% of the US95% of the US
healthcare economyhealthcare economy
is allocated to directis allocated to direct
medical caremedical care
 Only 5% is allocatedOnly 5% is allocated
to healthto health
improvementimprovement

45. National Goals &National Goals &
Objectives for HealthObjectives for Health
 Healthy People
followed by National
Goals and Objectives
 Healthy People 2000
Nation’s health
agenda
 Healthy People 2010
http://healthypeople.gov

46. Healthy People
2000, 2010  A comprehensive setA comprehensive set
ofof national healthnational health
objectivesobjectives for thefor the
decadedecade
 Developed by aDeveloped by a
collaborative processcollaborative process
 Designed toDesigned to measuremeasure
progressprogress over timeover time
 AA public healthpublic health
documentdocument that is partthat is part
strategic plan, partstrategic plan, part
textbook on publictextbook on public
health prioritieshealth priorities

47. Healthy People 2010Healthy People 2010
Coordinated ByCoordinated By
 The Office ofThe Office of
DiseaseDisease
Prevention andPrevention and
Health PromotionHealth Promotion
 U.S. DepartmentU.S. Department
of Health andof Health and
Human ServicesHuman Services
(USDHHS)(USDHHS)

48. Healthy People 2010Healthy People 2010
 Two overarchingTwo overarching
goalsgoals
 28 focus areas28 focus areas
 467 specific467 specific
objectivesobjectives
 10 Leading Health10 Leading Health
IndicatorsIndicators

49. Two Overarching Goals:Two Overarching Goals:
Increase qualityIncrease quality
and years ofand years of
healthy lifehealthy life
Eliminate healthEliminate health
disparitiesdisparities

50. Healthy People 2010
28 Focus Areas
(14 apply directly to PT)
 Access to Quality
Health Services
 Arthritis, Osteoporosis,
and Chronic Back
Conditions
 Cancer
 Chronic Kidney Disease
 Diabetes
 Disability and
Secondary Conditions
 Heart Disease and
Stroke
 HIV
 Maternal, Infant, and
Child Health
 Nutrition and
Overweight
 Occupational Safety
and Health
 Physical Activity and
Fitness
 Respiratory Diseases
 Tobacco Use

51. Healthy People 2010Healthy People 2010
10 Leading Health Indicators10 Leading Health Indicators
 Physical ActivityPhysical Activity
 Overweight andOverweight and
ObesityObesity
Tobacco Use
Substance Abuse
Responsible Sexual
Behavior
Mental Health
Injury and
Violence
Environmental
Quality
Immunization
Access to Health
Care

53. How Healthy is Indiana?
Indiana Healthy Weight
INShape Indiana
Fit City

59. Health Risk Appraisals (HRA’s)

60. Senior Fitness Test
Roberta E Rickli, C Jessie Jones

62. The Role of the Physical TherapistThe Role of the Physical Therapist
 Vision 2020: By 2020, physical therapy will be
provided by physical therapists who are doctors
of physical therapy, recognized by consumers
and other health care professionals as the
practitioners of choice to whom consumers
have direct access for the diagnosis of,
interventions for, and prevention of
impairments, functional limitations, and
disabilities related to movement, function, and
health.
HOD 06-00-24-35 (Program 01)
 Vision 2020: By 2020, physical therapy will be
provided by physical therapists who are doctors
of physical therapy, recognized by consumers
and other health care professionals as the
practitioners of choice to whom consumers
have direct access for the diagnosis of,
interventions for, and prevention of
impairments, functional limitations, and
disabilities related to movement, function, and
health.
HOD 06-00-24-35 (Program 01)
11/06

63. Roles of a Physical Therapist
Pathologies
Movement Science
Training Principles
Diverse Populations
Psychosocial Responses
Screening

64. Roles of a Physical Therapist
National goals include PT
Inherent credibility
Viewed as advocates, problem-solvers
Access to patient/client populations
Access to facilities and resources
Access to the public

65. American Physical Therapy
Association

66. APTA Vision 2020 Statement
By 2020, physical therapy will be provided by
physical therapists who are doctors of
physical therapy, recognized by consumers
and other health care professionals as the
practitioners of choice to whom consumers
have direct access for the diagnosis of,
interventions for, and prevention of
impairments, functional limitations, and
disabilities related to movement, function,
and health.

68. APTA Video Podcasts on
Health Promotion

71. Center for Disease Control

72. Screening Activities
Physiological parameters
Scoliosis
Posture
CVD, PVD
Pulmonary function
Sports health
Occupational health
Functional performance

74. Health Promotion Practice
Greater participation in community
health activities
Public Health projects
Health Fairs
Prevention education programs
Consultants for community agencies,
schools, businesses, health clubs etc.
Professional conferences- community
health projects

75. Health Promotion Practice
Integration of health promotion and
preventive health services within
traditional practice
Screening
Referral
Collaboration
Client education

76. Health Promotion Practice
Linking with fitness centers, YMCA’s,
YWCA’s, health clubs
PT practices located in these settings
Consultation with fitness personnel to
facilitate client recovery and
rehabilitation
Prevention education programs

77. Health Promotion Practice
Transition or Chronic Care Programs
Service to clients no longer in PT
Well-suited for clients with chronic illness
or extended recovery
Slows development of disorders, prevents
functional losses
Group, individualized programs

78. Health Promotion Practice
PT Private Practice
Combination PT and Health Promotion
PT- Medical Model
HP- Client-centered care
 Multidisciplinary Wellness centers

79. Health Promotion Practice
Health Promotion and wellness
programming- Seniors:
Long-term care
Assisted living community
Senior housing communities
Community groups
In homes

80. Health Promotion Practice
Other Health Promotion Niches:
Kids
School
Home
Women’s Health
Business Health
Worksite Wellness
Sports Health
Multidisciplinary wellness

81. APTA Position Statement on Health
Promotion and Wellness
By PTs and PTAs
The APTA recognizes that physical
therapists are uniquely qualifieduniquely qualified toto assume
leadershipleadership positions in efforts to preventprevent
injury and disabilityinjury and disability,, and fully supports the
positive rolespositive roles that physical therapists and
physical therapist assistants play in the
promotion of healthy lifestyles, wellnesspromotion of healthy lifestyles, wellness
and injury preventionand injury prevention..
HOD 06-93-25-50
Efforts coordinated through APTA Department of Practice,
Ken Harwood, PT, PhD, Director

82. HOD 06-04-09-09
Priority Goals of the APTAPriority Goals of the APTA
Goal 1:Goal 1: PhysicalPhysical
therapists aretherapists are
universallyuniversally
recognized andrecognized and
promoted as thepromoted as the
practitioners ofpractitioners of
choicechoice for personsfor persons
with conditions thatwith conditions that
affect movement,affect movement,
function,function, healthhealth, and
wellnesswellness.

83. Priority Goals of the APTAPriority Goals of the APTA
 Goal II:Goal II: PhysicalPhysical
therapists are universallytherapists are universally
recognized and promotedrecognized and promoted
as providers ofas providers of fitnessfitness,,
health promotionhealth promotion,,
wellnesswellness, and, and riskrisk
reductionreduction programs toprograms to
enhance quality of life forenhance quality of life for
persons across the life-persons across the life-
span.span.
11/06HOD 06-04-09-09

84. APTA Normative Model/Guide toAPTA Normative Model/Guide to
Physical Therapist Practice/Physical Therapist Practice/
CAPTE RequirementsCAPTE Requirements
Physical therapists involved in prevention,
promoting health, wellness, fitness &health, wellness, fitness &
screening activitiesscreening activities
Help patients/clients:
Achieve & restore optimal function
Minimize impairments, functional limitations,
disabilities
 Maintain healthMaintain health (prevent further deterioration or
future illness)
Create appropriate environmental adaptationsenvironmental adaptations
to optimize independent function

85. The Big Picture
Adapted from Health Promotion and Wellness: Expanding YourAdapted from Health Promotion and Wellness: Expanding Your
Practice ParadigmPractice Paradigm
American Physical Therapy Association (APTA)American Physical Therapy Association (APTA)
Bezner, Black, IngmanBezner, Black, Ingman
Pre-pathogenic PeriodPre-pathogenic Period Period of PathogenesisPeriod of Pathogenesis
Primary PreventionPrimary Prevention SecondarySecondary
PreventionPrevention
HealthHealth
PromotionPromotion
HealthHealth
ProtectionProtection
PreventativePreventative
HealthHealth
ServicesServices
TertiaryTertiary
PreventionPrevention
Early dxEarly dx
& prompt& prompt
treatmenttreatment
Prior toPrior to
symptomssymptoms
DisabilityDisability
LimitationLimitation
RehabilitationRehabilitation

86. Health Promotion Natural Extension
of PT’s Role Primary Care Practitioner
Examination
Evaluation
Diagnosis
Prognosis
(Including Plan
Of Care)
Intervention
Outcomes
Examples: Booth at Walmart; Lifelong PT, Annual ExamsExamples: Booth at Walmart; Lifelong PT, Annual Exams

87. Screening
Medical
Disease Lifestyle
Behaviors
(HRA)
Refer or Treat

88. Physical Activity and Health: A Report of the
Surgeon General, 1996
Commissioned by Secretary of HealthCommissioned by Secretary of Health
and Human Services in 1994and Human Services in 1994
Landmark review of the research onLandmark review of the research on
physical activity and healthphysical activity and health
Joint Venture of Agencies:Joint Venture of Agencies:
CDC lead federal agencyCDC lead federal agency
President’s Council on Physical FitnessPresident’s Council on Physical Fitness
and Sports (PCPFS)and Sports (PCPFS)

89. Most Recent CDC-ACSM GuidelinesMost Recent CDC-ACSM GuidelinesMost Recent CDC-ACSM GuidelinesMost Recent CDC-ACSM Guidelines
 All adults perform 30 or more minutes ofAll adults perform 30 or more minutes of
moderate-intensity physical activity on most,moderate-intensity physical activity on most,
and preferably all, days---either in a singleand preferably all, days---either in a single
session or “accumulated” in multiple bouts,session or “accumulated” in multiple bouts,
each lasting at least 8-10 minutes.each lasting at least 8-10 minutes.
 Or at least 3 days a week for 20 minutes a dayOr at least 3 days a week for 20 minutes a day
of vigorous intensity activityof vigorous intensity activity

90. An estimated 54 million persons
in the United States, or nearly
20% of the population currently
live with disabilities
(McNeil 1997)

91. Interaction of Concepts
International Classification of
Function (ICF, 2001)
Health ConditionHealth Condition
((disorder/diseasedisorder/disease))
EnvironmentalEnvironmental
FactorsFactors
PersonalPersonal
FactorsFactors
BodyBody
function&structurefunction&structure
(Impairment(Impairment))
ActivitiesActivities
(Limitation)(Limitation)
ParticipationParticipation
(Restriction)(Restriction)

92. Traditional Health Promotion
 “not to take care
of the sick and
disabled, but
rather to
prevent disease
and disability in
the healthy”

93. Purpose of Health Promotion
Programs for the Disabled
 Reduction of secondary
conditions (obesity,
hypertension, pressure sores)
 Maintain functional
independence
 Provide opportunity for
leisure and enjoyment
 Enhance quality of life by
reducing environmental
barriers to good health

94. Rimmer,
1999

95. NCPAD
NCPAD established in 1999 through a
grant through the CDC and Prevention’s
Disability and Health Branch
Established to synthesize and
disseminate research and
programmatic information on physical
activity and disability
Provides a model that attempts to
bridge the gap between rehabilitation
and community based health
promotion

96. NCPAD
Comprehensive source for information
related to physical activity and disability
Website contains: searchable databases
containing articles, citations, programs
and facilities and equipment vendors.
Website contains: fact sheets,
monographs, bibliographies

97. ACSM Guide to Exercise Testing Durstine
and Moore 2009
Methods Measures
Aerobic-
Cycle and wheelchair ergometer,
traditional or wheelchair treadmill,
combo arm and leg ergometer,
seated stepper, arm ergometer
BP, HR, RPE
Endurance
6 or12 min walk, arm/leg ergometer
Distance walked, time of
exercise at 60% peak
power
Strength
Mmt with or without hand held
dynomometer
Force generated on
dynomometer

98. ACSM Guide to Exercise Testing Durstine
and Moore 2009
Flexibility
Hand held goniometer
ROM in shoulder, elbow,
wrist, knee, ankle and
other joints of affected
limbs
Neuromuscular
Gait analysis, Berg balance,
functional reach, POMA
Gait speed, symmetry of
movement
Functional
Duke Mobility, FIM, Individualized
criterion referenced tests

99. ACSM Guide to Exercise Programming
Durstine and Moore 2009
Modes Intensity/freq/duration
Aerobic
Upper and lower body ergometer
cycle ergometer, treadmill, wheelchair
ergometer, wheelchair treadmill, arm
ergometer, swimming
seated stepper, seated aerobics, free
wheeling
RPE 13-20
50-80% peak HR
3-5 days/week
20-60 min session (or
multiple 10 min sessions)
Strength
Isometric exercise, weight machine
Free weights/dumbells, wrist weights,
rickshaw, lat pull-downs, rowing
3 sets of 8-12 reps
2-4 days/week

100. ACSM Guide to Exercise Programming
Durstine and Moore 2009
Modes Intensity/freq/duration
Flexibility
stretching
2 days a week (before or
after aerobic or strength
activities)
Neuromuscular
Coordination and balance activities
2 days/week (consider
performing on same day as
strength activities)

101. Aerobic Training Equipment Examples

102. Aerobic Training Alternatives

103. Strength Training Equipment Examples

104. Evidence-Based Community
Programs and Outcomes for TBI
Gordon 1998 Retrospective
review of aerobic
exercisers
decreased
fatigue,
decreased
migraines, less
depression,
improved
cognitive
function,
perception of
health and
social
interaction.

105. Evidence-Based Community
Programs and Outcomes for SCI
Ditor (2003) 9 month exercise
intervention
Less pain, stress,
increase in
quality of life
Manns(1999) Relationship
between fitness,
physical activity,
subjective quality
of life, and
handicap
Persons who
were more fit,
were generally
less handicapped

106. Helen M. Galvin Center for Health
and Fitness
 Located at the Rehabilitation Institute of Chicago
 Made possible by private donations
 4000 sq foot facility specifically created for people
with physical disabilities
 Free to the participants
 Provides an arena for persons to develop, maintain
and improve their physical well being
 Monthly attendance has averaged 1850 visits over the
past 2 years

107. An Emerging Market: Fitness Centers that
Can Serve the Disabled
 Linkages between
rehabilitation facilities and
community based fitness
centers
 Fitness centers are a
logical extension of the
rehabilitation continuum
by offering a location in
the person’s natural
environment
 Involvement in nutrition
seminars, relaxation
classes, and health fairs.