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Integrative and Lifestyle Medicine in Physical Therapy

Introduction (References)


Dean E. Physical therapy in the 21st century (Part I): toward practice informed by epidemiology and the crisis of lifestyle conditions. Physiother Theory Pract. 2009;25(5-6):330-353.

Dean E. Physical therapy in the 21st century (Part II): evidence-based practice within the context of evidence-informed practice. Physiother Theory Pract. 2009;25(5-6):354-368.

Dean E, Al-Obaidi S, De Andrade AD, et al. The First Physical Therapy Summit on Global Health: implications and recommendations for the 21st century. Physiother Theory Pract. 2011;27(8):531-547

Frerichs W, Kaltenbacher E, van de Leur JP, Dean E. Can physical therapists counsel patients with lifestyle-related health conditions effectively? A systematic review and implications. Physiother Theory Pract. 2012;28(8):571-587.

Chapter 1 (References)

Social Determinants of Health and Disease

Laura Keyser, PT, DPT, MPH
Dawn Magnusson, PT, PhD
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Chapter 2 (References)

Psychologically Informed Physical Therapy

Lindsay A. Ballengee, PT, DPT
Steven Z. George, PT, PhD, FAPTA
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  3. Main CJ, George SZ. Psychologically Informed Practice for Management of Low Back Pain: Future Directions in Practice and Research. Phys Ther. 2011;91(5):820-824. doi:10.2522/ptj.20110060
  4. Richmond H, Hall AM, Copsey B, et al. The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis. PLoS ONE. 2015;10(8). doi:10.1371/journal.pone.0134192
  5. Olatunji BO, Hollon SD. Preface: the current status of cognitive behavioral therapy for psychiatric disorders. Psychiatr Clin North Am. 2010;33(3):xiii-xix. doi:10.1016/j.psc.2010.04.015
  6. Williams L. The Oswestry Disability Index. :14.
  7. Hay EM, Dunn KM, Hill JC, et al. A randomised clinical trial of subgrouping and targeted treatment for low back pain compared with best current care. The STarT Back Trial Study Protocol. BMC Musculoskelet Disord. 2008;9(1):58. doi:10.1186/1471-2474-9-58
  8. Foster NE, Delitto A. Embedding Psychosocial Perspectives Within Clinical Management of Low Back Pain: Integration of Psychosocially Informed Management Principles Into Physical Therapist Practice—Challenges and Opportunities. Phys Ther. 2011;91(5):790-803. doi:10.2522/ptj.20100326
  9. Borrell-Carrio F. The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. Ann Fam Med. 2004;2(6):576-582. doi:10.1370/afm.245
  10. Beneciuk JM, George SZ, Greco CM, et al. Targeted interventions to prevent transitioning from acute to chronic low back pain in high-risk patients: development and delivery of a pragmatic training course of psychologically informed physical therapy for the TARGET trial. Trials. 2019;20(1):256. doi:10.1186/s13063-019-3350-3
  11. Weiser S, Lis A, Ziemke G, et al. Feasibility of Training Physical Therapists to Implement a Psychologically Informed Physical Therapy Program for Deployed U.S. Sailors and Marines with Musculoskeletal Injuries. Mil Med. 2018;183(suppl_1):503-509. doi:10.1093/milmed/usx229
  12. Jacobs CM, Guildford BJ, Travers W, Davies M, McCracken LM. Brief psychologically informed physiotherapy training is associated with changes in physiotherapists’ attitudes and beliefs towards working with people with chronic pain. Br J Pain. 2016;10(1):38-45. doi:10.1177/2049463715600460
  13. Keefe FJ, Main CJ, George SZ. Advancing Psychologically Informed Practice for Patients With Persistent Musculoskeletal Pain: Promise, Pitfalls, and Solutions. Phys Ther. 2018;98(5):398-407. doi:10.1093/ptj/pzy024
  14. Herschell AD, Kolko DJ, Baumann BL, Davis AC. The role of therapist training in the implementation of psychosocial treatments: a review and critique with recommendations. Clin Psychol Rev. 2010;30(4):448-466. doi:10.1016/j.cpr.2010.02.005
  15. Fritz JM, Cleland JA, Speckman M, Brennan GP, Hunter SJ. Physical therapy for acute low back pain: associations with subsequent healthcare costs. Spine. 2008;33(16):1800-1805. doi:10.1097/BRS.0b013e31817bd853
  16. Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine. 2012;37(25):2114-2121. doi:10.1097/BRS.0b013e31825d32f5
  17. Zadro J, O’Keeffe M, Maher C. Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review. BMJ Open. 2019;9(10):e032329. doi:10.1136/bmjopen-2019-032329
  18. Holopainen R, Simpson P, Piirainen A, et al. Physiotherapists’ perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions: a systematic review and metasynthesis of qualitative studies. Pain. Published online January 16, 2020. doi:10.1097/j.pain.0000000000001809
  19. Bement MKH, Sluka KA. The Current State of Physical Therapy Pain Curricula in the United States: A Faculty Survey. J Pain. 2015;16(2):144-152. doi:10.1016/j.jpain.2014.11.001
  20. Scudds RJ, Scudds RA, Simmonds MJ. Pain in the physical therapy (pt) curriculum: a faculty survey. Physiother Theory Pract. 2001;17(4):239-256. doi:10.1080/095939801753385744
  21. Synnott A, O’Keeffe M, Bunzli S, Dankaerts W, O’Sullivan P, O’Sullivan K. Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. J Physiother. 2015;61(2):68-76. doi:10.1016/j.jphys.2015.02.016
  22. Hoeger Bement MK, St. Marie BJ, Nordstrom TM, et al. An Interprofessional Consensus of Core Competencies for Prelicensure Education in Pain Management: Curriculum Application for Physical Therapy. Phys Ther. 2014;94(4):451-465. doi:10.2522/ptj.20130346
  23. CAPTE Accreditation Handbook. Accessed September 29, 2020. http://www.capteonline.org/AccreditationHandbook/
  24. Denneny D, Frijdal Nee Klapper A, Bianchi-Berthouze N, et al. The application of psychologically informed practice: observations of experienced physiotherapists working with people with chronic pain. Physiotherapy. 2020;106:163-173. doi:10.1016/j.physio.2019.01.014
  25. Ballengee LA, Covington, JC, George SZ. Introduction of a psychologically informed educational intervention for pre-licensure physical therapists in a classroom setting. BMC Med Educ.
  26. George SZ, Wittmer VT, Fillingim RB, Robinson ME. Comparison of graded exercise and graded exposure clinical outcomes for patients with chronic low back pain. J Orthop Sports Phys Ther. 2010;40(11):694-704. doi:10.2519/jospt.2010.3396
  27. Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. 2008;59(5):632-641. doi:10.1002/art.23563
  28. Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378(9802):1560-1571. doi:10.1016/S0140-6736(11)60937-9
  29. Beneciuk JM, George SZ. Pragmatic Implementation of a Stratified Primary Care Model for Low Back Pain Management in Outpatient Physical Therapy Settings: Two-Phase, Sequential Preliminary Study. Phys Ther. 2015;95(8):1120-1134. doi:10.2522/ptj.20140418
  30. Hall A, Richmond H, Copsey B, et al. Physiotherapist-delivered cognitive-behavioural interventions are effective for low back pain, but can they be replicated in clinical practice? A systematic review. Disabil Rehabil. 2018;40(1):1-9. doi:10.1080/09638288.2016.1236155
  31. Brunner E, De Herdt A, Minguet P, Baldew S-S, Probst M. Can cognitive behavioural therapy based strategies be integrated into physiotherapy for the prevention of chronic low back pain? A systematic review. Disabil Rehabil. 2013;35(1):1-10. doi:10.3109/09638288.2012.683848
  32. Lentz TA, Beneciuk JM, Bialosky JE, et al. Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort. J Orthop Sports Phys Ther. 2016;46(5):327-343. doi:10.2519/jospt.2016.6487
  33. Gabel CP, Melloh M, Burkett B, Osborne J, Yelland M. The Örebro Musculoskeletal Screening Questionnaire: Validation of a modified primary care musculoskeletal screening tool in an acute work injured population. Man Ther. 2012;17(6):554-565. doi:10.1016/j.math.2012.05.014
  34. Beneciuk JM, George SZ. Adding Physical Impairment to Risk Stratification Improved Outcome Prediction in Low Back Pain. Phys Ther. doi:10.1093/ptj/pzaa179

Chapter 3 (References and Supplemental Materials)

Coaching, Counseling, and the Science of Behavior Change

Janet Bezner, PT, DPT, PhD, FAPTA
MarySue Ingman, PT, DSc
  1. Guide to Physical Therapist Practice. Published October 5, 2020. Accessed October 5, 2020. http://guidetoptpractice.apta.org/
  2. Role of PT Diet Nutrition. APTA. Published September 20, 2019. Accessed October 5, 2020. https://www.apta.org/apta-and-you/leadership-and-governance/policies/role-of-pt-diet-nutrition
  3. Role of the Physical Therapist and APTA in Sleep Health. APTA. Published August 20, 2020. Accessed May 20, 2021. https://www.apta.org/apta-and-you/leadership-and-governance/policies/role-pt-apta-sleep-health
  4. Fruth S, Van Veld R, Despos C, Martin R, Hecker A, Sincroft E. The influence of a topic-specific, research-based presentation on physical therapists’ beliefs and practices regarding evidence-based practice. Physiother Theory Pract. 2010;26:537-557. doi:10.3109/09593980903585034
  5. Rea BL, Marshak HH, Neish C, Davis N. The Role of Health Promotion in Physical Therapy in California, New York, and Tennessee. Phys Ther. 2004;84(6):510-523. doi:10.1093/ptj/84.6.510
  6. Sjöquist ES, Brodin N, Lampa J, Jensen I, Opava CH. Physical Activity Coaching of Patients with Rheumatoid Arthritis in Everyday Practice: A Long-term Follow-up. Musculoskeletal Care. 2011;9(2):75-85. doi:10.1002/msc.199
  7. Healey WE, Broers KB, Nelson J, Huber G. Physical Therapists’ Health Promotion Activities for Older Adults. J Geriatr Phys Ther. 2012;35(1):35-48. doi:10.1519/JPT.0b013e318220d1f0
  8. Abaraogu UO, Ogaga MO, Dean E. Practices of Nigerian physiotherapists with respect to lifestyle risk factor assessment and intervention: A national cross-sectional survey. Physiother Theory Pract. 2017;33(6):497-507. doi:10.1080/09593985.2017.1318421
  9. McGough E, Kirk-Sanchez N, Liu-Ambrose T. Integrating Health Promotion Into Physical Therapy Practice to Improve Brain Health and Prevent Alzheimer Disease. J Neurol Phys Ther. 2017;41:S55. doi:10.1097/NPT.0000000000000181
  10. Lein DH, Clark D, Graham C, Perez P, Morris D. A Model to Integrate Health Promotion and Wellness in Physical Therapist Practice: Development and Validation. Phys Ther. 2017;97(12):1169-1181. doi:10.1093/ptj/pzx090
  11. Williams TL, Smith B, Papathomas A. Physical activity promotion for people with spinal cord injury: physiotherapists’ beliefs and actions. Disabil Rehabil. 2018;40(1):52-61. doi:10.1080/09638288.2016.1242176
  12. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: Toward an integrative model of change. J Consult Clin Psychol. 1983;51(3):390-395. doi:10.1037/0022-006X.51.3.390
  13. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. Am Psychol. 1992;47(9):1102-1114. doi:10.1037//0003-066x.47.9.1102
  14. Prochaska JO, Velicer WF. The Transtheoretical Model of Health Behavior Change. Am J Health Promot. 1997;12(1):38-48. doi:10.4278/0890-1171-12.1.38
  15. Bandura A, Freeman WH, Lightsey R. Self-Efficacy: The Exercise of Control. Springer, 1999.
  16. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55(1):68-78. doi:10.1037/0003-066X.55.1.68
  17. Bezner JR. Promoting Health and Wellness: Implications for Physical Therapist Practice. Phys Ther. 2015;95(10):1433-1444. doi:10.2522/ptj.20140271
  18. Dean E. Physical therapy in the 21st century (Part II): Evidence-based practice within the context of evidence-informed practice. Physiother Theory Pract. 2009;25(5-6):354-368. doi:10.1080/09593980902813416
  19. Dean E, Andrade AD de, O’Donoghue G, et al. The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases. Physiother Theory Pract. 2014;30(4):261-275. doi:10.3109/09593985.2013.856977
  20. Kelly S, Martin S, Kuhn I, Cowan A, Brayne C, Lafortune L. Barriers and Facilitators to the Uptake and Maintenance of Healthy Behaviours by People at Mid-Life: A Rapid Systematic Review. PloS One. 2016;11(1):e0145074. doi:10.1371/journal.pone.0145074
  21. Wolever RQ, Simmons LA, Sforzo GA, et al. A Systematic Review of the Literature on Health and Wellness Coaching: Defining a Key Behavioral Intervention in Healthcare. Glob Adv Health Med. 2013;2(4):38-57. doi:10.7453/gahmj.2013.042
  22. Hutting N, Johnston V, Staal JB, Heerkens YF. Promoting the Use of Self-management Strategies for People With Persistent Musculoskeletal Disorders: The Role of Physical Therapists. J Orthop Sports Phys Ther. 2019;49(4):212-215. doi:10.2519/jospt.2019.0605
  23. Moore M, Tschannen-Moran B. Coaching Psychology Manual. Wolters Kluwer Health/Lippincott, Williams & Wilkins; 2010.
  24. Hutting N, Johnston V, Staal JB, Heerkens YF. Promoting the Use of Self-management Strategies for People With Persistent Musculoskeletal Disorders: The Role of Physical Therapists. J Orthop Sports Phys Ther. 2019;49(4):212-215. doi:10.2519/jospt.2019.0605
  25. Moore M, Tschannen-Moran B. Coaching Psychology Manual. Wolters Kluwer Health/Lippincott, Williams & Wilkins; 2010.
  26. Miller WR, Rollnick S. Motivational Interviewing Helping People Change. . 3rd ed. Guilford Press; 2013.
  27. Vong SK, Cheing GL, Chan F, So EM, Chan CC. Motivational Enhancement Therapy in Addition to Physical Therapy Improves Motivational Factors and Treatment Outcomes in People With Low Back Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2011;92(2):176-183. doi:10.1016/j.apmr.2010.10.016
  28. Pignataro RM, Huddleston J. The Use of Motivational Interviewing in Physical Therapy Education and Practice: Empowering Patients Through Effective Self-Management. J Phys Ther Educ. 2015;29(2):62-71.
  29. Lundahl B, Moleni T, Burke BL, et al. Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Educ Couns. 2013;93(2):157-168. doi:10.1016/j.pec.2013.07.012
  30. Erickson SJ, Gerstle M, Feldstein SW. Brief Interventions and Motivational Interviewing With Children, Adolescents, and Their Parents in Pediatric Health Care Settings: A Review. Arch Pediatr Adolesc Med. 2005;159(12):1173. doi:10.1001/archpedi.159.12.1173
  31. Morton K, Beauchamp M, Prothero A, et al. The effectiveness of motivational interviewing for health behaviour change in primary care settings: a systematic review. Health Psychol Rev. 2015;9(2):205-223. doi:10.1080/17437199.2014.882006
  32. Moral RR, Torres LAP de, Ortega LP, et al. Effectiveness of motivational interviewing to improve therapeutic adherence in patients over 65 years old with chronic diseases: A cluster randomized clinical trial in primary care. Patient Educ Couns. 2015;98(8):977-983. doi:10.1016/j.pec.2015.03.008
  33. Sjöling M, Lundberg K, Englund E, Westman A, Jong MC. Effectiveness of motivational interviewing and physical activity on prescription on leisure exercise time in subjects suffering from mild to moderate hypertension. BMC Res Notes. 2011;4(1):352. doi:10.1186/1756-0500-4-352
  34. Lee WWM, Choi KC, Yum RWY, Yu DSF, Chair SY. Effectiveness of motivational interviewing on lifestyle modification and health outcomes of clients at risk or diagnosed with cardiovascular diseases: A systematic review. Int J Nurs Stud. 2016;53:331-341. doi:10.1016/j.ijnurstu.2015.09.010
  35. Ingman M, Bezner JR, Black B, Vaughan PW. Development and reliability of the Physical Therapy Healthy Lifestyle Appraisal: a new assessment tool to guide behavior change. Cardiopulm Phys Ther J. 2022;33:77-86.
Supplemental Materials
Table 1. Physical Activity Guidelines for Americans1-3
Preschool-Aged Children (ages 3-5 years) Children and Adolescents (ages 6-17 years) Adults Older Adults
Physically active throughout the day. 60 minutes or more per day at moderate- or vigorous intensity. 150-300 minutes per week of moderate-intensity, or 75-150 minutes per week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity activity. Preferably, activity should be spread throughout the week. Same guidelines as for adults. Their level of effort for physical activity should be relative to their level of fitness. If unable to perform 150 minutes of moderate-intensity aerobic activity a week because of chronic conditions, they should be as physically active as their abilities and conditions allow.
Adult caregivers should encourage a variety of active play. Aerobic: At least 3 days per week should be of vigorous intensity. Move more and sit less throughout the day. Some physical activity is better than none. Include multicomponent physical activity that includes balance training as well as aerobic and muscle-Strengthening activities.
Muscle-strengthening: Part of the 60 minutes or more of daily physical activity should include muscle-strengthening, at least 3 days per week. Additional health benefits are gained by engaging in physical activity beyond 300 minutes of moderate-intensity physical activity per week.
Bone-strengthening: Part of the 60 minutes or more of daily physical activity should include bone-strengthening and should be at least 3 days per week. Muscle-strengthening: Moderate or greater intensity of all major muscle groups on 2 or more days per week.
Table 2. USDA 2020-2025 Dietary Guidelines4

The Guidelines

Make every bite count with the Dietary Guidelines for Americans.
  1. Follow a healthy dietary pattern at every life stage.
    • At every life stage—infancy, toddlerhood, childhood, adolescence, adulthood, pregnancy, lactation, and older adulthood—it is never too early or too late to eat healthfully.
      • For about the first 6 months of life, exclusively feed infants human milk. Continue to feed infants human milk through at least the first year of life, and longer if desired. Feed infants iron-fortified infant formula during the first year of life when human milk is unavailable. Provide infants with supplemental vitamin D beginning soon after birth.
      • At about 6 months, introduce infants to nutrient-dense complementary foods. Introduce infants to potentially allergenic foods along with other complementary foods. Encourage infants and toddlers to consume a variety of foods from all food groups. Include foods rich in iron and zinc, particularly for infants fed human milk.
      • From 12 months through older adulthood, follow a healthy dietary pattern across the lifespan to meet nutrient needs, help achieve a healthy body weight, and reduce the risk of chronic disease.
  1. Customize and enjoy nutrient-dense food and beverage choices to reflect personal preferences, cultural traditions, and budgetary considerations.
    • A healthy dietary pattern can benefit all individuals regardless of age, race, or ethnicity, or current health status. The Dietary Guidelines provides a framework intended to be customized to individual needs and preferences, as well as the foodways of the diverse cultures in the United States.
  1. Focus on meeting food group needs with nutrient-dense foods and beverages, and stay within calorie limits.
    • An underlying premise of the Dietary Guidelines is that nutritional needs should be met primarily from foods and beverages—specifically, nutrient-dense foods and beverages. Nutrient-dense foods provide vitamins, minerals, and other health-promoting components and have no or little added sugars, saturated fat, and sodium. A healthy dietary pattern consists of nutrient-dense forms of foods and beverages across all food groups, in recommended amounts, and within calorie limits.
    • The core elements that make up a healthy dietary pattern include:
      • Vegetables of all types—dark green; red and orange; beans, peas, and lentils; starchy; and other vegetables
      • Fruits, especially whole fruit
      • Grains, at least half of which are whole grain
      • Dairy, including fat-free or low-fat milk, yogurt, and cheese, and/or lactose-free versions and fortified soy beverages and yogurt as alternatives
      • Protein foods, including lean meats, poultry, and eggs; seafood; beans, peas, and lentils; and nuts, seeds, and soy products
      • Oils, including vegetable oils and oils in food, such as seafood and nuts
  1. Limit foods and beverages higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages.
    • At every life stage, meeting food group recommendations—even with nutrient-dense choices—requires most of a person’s daily calorie needs and sodium limits. A healthy dietary pattern doesn’t have much room for extra added sugars, saturated fat, or sodium—or for alcoholic beverages. A small amount of added sugars, saturated fat, or sodium can be added to nutrient-dense foods and beverages to help meet food group recommendations, but foods and beverages high in these components should be limited.
    • Limits are:
      • Added sugars—Less than 10 percent of calories per day starting at age 2. Avoid foods and beverages with added sugars for those younger than age 2.
      • Saturated fat—Less than 10 percent of calories per day starting at age 2.
      • Sodium—Less than 2,300 milligrams per day—and even less for children younger than age 14.
      • Alcoholic beverages—Adults of legal drinking age can choose not to drink, or to drink in moderation by limiting intake to 2 drinks or less in a day for men and 1 drink or less in a day for women, when alcohol is consumed. Drinking less is better for health than drinking more. There are some adults who should not drink alcohol, such as women who are pregnant.
Table 3. National Sleep Foundation Recommendations5-7
Ages Recommended May be appropriate Not recommended
0-3 months
14 to 17 hours 11 to 13 hours
18 to 19 hours
Less than 11 hours
More than 19 hours
4-11 months
12 to 15 hours 10 to 11 hours
16 to 18 hours
Less than 10 hours
More than 18 hours
1-2 years
11 to 14 hours 9 to 10 hours
15 to 16 hours
Less than 9 hours
More than 16 hours
3-5 years
10 to 13 hours 8 to 9 hours
14 hours
Less than 8 hours
More than 14 hours
School-aged Children
6-13 years
9 to 11 hours 7 to 8 hours
12 hours
Less than 7 hours
More than 12 hours
14-17 years
8 to 10 hours 7 hours
11 hours
Less than 7 hours
More than 11 hours
Young Adults
18-25 years
7 to 9 hours 6 hours
10 to 11 hours
Less than 6 hours
More than 11 hours
26-64 years
7 to 9 hours 6 hours
10 hours
Less than 6 hours
More than 10 hours
Older Adults
≥ 65 years
7 to 8 hours 5 to 6 hours
9 hours
Less than 5 hours
More than 9 hours
Table 4. Stress Consequences and Healthy Management of Stress8-10
Health consequences of chronic stress Effective Stress management behaviors
  • Anxiety
  • Depression
  • Digestive problems
  • Headaches
  • Heart disease
  • Sleep problems
  • Weight gain
  • Memory and concentration impairment
  • Try to eliminate the stressors
  • Cultivate social support
  • Seek good nutrition
  • Relax your muscles
  • Meditate
  • Protect your sleep
  • Get physical
  • Take a moment in nature
  • Keep your pleasurable activities
  • Reframe your thinking
  • Seek professional help
Table 5. Self-Determination Theory11
Construct Physical Therapist’s Role
Autonomy Provide relevant information and meaningful rationales for change.
Use an interpersonal style that emphasizes choice and minimizes control so individuals don’t feel pressured or controlled.
Support the individual as they explore resistances and barriers to change.
Help them identify congruent pathways toward their lifestylegoals.
Competence Provide relevant inputs and feedback.
Provide the tools and skills for change.
Support to overcome competence- or control-related barriers.
Help patients to achieve mastery.
Relatedness Respect, understand and care for the patient.
Encourage the individual to share their goals with significant others in their life.
Perception that significant others are invested and understand the person’s challenges can reliably serve as a psychological and emotionalresource.
References for Supplemental Materials.
  1. President’s Council on Sports F& N. Physical Activity Guidelines for Americans. HHS.gov. Published July 20, 2012. Accessed July 25, 2020. https://www.hhs.gov/fitness/be-active/physical-activity-guidelines-for-americans/index.html
  2. Centers for Disease Control and Prevention. FastStats. Published August 10, 2020. Accessed October 7, 2020. https://www.cdc.gov/nchs/fastats/exercise.htm
  3. National Physical Activity Plan Alliance. NPAP. Accessed July 25, 2020. https://www.physicalactivityplan.org/projects/reportcard.html
  4. U.S. Department of Agriculture and U.S. Department of. Health and Human Services. Dietary Guidelines for Americans, 2020-2025. www.dietaryguidelines.gov
  5. National Sleep Foundation Recommends New Sleep Times. Sleep Foundation. Accessed July 14, 2020. https://www.sleepfoundation.org/national-sleep-foundation-recommends-new-sleep-times
  6. CDC - Data and Statistics - Sleep and Sleep Disorders. Published March 5, 2019. Accessed July 25, 2020. https://www.cdc.gov/sleep/data_statistics.html
  7. CDC. Students and Sleep. Centers for Disease Control and Prevention. Published February 5, 2018. Accessed July 25, 2020. https://www.cdc.gov/features/students-sleep/index.html
  8. American Psychological Association. Stress. Accessed July 25, 2020. https://www.apa.org/topics/stress
  9. Chronic stress puts your health at risk. Mayo Clinic. Accessed July 25, 2020. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress/art-20046037
  10. Manage Stress - MyHealthfinder | health.gov. Accessed October 7, 2020. https://health.gov/myhealthfinder/topics/health-conditions/heart-health/manage-stress
  11. Smoking & Tobacco Use | CDC. Published June 15, 2020. Accessed July 25, 2020. https://www.cdc.gov/tobacco/index.htm

Chapter 4 (References)

Biopsychosocial Interventions to Promote Resilience

Ginger Garner, PT, DPT, ATC/L
Joe Tatta, PT, DPT
  1. Schuman-Olivier Z, Trombka M, Lovas DA, et al. Mindfulness and Behavior Change. Harv Rev Psychiatry. 2020;28(6):371-394. doi:10.1097/HRP.0000000000000277
  2. Sisto A, Vicinanza F, Campanozzi LL, Ricci G, Tartaglini D, Tambone V. Towards a Transversal Definition of Psychological Resilience: A Literature Review. Medicina (Kaunas). 2019;55(11):E745. doi:10.3390/medicina55110745
  3. Gentili C, Rickardsson J, Zetterqvist V, Simons LE, Lekander M, Wicksell RK. Psychological Flexibility as a Resilience Factor in Individuals With Chronic Pain. Front Psychol. 2019;10:2016. doi:10.3389/fpsyg.2019.02016
  4. Helmreich I, Kunzler A, Chmitorz A, et al. Psychological interventions for resilience enhancement in adults. Cochrane Database Syst Rev. 2017;2017(2):CD012527. doi:10.1002/14651858.CD012527
  5. Hayes SC, Hofmann SG, Stanton CE, et al. The role of the individual in the coming era of process-based therapy. Behav Res Ther. 2019;117:40-53. doi:10.1016/j.brat.2018.10.005
  6. A-Tjak JGL, Davis ML, Morina N, Powers MB, Smits JAJ, Emmelkamp PMG. A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychother Psychosom. 2015;84(1):30-36. doi:10.1159/000365764
  7. Dindo L, Van Liew JR, Arch JJ. Acceptance and Commitment Therapy: A Transdiagnostic Behavioral Intervention for Mental Health and Medical Conditions. Neurotherapeutics. 2017;14(3):546-553. doi:10.1007/s13311-017-0521-3
  8. Kashdan TB. Psychological Flexibility as a Fundamental Aspect of Health. Clin Psychol Rev. 2010;30(7):865-878. doi:10.1016/j.cpr.2010.03.001
  9. Hofmann SG, Hayes SC. The Future of Intervention Science: Process-Based Therapy. Clinical Psychological Science. 2019;7(1):37-50. doi:10.1177/2167702618772296
  10. Tatta J, Willgens AM, Palombaro KM. Mindfulness-and-Acceptance-Based Interventions (MABIs) in Physical Therapist Practice: The Time Is Now [published online ahead of print, 2022 Jan 3]. Phys Ther. 2022;pzab293. doi:10.1093/ptj/pzab293
  11. Eilenberg T, Hoffmann D, Jensen JS, Frostholm L. Intervening variables in group-based acceptance & commitment therapy for severe health anxiety. Behav Res Ther. 2017;92:24-31. doi:10.1016/j.brat.2017.01.009
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Chapter 5 (References)

Stress Management and Mindfulness Training

Annette Willgens, PT, EdD
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Chapter 6 (References and Supplemental Materials)

Physical Activity Across the Lifespan

Ginger Garner, PT, DPT, ATC/L
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Supplemental Materials

PA and Epigenetic Influence

The following common genetic polymorphisms appear to impact cognitive and physiological response to PA.1

  • apolipoprotein E (APOE) ε4, which exists as three polymorphic alleles - APOE ε2, APOE ε3 and APOE ε4. APOE ε4 allele is associated with significantly greater risk of developing Alzheimer’s Disease2, increased gait variability over time in older adults with mild cognitive impairment3 and reduced grip strength.4
  • brain-derived neurotrophic factor (BDNF) Val66Met- BDNF is a neurotrophic critical to neuronal proliferation and survival, synaptic plasticity, and learning and memory cellular function.5 The Met allele impairs the precursor to BDNF by approximately 30% when compared to Val carriers. It is not yet possible to draw conclusions that the Val allele is neuroprotective and the Met allele is related to poorer cognitive performance, especially since this particular study found the Met allele was protective against declines in executive functioning for females, but only in white participants. Additionally, the BDNF Val66Met polymorphism has been associated with risk for major depression6 in females.7 Among BDNF Val/Val homozygotes, higher PA is associated with larger hippocampus and temporal lobe volume, but the opposite is found for Met carriers.6
  • Catechol-O-methyltransferase (COMT) - COMT has an impact on dopamine signaling in the prefrontal cortex, whereas the association of Met/Val with better gait performance appears to be due to the impact of COMT on tonic dopamine regulation in the striatum in men only. The associations between COMT, gait and executive function were influenced by gender. The COMT genotype was related to gait velocity in men but not in women.8 Another study showed that PA levels, via dopamine regulation, moderates cognitive and mobility gains by enhancing participation in PA. This mechanism is possibly due to genotypes that are related to higher dopamine function are associated with greater increases in PA than genotypes related to lower dopamine function.9

More research in this area is needed to provide evidence-based recommendations tailored to different genotypes. For example, studies should look at how different polymorphisms respond to the modes of PA (aerobic, strength training, etc.) in order to ascertain if PA gains will be blunted in those with these genetic polymorphisms, and how to personalize PA prescription to optimize benefits and longevity in carriers.

PA Intervention

The Self-Efficacy for Home Exercise Programs Scale (SEHEPS) is a 12-item, 2 minute patient-reported questionnaire that assesses self-efficacy for prescribed home exercise using a 7 point likert scale that scores confidence level.

How confident are you that you could perform the prescribed exercises correctly... Not Confident Somewhat Confident Very Confident
...as often as prescribed by your clinician? NA
0 1 2 3 4 5 6
...when you are bored by the program? NA
0 1 2 3 4 5 6
...when you feel pain when exercising? NA
0 1 2 3 4 5 6
...when you have to exercise alone? NA
0 1 2 3 4 5 6
...when you do not enjoy it? NA
0 1 2 3 4 5 6
...when you are given written exercise instruction? NA
0 1 2 3 4 5 6
...when you are too busy with other activities? NA
0 1 2 3 4 5 6
...when you are given video exercise instruction? NA
0 1 2 3 4 5 6
...when you feel tired? NA
0 1 2 3 4 5 6
...when you feel stressed? NA
0 1 2 3 4 5 6
...when you feel depressed? NA
0 1 2 3 4 5 6
...when you do not have supervision or clinician feedback? NA
0 1 2 3 4 5 6

Abbreviation: NA, not applicable

PA Prescription

Case Example

Sarah, a 37 year old postpartum female, wants to return to PA 3 months after having a vaginal, single birth to a healthy baby girl, her first child and only pregnancy. Currently, she spends an estimated hour each day doing housework and lifting her baby to care for her, including breastfeeding. She is 5 foot, 4 inches and 160 pounds with a BMI of 27.4, putting her in the overweight category.

She wants to lose enough weight to bring her BMI to 22, which would be approximately 30 pounds. She has stress incontinence per patient interview and a diastasis rectus abdominis, neither of which has resolved. She has no other significant previous medical history, has been screened for postpartum depression, which is negative, and has been cleared for PA and return to full activity by her midwife.

Sarah reports having previously participated in yoga and Pilates classes, jogging/walking her dog, and is feeling anxious to return to activity so she can lose weight and improve her energy levels; but is unsure of how to do that since giving birth.

Domains & Dimensions of PA

Modes of PA include the following:

  • Aerobic: relating to cardiorespiratory or endurance activity
  • Anaerobic: higher levels of activity surpassing the usual oxygen-metabolic pathways
  • Muscle-strengthening: resistance training and weightlifting requiring muscular activation against an external object or bodyweight
  • Bone-strengthening: weight-bearing activities producing a force against the body
  • Balance: actively resisting forces that cause falls
  • New Consideration: Mindfulness-Based activity as part of PA prescription, which can be multi-modal (satisfy most of the modes of PA listed above)
Using the FITT Principle

For Sarah, her recommended frequency and time would need to accumulate a minimum of 150 minutes of moderate-intensity activity weekly, with strength training on a minimum of two days of the week that covers all major muscle groups. Because she is newly postpartum and has not been evaluated by a PT yet nor has she been active since giving birth, it is safest to slowly ramp up her level activity and avoid vigorous PA until her postpartum issues have resolved or the PT feels it is appropriate to begin to train vigorously.

The type of PA to meet the aerobic portion could be walking. It is easily accessible in her neighborhood, with sidewalks and walking trails, and low cost. Frequency and time could be met by walking her dog or pushing her daughter in a stroller for two 15 minute or daily 30 minute walks five days a week, for a total of 150 minutes.

For strength-training, functional training using a combination of yoga and domestic activities could be used to target all major muscle groups and also combine physical therapy for her postpartum condition(s).

To include a mindfulness component, Sarah can be encouraged to think outside the box. She doesn’t have to be on a “yoga mat” in order to be practicing mindfulness and yoga. Her stroller walk could be mindfulness-based, and it is relatively simple to add in a short course (no more than 5-10 minutes per session) pelvic floor physical therapy that is yoga-based and strength-based, in order to support her full recovery.

Also, time management is difficult once children come into the picture. Mothers are expected to somehow recover from the ultramarathon of birth while taking care of a new (also vulnerable) person. There are no standards for postpartum care for pelvic physical therapy, which further complicates recovery. Additionally, depending on where Sarah lives, she may have no maternity leave and may have to return to work before she has fully recovered physically, emotionally, and spiritually. Social support may also factor into how much time Sarah has to dedicate to recovery and self-care.

Sarah - 3 month Postpartum PA Prescription Moderate-Intensity PA (>150 minutes/week or 500 MET) - 3.0-6.0 METs (3.5 to 7 kcal/min) Muscle-Strengthening Activity (at least days/week working all major muscle groups)
Type: Mindfulness-Based Brisk Walking >3 miles/hour x 5 days/week x 30 minutes each bout

3 METs (intensity of 3 miles/hour or greater) x 30 minutes (time) once day (frequency) = 90 MET min/day x 5 days/week = 450 METs/week
Along the walk Sarah can also include moving Yoga-based postures and occasional standing postures like Chair, Warrior I, Warrior II, Tree, and similar postures aligned using the Medical Therapeutic Yoga Method as a guide for safety10.
Type: Childcare (carrying, bathing, dressing, transporting, etc.) 3 METs (intensity) x 30 minutes (time) x two times/day (frequency) = 180 MET min/day x 5 days/week = 900 METs/week A pelvic PT can work with Sarah to incorporate pelvic floor physical therapy into her daily childcare routine, through teaching ergonomically correct strength- and mobility-based movements that will improve her proprioception and interoception and seamlessly fit into childcare and household management.
Determining PA Intensity

Her intensity inside this activity could be calculated through use of the Borg Rate of Perceived Exertion or the Talk Test, which are preferred methods to heart rate calculation (see below). See the table below for examples of PA intensity to guide PA prescription.

Case example - For Sarah - her calculation would be as follows:
220-37 = 183
64%: 183 x .64 = 117
76%: 183 x .76 = 139
For moderate-intensity PA, Sarah’s target heart rate would be between 117-139.

When she is ready to progress to vigorous-intensity PA, Sarah’s target heart rate would be:
77%: 183 x .77 = 140
93%: 183 x .93 = 170
For vigorous-intensity PA, Sarah’s target heart rate would be between 140-170. Target heart rate can only be used if Sarah is not taking medications that alter heart rate or pulse.

CDC & American College of Sports Medicine PA Intensity Guidelines

Source: General Physical Activities Defined by Level of Intensity.11

Moderate activity+ 3.0 to 6.0 METs* (3.5 to 7 kcal/min) Vigorous activity is greater than 6.0 METs* (more than 7 kcal/min)
Brisk walking at 3-4.5 mph on a level surface or race walking less than 5 mph; hiking Racewalking and aerobic walking—5 mph or faster Jogging or running Wheeling your wheelchair Walking and climbing briskly up a hill Backpacking Mountain climbing, rock climbing, rappelling Roller skating or in-line skating at a brisk pace
Cycling 5-9 mph Bicycling more than 10 mph or bicycling on steep uphill terrain Stationary bicycling—using vigorous effort
Yoga (light), gymnastics, home exercises, jumping on a trampoline, boxing, weight training Calisthenics—push-ups, pull-ups, vigorous effort Karate, judo, tae kwon do, jujitsu Jumping rope; Performing jumping jacks Using a stair climber machine at a fast pace Using a rowing machine—with vigorous effort Using an arm cycling machine—with vigorous effort; Circuit weight training , Boxing—in the ring, sparring Wrestling—competitive
Aerobic dancing, high impact, water aerobics Aerobic dancing, high impact step aerobics, water jogging, teaching an aerobics dance class
Dancing Professional ballroom dancing—energetically Square dancing—energetically Folk dancing—energetically Clogging
Sports such as doubles tennis, shooting baskets, softball, volleyball, golfing (wheeling or carrying clubs) Singles tennis, wheelchair tennis or basketball, beach volleyball on sand court
Juggling, cricket, badminton, archery, fencing, playing frisbee Handball—general or team Racquetball Squash
Downhill skiing with light effort, ice skating, sailing, snowmobiling Downhill skiing—racing or with vigorous effort Ice-skating—fast pace or speed skating Cross-country skiing Sledding Tobogganing Playing ice hockey
Swimming, snorkeling, body surfing, waterskiing, diving, treading water slowly Swimming—steady paced laps Synchronized swimming Treading water—fast, vigorous effort Water jogging Water polo Water basketball Scuba diving
Canoeing, rowing less than 4 mph, kayaking on calm water, washing a boat Canoeing or rowing—4 or more mph Kayaking in whitewater rapids
Fishing while walking or wading -
Hunting deer, pheasant, grouse or small game while walking -
Horseback riding, saddling or grooming a horse Horseback riding—trotting, galloping, jumping, or in competition Playing polo
Playing on school playground equipment, skateboarding, in-line skating at leisurely pace Running Skipping Jumping rope Performing jumping jacks Roller-skating or in-line skating—fast pace
Playing instruments or singing while actively moving Playing a heavy musical instrument while actively running in a marching band
Gardening or yard work (lifting less than 10 lbs per minute), shoveling light snow Gardening or yard work - Heavy or rapid shoveling (more than 10 lbs per minute), digging ditches, or carrying heavy loads Felling trees, carrying large logs, swinging an ax, hand-splitting logs, or climbing and trimming trees Pushing a non-motorized lawn mower; shoveling heavy snow
Moderate housework - scrubbing the floor or Heavy housework: moving or pushing heavy bathtub while on hands and knees, hanging laundry on a clothesline, sweeping an outdoor area, cleaning out the garage, washing windows, moving light furniture, packing or unpacking boxes, walking and putting household items away, carrying out heavy bags of trash or recyclables, putting groceries away Heavy housework - moving or pushing heavy furniture (75 lbs or more), carrying household items weighing 25 lbs or more up a flight or stairs, or shoveling coal into a stove Standing, walking, or walking down a flight of stairs while carrying objects weighing 50 lbs or more; carrying 25 lbs or more of groceries at a time up a flight of stairs or pushing a full grocery cart or shopping while carrying young children
Caregiving - Actively playing with children, walking while carrying a child less than 50 pounds, walking while pushing a child in a stroller or adult in a wheelchair, bathing and dressing an adult, handling uncooperative children (chasing, dressing, lifting into seat, etc.) Caregiving - Vigorously playing with children—running longer distances or playing strenuous games with children Race walking or jogging while pushing a stroller designed for sport use Carrying an adult or a child weighing 25 lbs or more up a flight of stairs Standing or walking while carrying an adult or a child weighing 50 lbs or more
Animal care - grooming, feeding, playing with or training animals Animal care - forking bales of hay or straw, cleaning a barn or stables, or carrying animals weighing over 50 lbs Handling or carrying heavy animal-related equipment or tack
Home repair and general home construction - cleaning gutters, caulking, refinishing furniture, removing carpet, laying tiles, carpet, painting, roofing; carpentry work Very hard physical labor, standing or walking while carrying heavy loads of 50 lbs or more, taking loads of 25 lbs or more up a flight of stairs or ladder (e.g., carrying roofing materials onto the roof), or concrete or masonry work; Hand-sawing hardwoods
Automobile bodywork - washing, waxing car Pushing a disabled car
Occupations that require extended periods of walking, pushing or pulling objects weighing less than 75 lbs, standing while lifting objects weighing less than 50 lbs, or carrying objects of less than 25 lbs up a flight of stairs Occupations that require extensive periods of running, rapid movement, pushing or pulling objects weighing 75 lbs or more, standing while lifting heavy objects of 50 lbs or more, walking while carrying heavy objects of 25 lbs or more
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Chapter 7 (References)

Diet and Nutrition

Joe Tatta, PT, DPT
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Chapter 8 (References)

Sleep and Relaxation

Catherine Siengsukon, PT, PhD
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Chapter 9 (References)

Tobacco Cessation, Substance Abuse, and Recovery

Eric Chaconas, PT, DPT, PhD
Rose Pignataro, PT, DPT, PhD
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Chapter 10 (References)

Environmental Influences on Health:
The Tonic of Wildness

Todd Davenport, PT, DPT, MPH
Filip Maric, PT, PhD
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Chapter 11 (References)


Adriaan Louw, PT, PhD
Brett Neilson, PT, DPT, DSc
Jessie Podolak, PT, DPT
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  88. Schmidt SG. Recognizing potential barriers to setting and achieving effective rehabilitation goals for patients with persistent pain. Physiother Theory Pract. 2016;32(5):415-426.

Chapter 12 (References)

Mental Wellness and Spiritual Health

Timothy Benedict, PT, DPT, PhD
Jeremy C. Fletcher, PT, DPT
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  45. Yoshikawa K, Brady B, Perry MA, Devan H. Sociocultural factors influencing physiotherapy management in culturally and linguistically diverse people with persistent pain: a scoping review. Physiotherapy. 2020;107:292-305.
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  47. Johnstone B, Yoon DP. Relationships between the Brief Multidimensional Measure of Religiousness/Spirituality and health outcomes for a heterogeneous rehabilitation population. Rehabilitation Psychology. 2009;54(4):422.
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  49. Chiareli AA. Constructing a” Christian Sociological Re-Imagination:” Creation, Fall, and Redemption as a Unifying Analytical Framework. Journal of Sociology and Christianity. 2019;9(1):27-47.
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  53. Byrne N. Differences in types and levels of altruism based on gender and program. Journal of Allied Health. 2008;37(1):22-29.
  54. Figley CR. Compassion fatigue: Psychotherapists’ chronic lack of self care. Journal of clinical psychology. 2002;58(11):1433-1441.
  55. Meadors P, Lamson A. Compassion fatigue and secondary traumatization: Provider self care on intensive care units for children. Journal of Pediatric Health Care. 2008;22(1):24-34.
  56. Balogun JA, Titiloye V, Balogun A, Oyeyemi A, Katz J. Prevalence and determinants of burnout among physical and occupational therapists. Journal of allied health. 2002;31(3):131-139.
  57. Sorenson C, Bolick B, Wright K, Hamilton R. Understanding compassion fatigue in healthcare providers: A review of current literature. Journal of Nursing Scholarship. 2016;48(5):456-465.
  58. Wandling BJ, Smith BS. Burnout in orthopaedic physical therapists. Journal of Orthopaedic & Sports Physical Therapy. 1997;26(3):124-130.
  59. Akbari M, Hossaini SM. The relationship of spiritual health with quality of life, mental health, and burnout: The mediating role of emotional regulation. Iranian journal of psychiatry. 2018;13(1):22.
  60. Karr S. Avoiding physician burnout through physical, emotional, and spiritual energy. Current opinion in cardiology. 2019;34(1):94-97.
  61. Frederick TV, Dunbar S, Thai Y. Burnout in Christian perspective. Pastoral Psychology. 2018;67(3):267-276.
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  63. Rindt-Hoffman S, Kernes JL, Bui NH. Attachment style, spirituality, and compassionate love among mental health professionals. Journal of Mental Health Counseling. 2019;41(2):112-126.
  64. MacLean CD, Susi B, Phifer N, et al. Patient preference for physician discussion and practice of spirituality: Results from a multicenter patient survey. Journal of General Internal Medicine. 2003;18(1):38-43.
  65. King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. Journal of family practice. 1994;39(4):349-352.
  66. Hardiman P, Simmonds JG. Spiritual well-being, burnout and trauma in counsellors and psychotherapists. Mental Health, Religion & Culture. 2013;16(10):1044-1055.
  67. Organization WH. International Classification of Functioning, Disability and Health (ICF). https://www.who.int/classifications/international-classification-of-functioning-disability-and-health. Published 2020. Accessed.
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  69. Park CL. Making sense of the meaning literature: an integrative review of meaning making and its effects on adjustment to stressful life events. Psychological bulletin. 2010;136(2):257.
  70. Almeida VM, Carvalho C, Pereira MG. The contribution of purpose in life to psychological morbidity and quality of life in chronic pain patients. Psychology, Health & Medicine. 2020;25(2):160-170.
  71. Shaygan M, Shayegan L. Understanding the Relationship Between Spiritual Well-Being and Depression in Chronic Pain Patients: The Mediating Role of Pain Catastrophizing. Pain Management Nursing. 2019;20(4):358-364.
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  73. Pargament KI, Ensing DS, Falgout K, et al. God help me:(I): Religious coping efforts as predictors of the outcomes to significant negative life events. American journal of community psychology. 1990;18(6):793-824.
  74. Ferreira-Valente A, Sharma S, Torres S, et al. Does religiosity/spirituality play a role in function, pain-related beliefs, and coping in patients with chronic pain? A systematic review. Journal of religion and health. 2019:1-55.
  75. Barskova T, Oesterreich R. Post-traumatic growth in people living with a serious medical condition and its relations to physical and mental health: A systematic review. Disability and rehabilitation. 2009;31(21):1709-1733.
  76. De Castella R, Simmonds JG. “There’s a deeper level of meaning as to what suffering’s all about”: experiences of religious and spiritual growth following trauma. Mental Health, Religion & Culture. 2013;16(5):536-556.
  77. Hall MEL, Shannonhouse L, Aten J, McMartin J, Silverman EJ. Religion-specific resources for meaning-making from suffering: Defining the territory. Mental Health, Religion & Culture. 2018;21(1):77-92.
  78. Creed PA, Rogers ME, Praskova A, Searle J. Career calling as a personal resource moderator between environmental demands and burnout in Australian junior doctors. Journal of Career Development. 2014;41(6):547-561.
  79. Cooperstein KR, Schwartz KB. Reasons for choosing occupational therapy as a profession: Implications for recruitment. American Journal of Occupational Therapy. 1992;46(6):534-539.
  80. Dierckx K, Deveugele M, Roosen P, Devisch I. Implementation of Shared Decision Making in Physical Therapy: Observed Level of Involvement and Patient Preference. Physical therapy. 2013;93(10):1321-1330.
  81. Steiner WA, Ryser L, Huber E, Uebelhart D, Aeschlimann A, Stucki G. Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Physical therapy. 2002;82(11):1098-1107.
  82. Marantz PR. Blaming the victim: the negative consequence of preventive medicine. American journal of public health. 1990;80(10):1186-1187.
  83. Burns JW, Bruehl S. Anger management style, opioid analgesic use, and chronic pain severity: a test of the opioid-deficit hypothesis. Journal of behavioral medicine. 2005;28(6):555-563.
  84. Sullivan MJ, Adams H, Horan S, Maher D, Boland D, Gross R. The role of perceived injustice in the experience of chronic pain and disability: scale development and validation. Journal of occupational rehabilitation. 2008;18(3):249-261.
  85. Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with ‘unexplained’ chronic musculoskeletal pain: practice guidelines. Man Ther. 2011;16(5):413-418.
  86. Turk DC, Swanson KS, Tunks ER. Psychological approaches in the treatment of chronic pain patients—when pills, scalpels, and needles are not enough. The Canadian Journal of Psychiatry. 2008;53(4):213-223.
  87. LAVAND’HOMME P. Communication between Health Care Professionals and Chronic Pain Patients Time to change the “Pain Game”. Acta Orthopædica Belgica. 2015;81:572-577.
  88. Cano A, Leong L, Heller JB, Lutz JR. Perceived entitlement to pain-related support and pain catastrophizing: Associations with perceived and observed support. PAIN®. 2009;147(1-3):249-254.
  89. Oosting E, Dronkers J, Hoogeboom T, van Meeteren N, Speelman WM. Personal meaning in relation to daily functioning of a patient in physical therapy practice: narratives of a patient, a family member, and physical therapist. Disability and rehabilitation. 2018;40(10):1220-1226.
  90. Abu-Raiya H, Pargament KI. Religious coping among diverse religions: Commonalities and divergences. Psychology of Religion and Spirituality. 2015;7(1):24.
  91. Nosse LJ, Sagiv L. Theory-based study of the basic values of 565 physical therapists. Physical therapy. 2005;85(9):834-850.
  92. Mikulincer M, Gillath O, Sapir-Lavid Y, et al. Attachment theory and concern for others’ welfare: Evidence that activation of the sense of secure base promotes endorsement of self-transcendence values. Basic and Applied Social Psychology. 2003;25(4):299-312.
  93. Godfrey E, Wileman V, Galea Holmes M, et al. Physical Therapy Informed by Acceptance and Commitment Therapy (PACT) Versus Usual Care Physical Therapy for Adults With Chronic Low Back Pain: A Randomized Controlled Trial. The journal of pain : official journal of the American Pain Society. 2020;21(1-2):71-81.
  94. Wong YJ, Owen J, Gabana NT, et al. Does gratitude writing improve the mental health of psychotherapy clients? Evidence from a randomized controlled trial. Psychotherapy research : journal of the Society for Psychotherapy Research. 2018;28(2):192-202.
  95. Goubert L, Trompetter H. Towards a science and practice of resilience in the face of pain. European Journal of Pain. 2017;21(8):1301-1315.
  96. Louw A, Puentedura EL, Zimney K. Teaching patients about pain: It works, but what should we call it? Physiotherapy theory and practice. 2016;32(5):328-331.

Chapter 13 (References and Supplemental Materials)


Christine Robenalt, PT, MPT
  1. Bzdok D, Dunbar RIM. The Neurobiology of Social Distance. Trends Cogn Sci. 2020;24(9):717-733. doi:10.1016/j.tics.2020.05.016
  2. Alegría-Torres JA, Baccarelli A, Bollati V. Epigenetics and lifestyle. Epigenomics. 2011;3(3):267-277. doi:10.2217/epi.11.22
  3. Shiel, WC. Medical Definition of Stress. MedicineNet Website https://www.medicinenet.com/stress/definition.htm. Accessed December 2020.
  4. Hurley, K. What is Resilience? Your Guide to Facing Life’s Challenges, Adversities and Crises. Everyday Health Website. https://www.everydayhealth.com/wellness/resilience/. Last updated December 2020. Accessed December 2020.
  5. Bolick B, Rueter-Rice K, Madden M, et al. Child Life: Developmental Considerations. Pediatric Acute Care: A Guide for Interprofessional Practice, second edition. St. Louis, Missouri: Elsevier; 2012:32. https://books.google.com/books?hl=en&lr=&id=L2vsDwAA QBAJ&oi=fnd&pg=PP1&ots=cD17L7l7S6&sig=4dOiGza-S5P2Zvwx7Ow1qwza5wc#v=onepage&q&f=false. Accessed December 2020.
  6. Hughes D, Baylin J. Brain-Based Parenting The Neuroscience of Caregiving for Healthy Attachment, W.W. Norton & Company, INC, 2012: 6, 42-50.
  7. Babies cues and interactions. The Royal Children’s Hospital Melbourne website. https://www.rch.org.au/cocoon/your-baby/cues-and-interactions/. Accessed December 2020.
  8. Habib, N. Activate Your Vagus Nerve Unleash Your Body’s Natural Ability to Heal, Ulysses Press, 2019, 131-134.
  9. Field, Tiffany. Touch, Massachusetts Institute of Technology, 2001:130-133.
  10. Yang YC, Boen C, Gerken K, Li T, Schorpp K, Harris KM. Social relationships and physiological determinants of longevity across the human life span. Proc Natl Acad Sci U S A. 2016;113(3):578-583. doi:10.1073/pnas.1511085112
  11. Schröder M, Lüdtke J, Fux E, et al. Attachment disorder and attachment theory - Two sides of one medal or two different coins?. Compr Psychiatry. 2019;95:152139. doi:10.1016/j.comppsych.2019.152139
  12. Gatmaitan, M., & Lyons, A. Early intervention specialist program: Coaching manual. Unpublished training document, Kent State University, Kent, OH. 2013.
  13. O’Neil, M, Fragala-Pinkham, M, Miles, C, Rowland, J. Academy of Pediatric Physical Therapy Fact Sheet - The Role and Scope of Pediatric Physical Therapy in Fitness, Wellness, Health Promotion, and Prevention. https://pediatricapta.org/includes/fact-sheets/ pdfs/12%20Role%20and%20Scope%20in%20Fitness%20Health%20Promo.pdf. Published 2012. Accessed December 2020.
  14. Hodges RE, Minich DM. Modulation of Metabolic Detoxification Pathways Using Foods and Food-Derived Components: A Scientific Review with Clinical Application. J Nutr Metab. 2015;2015:760689. doi:10.1155/2015/760689
  15. STAR Institute, Resources, Tips and Downloadable Flyers. Accessed May 6 2021. https://sensoryhealth.org/basic/resources-tips-downloadable-flyers.
  16. Southwell BR. Treatment of childhood constipation: a synthesis of systematic reviews and meta-analyses. Expert Rev Gastroenterol Hepatol. 2020;14(3):163-174. doi:10.1080/17474124.2020.1733974
  17. Feeding America, Child Hunger Facts. Accessed November 10, 2021. https://www.feedingamerica.org/hunger-in-america/child-hunger-facts
  18. U.S. Department Health and Human Services. Physical Activity Guidelines for Americans, second edition. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines _2nd_edition.pdf. Published 2018. Accessed December 2020.
  19. Benedetta Pongiglione, Margaret L Kern, J D Carpentieri, H Andrew Schwartz, Neelaabh Gupta, Alissa Goodman, Do children’s expectations about future physical activity predict their physical activity in adulthood?, International Journal of Epidemiology, Volume 49, Issue 5, October 2020, Pages 1749–1758, https://doi.org/10.1093/ije/dyaa131
  20. Utesch T, Bardid F, Büsch D, Strauss B. The Relationship Between Motor Competence and Physical Fitness from Early Childhood to Early Adulthood: A Meta-Analysis. Sports Med. 2019;49(4):541-551. doi:10.1007/s40279-019-01068-y
  21. Jurado-Castro JM, Gil-Campos M, Gonzalez-Gonzalez H, Llorente-Cantarero FJ. Evaluation of Physical Activity and Lifestyle Interventions Focused on School Children with Obesity Using Accelerometry: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2020;17(17):6031. Published 2020 Aug 19. doi:10.3390/ijerph1717603
  22. Swartz MC, Teague AK, Wells SJ, et al. Feasibility and Acceptability Findings of an Energy Balance Data Repository of Children, Adolescents, and Young Adults with Cancer. J Clin Med. 2020;9(9):2879. Published 2020 Sep 6. doi:10.3390/jcm9092879
  23. West SL, Banks L, Schneiderman JE, et al. Physical activity for children with chronic disease; a narrative review and practical applications. BMC Pediatric. 2019;19(1):12. Published 2019 Jan 8. doi:10.1186/s12887-018-1377-3
  24. Cullen KE. Vestibular processing during natural self-motion: implications for perception and action. Nat Rev Neuroscience. 2019;20(6):346-363. doi:10.1038/s41583-019-0153-1
  25. Mallorquí-Bagué N, Garfinkel SN, Engels M, et al. Neuroimaging and psychophysiological investigation of the link between anxiety, enhanced affective reactivity and interoception in people with joint hypermobility. Front Psychol. 2014;5:1162. Published 2014 Oct 14. doi:10.3389/fpsyg.2014.01162
  26. Peiffer A, Brichet M, De Tiège X, Peigneux P, Urbain C. The power of children’s sleep - Improved declarative memory consolidation in children compared with adults [published correction appears in Sci Rep. 2020 Jul 24;10(1):12746]. Sci Rep. 2020;10(1):9979. Published 2020 Jun 19. doi:10.1038/s41598-020-66880-3
  27. Madrid-Valero, Juan J et al. “Children Sleep and Antisocial Behavior: Differential Association of Sleep with Aggression and Rule-Breaking.” Journal of abnormal child psychology vol. 47,5 (2019): 791-799. doi:10.1007/s10802-018-0480-0
  28. Tambalis, Konstantinos D et al. “Insufficient Sleep Duration Is Associated With Dietary Habits, Screen Time, and Obesity in Children.” Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine vol. 14,10 1689-1696. 15 Oct. 2018, doi:10.5664/jcsm.7374
  29. Schoch SF, Huber R, Kohler M, Kurth S. Which are the Central Aspects of Infant Sleep? The Dynamics of Sleep Composites across Infancy. Sensors (Basel). 2020;20(24):7188. Published 2020 Dec 15. doi:10.3390/s20247188
  30. Higuera V. What is the Best Room Temperature for Baby. Healthline website. https://www.healthline.com/health/baby/room-temperature-for-baby. Published February 21, 2020. Accessed December 2020.
  31. LeBourgeois MK, Hale L, Chang A, et al. Digital Media and Sleep in Childhood and Adolescence. Pediatrics Nov 2017, 140 (Supplement 2) S92-S96; DOI: 10.1542/peds.2016-1758J
  32. Pabary R, Goubau C, Russo K, Laverty A, Abel F, Samuels M. Screening for sleep-disordered breathing with Pediatric Sleep Questionnaire in children with underlying conditions. J Sleep Res. 2019;28(5):e12826. doi:10.1111/jsr.12826
Supplemental Materials

Item #1 – Sparkler Parents Podcast, a podcast for parents to help cultivate present moment awareness. https://anchor.fm/sparklerparents

Item #2 - Massage Sequence

The following sequence can be repeated on all areas of the child’s body.

  1. Begin with asking the child if he or she would like a massage.
  2. Start with an area of the body where the child tolerates touch.
  3. Downward Glide - Provide deep pressure to both sides of the body at the same time as you smoothly stroke downward. Repeat each area 3-5 times:
    • shoulders to hands
    • hips to feet
    • upper back to lower back
    • chest to lower belly.
  1. Upward Glide - Same stroke as above,but stroke up in the opposite direction along both sides of the body 3-5 times each area.
  2. Same side stretch - Start in the middle on one side and stroke in the opposite direction,
    applying a gentle stretch (2-3 seconds) at the end points, repeat on each side 3-5 times. This can be performed along each:
    • Arm
    • Leg
    • Torso, between the shoulder and hip.
  1. Rolling dough - Use both of your hands on either side of one shoulder or hip and gently squeeze into the muscle as you roll the limb between your hands, like rolling a dough snake. Smoothly move down the limb. Repeat 3-5 times per limb.
  2. Ending accents - End the massage with a firm, yet comforting, squeeze at the shoulders, hands, hips and feet. The pressure can be sustained for 1-2 seconds. Thank the child and the child’s body for relaxing and enjoying the massage.

Item #3 – Nutrition Links

Food allergy, intolerance, or sensitivity: What’s the difference, and why does it matter?

American Academy of Allergy, Asthma and Immunology

STAR Institute

Enteral Nutrition Article

Ketogenic Diet for Seizures

GiKids is a website established by the North American Society for Pediatric Gastroenterology,
Hepatology and Nutrition (NASPGHAN)

Food Insecurity

Harvard University Healthy Eating Plate

Chapter 14 (References and Supplemental Materials)


Elizabeth Dean, PT, PhD
Anne Söderlund, PT, PhD
  1. Dean E, Söderlund A. What is the role of lifestyle behaviour change associated with non-communicable disease risk in managing musculoskeletal health conditions with special reference to chronic pain? BMC Musculoskelet Disord. 2015 Apr 13;16:87. doi: 10.1186/s12891-015-0545-y.
  2. Gallo J, Raska M, Kriegova E, et al. Inflammation and its resolution and the musculoskeletal system. J Orthop Translat. 2017 Jul; 10: 52–67. Published online 2017 Jun 3. doi: 10.1016/j.jot.2017.05.007.
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Supplemental Materials
Table 2. Supplement: Strategies to strengthen self-efficacy with their definitions, examples, and practical tips. Informed by Bandura (1997).
Strategies to Build Self-efficacy Definition, Examples, and Practical Tips
Mastery of experience/behavior Definition: Previous success in performance increases one’s self-efficacy beliefs for future behavior; and conversely, failing in performance can decrease self-efficacy.

Example: Walking with manageable pain positively influences walking self-efficacy and increases the likelihood of that behavior.

Tip: Goal for the specific behavior must be realistic.
Vicarious experience Definition: Social comparison with others in similar situations influences self-efficacy.

Example: Observing others with shoulder problems performing exercise at a gym increases patient’s self-efficacy for gym exercises.

Media and specifically social media can be a source for vicarious influence or modeling either positively which is desirable, or negatively, which is undesirable.

Tip: Identify information and sources of comparison that the patient is being influenced by.
Verbal persuasion Definition: Persuasive instructive advice by health care staff and significant others can increase self-efficacy in performing new behavior.

Example: Health care providers usually give the patient positive feedback and encouragement, which can have a positive effect. But, if the patient’s significant others do not similarly support the patient, self-efficacy may decrease.

Tip: Include significant others if possible, when talking to the patient about changing behavior.
Physiological and affective states Definition: Somatic symptoms and emotional reactions in stressful situations can lead to perceived vulnerability and thus decrease self-efficacy for the new behavior.

Example: A patient with shoulder problems may perceive quitting smoking as stressful and react with palpitations, perspiration, and anxiety making the situation more aversive.

Tip: Identify patient’s physiological and emotional reactions to stressful situations.

Bandura A. Self-efficacy: The exercise of control. New York: W.H. Freeman and Company; 1997.

Table 3. Behavior change supporting interventions for initiation, adherence and maintenance of behavior. Informed by Abraham and Michie (2008).
Behavior Change Supporting Interventions Practical Tips
Provide information Communicate in a person-centered manner with active listening about needed lifestyle changes; and pros and cons of the old and new behavior (decision balance analysis).

Provide information and discuss the targeted lifestyle changes and prioritizing these targeted behaviors.

Identify the stage of readiness to change each given behavior targeted for change and establish and the need for instituting the 5 A’s if the patient is at the contemplation stage or higher; or the 5 R’s if the patient is at the pre-contemplation stage, i.e., not ready to change.
Set goals, develop an action plan, and revise goals as indicated Prioritize goals and goal setting are based on the patient’s preferences. Often it is advisable to focus on one lifestyle behavior at a time to maximize success in reaching each specific goal, thereby increase the patient’s self-efficacy for behavior change (see table 2 on Strategies to Strengthen Self-efficacy).

Set goals along with a detailed action plan about what the person plans to do, i.e., where, when, how, and with whom.

Use SMART to define each goal: Specific, Measurable, Action-based, Realistic, and Time framed. In addition, for increasing physical activity, the activities must be engaging and enjoyable.

Ensure goals are excessive or too long-term. Ambitious goals can be partitioned into multiple sub-goals. Multiple goals addressing several behaviors need to be distinct and partitioned into small steps that can be achieved in the short term. Achievements are perceived as rewarding, in turn, will increase the likelihood new lifestyle practices will be maintained.

As goals are achieved, revise and progress them to facilitate adherence to new lifestyle behavior practices.
Set graded tasks Set easy tasks first and gradually increase complexity of the behavior which will increase adherence. This means also, that the patient will succeed in the tasks, thus increase self-efficacy in the target behavior.

Example: In smoking cessation, start with refraining at home in a situation where one is least tempted to smoke. When that goal has been reached move to the work context and then to a dinner with friends (party), and then in stressful situations.
Teach self-monitoring Record specific behaviors with a diary or digital mobile applications which is one of the most effective behavior change interventions. Report what has been done, how it was done, what were the physical and emotional consequences, all agreed to with the patient.

Example: Identify thoughts, feelings, emotions and beliefs related to the new behavior being learned such as those related to the frequency of physical activity. Self-monitoring also increases adherence to rehearsal of the behavior.
Provide feedback and reinforcement Give feedback and reinforcement to the patient about the behavior and related to the patient’s reports from self-monitoring.

Teach patient to give feedback and reinforcement to her/himself. Also, encourage patient to teach their significant others to give feedback and reinforcement to the patient.

Feedback and reinforcement also increase adherence and maintenance of the new behavior throughout the follow-up sessions.
Teach problem solving Teach the patient problem solving skills for risk situations for relapsing to old behavior to maximize maintenance of the new behaviour.

Example: Plan for how the patient can best support her/himself to refrain if s/he, for example, reaches for a cigarette.
Identify barriers for maintenance Teach the patient how to identify barriers for performing the behavior and how to handle them.
Use social comparison Encourage the patient to observe how others manage to perform the patient’s new behavior. This can be done in real life situations with peer-patients or using video recordings.

Abraham C, Michie S. A taxonomy of behavior change techniques used in interventions. Health Psychol. 2008;27(3):379-87.


A Health and Lifestyle Framework for Physical Therapist Clinical Practice Guidelines for Individuals with Orthopedic Conditions:

Sampling of Evidence Supporting Lifestyle Behavior Change as a Priority for Maximizing Musculoskeletal Health

On-going Assessments:

  • Multi-system health status to rule out factors and conditions that can contribute to functional impairment other than musculoskeletal conditions.
  • Medications and their effects with respect to maximizing functional capacity and health-related quality of life and potentially compromising activity and health-related quality of life.

Positive Healthy Lifestyle Practices
Sampling of Evidence Supporting Effects of Adverse Lifestyle Practice on Low-grade Systemic Inflammation and Musculoskeletal Health, and Related Assessment and Interventions for Positive Lifestyle Behavior Change
Not Smoking
Assessment and Evaluation

  • History of smoking and quit attempts
  • Readiness to change; 5 A’s if ready to change, 5 R’s if not ready to change*
  • Facilitators and barriers
  • Adherence to smoking cessation initiatives and provide judicious support and reinforcement

Promote smoking cessation initiatives, provide related resources, and support initiatives of other health professional
Dilyara YG, Mieke AD, Creutzberg EC, et al. Systemic effects of smoking. Chest. 2007;131:1557-1566. Briggs AM, Straker LM, Wark JD. Bone health and back pain: What do we know and where should we go? Osteoporosis Int. 2009;20(2):209-219. Abate M, Vanni D, Pantalone A, et al. Cigarette smoking and musculoskeletal disorders. Muscles Ligaments Tendons J. 2013 Jul 9;3(2):63-69.

Zaccardelli A, Friedlander HM, Ford JA, et al. Potential of lifestyle changes for reducing the risk of developing rheumatoid arthritis: Is an ounce of prevention worth a pound of cure? Clin Ther. 2019 Jul;41(7):1323-1345.

Silverstein P. Smoking and wound healing. Am J Med. 1992;93(1A):22S-24S.

A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. JAMA. 2000;283(24):3244-54.

Smoking and bone health [Internet]. Bethesda, MD: NIH Osteoporosis and Related Bone Diseases National Resource Center; 2012 [cited 2014 Jan 20]. Available from: http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/bone_smoking.asp How Smoking Slows Down Healing After An Injury. National Pain and Spine Centers. https://www.treatingpain.com/news-updates/2020/march/how-smoking-slows-down-healing-after-an-injury/

Refer to chapter section on ‘Lifestyle Medicine Competencies in Physical Therapist Practice: Assessment and Interventions’ for specific evidence-based lifestyle behavior change strategies.
Consuming Whole-food Plant-based Diet
Assessment and Evaluation

  • History of smoking and quit attempts
  • Readiness to change; 5 A’s if ready to change, 5 R’s if not ready to change*
  • Facilitators and barriers
  • Adherence to smoking cessation initiatives and provide judicious support and reinforcement

Promote smoking cessation initiatives, provide related resources, and support initiatives of other health professional
Dilyara YG, Mieke AD, Creutzberg EC, et al. Systemic effects of smoking. Chest. 2007;131:1557-1566. Briggs AM, Straker LM, Wark JD. Bone health and back pain: What do we know and where should we go? Osteoporosis Int. 2009;20(2):209-219. Abate M, Vanni D, Pantalone A, et al. Cigarette smoking and musculoskeletal disorders. Muscles Ligaments Tendons J. 2013 Jul 9;3(2):63-69.

Zaccardelli A, Friedlander HM, Ford JA, et al. Potential of lifestyle changes for reducing the risk of developing rheumatoid arthritis: Is an ounce of prevention worth a pound of cure? Clin Ther. 2019 Jul;41(7):1323-1345.

Silverstein P. Smoking and wound healing. Am J Med. 1992;93(1A):22S-24S.

A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. JAMA. 2000;283(24):3244-54.

Smoking and bone health [Internet]. Bethesda, MD: NIH Osteoporosis and Related Bone Diseases National Resource Center; 2012 [cited 2014 Jan 20]. Available from: http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/bone_smoking.asp How Smoking Slows Down Healing After An Injury. National Pain and Spine Centers. https://www.treatingpain.com/news-updates/2020/march/how-smoking-slows-down-healing-after-an-injury/

Refer to chapter section on ‘Lifestyle Medicine Competencies in Physical Therapist Practice: Assessment and Interventions’ for specific evidence-based lifestyle behavior change strategies.
Maintaining a Healthy Weight
Assessment and Evaluation

  • Weekly records of body weight (recognizing this can be influenced by fluid retention) and waist-hip ratio
  • Readiness to change*; 5 A’s if ready to change and 5 R’s if not ready to change
  • Facilitators and barriers
  • Adherence to healthy nutrition and provide judicious support and reinforcement

Promote healthy nutrition, provide related resources, and support initiatives of other health professionals

Note: weight loss judiciously in patients with heart failure due to the obesity paradox observed in these patients
Greger M. How not to diet. Evidence synthesis monograph. Flatiron Books: New York, NY. 2019.

Arranz L, Rafecas M, Alegre C. Effects of obesity on function and quality of life in chronic pain conditions. Curr Rheumatol Rep. 2014 Jan;16(1):390.

Liljensoe A, Lauersen JO, Soballe K, et al. Overweight preoperatively impairs clinical outcome after knee arthroplasty: a cohort study of 197 patients 3-5 years after surgery. Acta Orthop. 2013 Aug;84(4):392-397.

Hulsmans M, Geeraert B, De Keyzer D, et al. Interleukin-1 receptor-associated kinase-3 is a key inhibitor of inflammation in obesity and metabolic syndrome. PLoS One. 2012;7(1):e30414.

Zaccardelli A, Friedlander HM, Ford JA, et al. Potential of lifestyle changes for reducing the risk of developing rheumatoid arthritis: Is an ounce of prevention worth a pound of cure? Clin Ther. 2019 Jul;41(7):1323-1345.

Issa RI, Griffin TM. Pathobiology of obesity and osteoarthritis: integrating biomechanics and inflammation. Pathobiol Aging Age Relat Dis. 2012 May 9;2(2012):17470.

Stienstra R, Duval C, Muller M, et al. PPARs, obesity, and inflammation. PPAR Res. 2007:95974.

Dean E, Gormsen Hansen R. Prescribing optimal nutrition and physical activity as “first-line” interventions for best practice management of chronic low-grade inflammation associated with osteoarthritis: evidence synthesis. Arthritis. 2012;560634.

Guneli E, Gumustekin M, Ates M. Possible involvement of ghrelin on pain threshold in obesity. Med Hypotheses. 2010 Mar;74(3):452-454.

Shiri R, Viikari-Juntura E, Varonen H, et al. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006 Dec 1;164(11):1065-1074.

Kushner RF. Road maps for clinical practice: case studies in disease prevention and health promotion-assessment and management of adult obesity: a primer for physicians [Internet]. Atlanta, GA: American Medical Association; 2003 [cited 2014 Jan 20]; Available from: www.yaleruddcenter.org/resources/upload/docs/what/bias/AMAprimerforobesitycommunication.pdf.

DeMarco MA, Maynard JW, Huizinga MM, et al. Obesity and younger age at gout onset in a community-based cohort. Arthritis Care Res (Hoboken). 2011;63(8):1108-1114.

Mezhov V, Ciccutini FM, Hanna FS, et al. Does obesity affect knee cartilage? A systematic review of magnetic resonance imaging data. Obes Rev. 2014 Feb;15 (2): 143-157.

Paulis WD, Silva S, Koes BW, et al. Overweight and obesity are associated with musculoskeletal complaints as early as childhood: a systematic review. Obes Rev. 2014 Jan;15(1):52-67.

Seaman DR. Body mass index and musculoskeletal pain: is there a connection? Chiropr Man Therap. 2013 May 20;21(1):15.

Bierma-Zeinstra SM, Koes BW. Risk factors and prognostic factors of hip and knee osteoarthritis. Nat Clin Pract Rheumatol. 2007 Feb;3(2):78-85.

Woolner J, Dean E. Status of weight reduction as an intervention in physical therapy management of low back pain: systematic review and implications. Eur J Physiother. 2013;15(2):46-55.

Kandil A, Novicoff W, Browne J. Obesity and total joint arthroplasty: do patients lose weight following surgery? Phys Sportsmed. 2013;41(2):34-37.

Refer to chapter section on ‘Lifestyle Medicine Competencies in Physical Therapist Practice: Assessment and Interventions’ for specific evidence-based lifestyle behavior change strategies.
Consuming Moderate, or No, Alcohol
Assessment and Evaluation

  • Alcohol use and consumption; past and present; administer CAGE Questionnaire
  • Readiness to change*; 5 A’s if ready to change and 5 R’s if not ready to change
  • Facilitators and barriers
  • Adherence to moderate alcohol initiatives and provide judicious support and reinforcement

Promote moderate, if any, alcohol consumption initiatives (men: 2 drinks/day; women: 1 drink/day), provide related resources, and support initiatives of other health professionals and support group participation, e.g., Alcoholics Anonymous
Gaydos J, McNally A, Guo R, et al. Alcohol abuse and smoking alter inflammatory mediator production by pulmonary and systemic immune cells. Trans Res Acute Lung Inj Pulm Fib. 2016; 310:L507-L518.

Wang HJ, Zakhari S, Jung MK. Alcohol, inflammation, and gut-liver-brain interactions in tissue damage and disease development. World J Gastroenterol. 2010;16(11):1304–1313.

Sarkar D, Jung MK, Wang HJ. Alcohol and the immune system. Alcohol Res. 2015;37(2):153-155.

National Institute of Alcohol Abuse and Alcoholism. National Institute of Health. Alcohol’s effect on the body. www.niaaa.nih.gov/alcohols-effects-health/alcohols-effects-body.

US Preventive Services Task Force. Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults. US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(18):1899-1909.

Jain NB, Ayers GD, Fan R, et al. Predictors of pain and functional outcomes after operative treatment for rotator cuff tears. Shoulder Elbow Surg. 2018;27(8):1393–1400.

Passaretti D, Candela V, Venditto T, et al. Association between alcohol consumption and rotator cuff tear. Acta Orthop. April, 2016; 87(2): 165–168.

Avishai E, Yeghiazaryan K, Golubnitschaja O. Impaired wound healing: facts and hypotheses for multi-professional considerations in predictive, preventive and personalised medicine. EPMA J. 2017; 8(1):23–33.

Drink Quantity Recommendations. Dietary Guidelines for Americans 2020-2025. 8 ed. https://health.gov/sites/default/files/2019-09/2015-2020_Dietary_Guidelines.pdf (NOTE: guideline recommendations only, as these are for generally healthy individuals) Ewing JA. Detecting alcoholism. The CAGE Questionnaire. JAMA. 1984;252(14):1905-1907. Modified Single Alcohol Screening Questionnaire (M SASQ) and Remaining Alcohol Harm Assessment Questions from AUDIT. https://assets.publishing.service.gov.uk/government/uploads/system/ uploads/attachment_data/file/684829/Single_question_alcohol_use_test__M_SASQ_.pdf

Refer to chapter section on ‘Lifestyle Medicine Competencies in Physical Therapist Practice: Assessment and Interventions’ for specific evidence-based lifestyle behavior change strategies.
Reducing Sedentariness
  • Sitting for short defined periods only; e.g., upright and moving every 30 minutes, parameters based on assessment to reduce total sedentariness and bouts of sedentariness

Assessment and Evaluation

  • Sedentary behavior; past and present
  • Readiness to change; 5 A’s if ready to change and 5 R’s if not ready to change
  • Facilitators and barriers
  • Adherence to being upright and moving initiatives and provide judicious support and reinforcement

Promote frequent upright and moving initiatives, provide related resources, and support initiatives of other health professionals
Stefánsdóttir RS. Sedentary behavior and musculoskeletal pain: a five-year longitudinal Icelandic study. Doctoral Thesis. https://skemman.is/bitstream/1946/26263/1/MPH_lokaritgerd.pdf.

Whedon GD. Disuse osteoporosis: physiological aspects. Calcif Tissue Int. 1984;36Suppl 1:S146-50.

Park JH, Moon JH, Kim HJ, et al. Sedentary lifestyle: Overview of updated evidence of potential health risks. Korean J Fam Med. 2020;41(6):365-373.

Chen SM, Liu MF, Cook J, et al. Sedentary lifestyle as a risk factor for low back pain: a systematic review. Int Arch Occup Environ Health. 2009;82(7):797-806.

Lis AM, Black KM, Korn H, et al. Association between sitting and occupational LBP. Eur Spine J. 2007;16(2):283-98.
Van Uffelen JG, Wong J, Chau JY, et al. Occupational sitting and health risks: a systematic review. Am J Prev Med. 2010 Oct 31;39(4):379-88.

Tudor-Locke C, Craig CL, Thyfault JP, et al. A step-defined sedentary lifestyle index: <5000 steps/day. Appl Physiol Nutr Metab. 2013;38(2):100-114.

Refer to chapter section on ‘Lifestyle Medicine Competencies in Physical Therapist Practice: Assessment and Interventions’ for specific evidence-based lifestyle behavior change strategies.
Being Regularly Physically Active
e.g., every 3-4 hours, parameters based on assessment

Assessment and Evaluation

  • Physical activity status, past and present
  • Walking; number of steps
  • Readiness to change; 5 A’s if ready to change and 5 R’s if not ready to change
  • Facilitators and barriers
  • Adherence to increased physical activity initiatives and provide judicious support and reinforcement

Promote physical activity initiatives, provide related resources, and support initiatives of other health professionals
Hootman JM, Macera CA, Ham SA, et al. Physical activity levels among the general US adult population and in adults with and without arthritis. Arthritis Rheum. 2003;49(1):129-135.

Celis-Morales CA, Perez-Bravo F, Ibanez L, et al. Objective vs. self-reported physical activity and sedentary time: effects of measurement method on relationships with risk biomarkers. PLoS ONE. 2012;7(5):e36345.

Draganidis D, Jamurtas AZ, Stampoulis T, et al. Disparate habitual physical activity and dietary intake profiles of elderly men with low and elevated systemic inflammation. Nutrients. 2018;10(5):566

Gennuso KP, Gangnon RE, Matthews CE, et al. Sedentary behavior, physical activity, and markers of health in older adults. Med Sci Sports Exerc. 2013;45(8):1493-1500.

Smuck M, Kao M, Brar N, et al. Does physical activity influence the relationship between low back pain and obesity? Spine J. 2014;14(2):209-216.

Teichtahl AJ, Urquhart DM, Wang Y, et al. Physical inactivity is associated with narrower lumbar intervertebral discs, high fat content of paraspinal muscles and low back pain and disability. Arthritis Res Ther. 2015 Dec 1;17(1):17.

Zaccardelli A, Friedlander HM, Ford JA, et al. Potential of lifestyle changes for reducing the risk of developing rheumatoid arthritis: Is an ounce of prevention worth a pound of cure? Clin Ther. 2019 Jul;41(7):1323-1345.

Nilsen TI, Holtermann A, Mork PJ. Physical exercise, body mass index, and risk of chronic pain in the low back and neck/shoulders: Longitudinal data from the Nord-Trøndelag Health Study. Am J Epidemiol. 2011 Jun 1:kwr087.

Holth H, Werpen H, Zwart JA, et al. Physical inactivity is associated with chronic musculoskeletal complaints 11 years later: results from the Nord-Trøndelag Health Study. BMC Musculoskeletal Disorders. 2008;9(1):1.

Sitthipornvorakul E, Janwantanakul P, Purepong N, et al. The association between physical activity and neck and low back pain: a systematic review. Eur Spine J. 2011;20(5):677-89.

Hildebrandt VH, Bongers PM, Dul J, et al. The relationship between leisure time, physical activities and musculoskeletal symptoms and disability in worker populations. Int Arch Occup Environ Health. 2000 Oct 1;73(8):507-18. Coombes JS, Law J, Lancashire B, et al. “Exercise is medicine”: curbing the burden of chronic disease and physical inactivity. Asia Pac J Public Health. 2015;27(2):NP600-5.

Physical activity guidelines for Americans. 2nd Ed. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf.

Delitto A, George SZ, Van Dillen LR, et al. Low back pain: clinical practice guidelines linked to the International Classification of Functioning. J Orthop Sports Phys Ther. 2012;42(4):A1-A57.

McDonough SM, Tully MA, Boyd A, et al. Pedometer-driven walking for chronic low back pain: a feasibility randomized controlled trial. Clin J Pain. 2013;29(11):972-81.

Nawrocka A, Niestrój-Jaworska M, Mynarski A, et al. Association between objectively measured physical activity and musculoskeletal disorders, and perceived work ability among adult, middle-aged and older women. J. Clin Interv Aging. 2019;14:1975-1983.

Warburton DE, Nicol CW, Bredin SS. Prescribing exercise as preventive therapy. CMAJ. 2006;174 (7):961-974.

WHO Physical inactivity a leading cause of disease and disability, warns WHO [Internet]. World Health Organization; 2002 [updated 2014; cited 2014 Jan 20] Available from: http://www.who.int/mediacentre/news/releases/release23/en/index.html.

International Physical Activity Questionnaire: IPAQ: short last 7 days self-administered format. [Internet]. IPAQ website; 2001[cited 2014 Feb 22]. Available from:


Tudor-Locke C, Bassett DR Jr. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Med. 2004;34(1):1-8.

Get Active Questionnaire. Canadian Society of Exercise Physiologists. http://www.ipaq.ki.se/questionnaires/IPAQ_S7S_FINAL_MAY_01.pdf.

Refer to chapter section on ‘Lifestyle Medicine Competencies in Physical Therapist Practice: Assessment and Interventions’ for specific evidence-based lifestyle behavior change strategies.
Participating in Structured Exercise**
Assessment and Evaluation

  • Structured exercise status, past and present (types, intensities, durations, frequencies, and courses), parameters based on assessment
  • Readiness to change*; 5 A’s if ready to change and 5 R’s if not ready to change
  • Facilitators and barriers
  • Attitudes, beliefs and experiences with exercise programs in the past; in addition to SMART goals, Activities/exercises that are enjoyable and engaging
  • Adherence to structured exercise initiatives and provide judicious support and reinforcement

Promote structured exercise initiatives, provide related resources, and support initiatives of other health professionals
Need for structured exercise is variable given need for functional outcomes; role for general conditioning but emphasis may need to be frequency of physical activity and functionally based.

Exercise for patients with secondary diagnoses of cardiac, pulmonary and metabolic conditions is not possible without consideration of:

  1. Underlying contributors such as ischemic heart disease, hypertension, and type 2 diabetes, obesity
  2. Prevalence of musculoskeletal conditions in patients with heart disease, e.g., arthritis
  3. Prevalence of mental ill health issues independent of or associated with heart ill health, e.g., fear, anxiety, depression, stress
Vuori I. Exercise and physical health: musculoskeletal health and functional capabilities. Res Q Exerc Sport. 1995;66(4):276-285.

Beavers KM, Brinkley TE, Nicklas BJ. Effect of exercise training on chronic inflammation. Clin Chim Acta. 2010; 411:785–793.

Nicklas BJ, Brinkley TE. Exercise training as a treatment for chronic inflammation in the elderly. Exerc Sport Sci Rev. 2009; 37(4):165–170.

Refer to chapter section on ‘Lifestyle Medicine Competencies in Physical Therapist Practice: Assessment and Interventions’ for specific evidence-based lifestyle behavior change strategies.
Sleeping Optimally
Assessment and Evaluation

  • Sleep history quality and quantity with established questionnaires
  • Readiness to change*; 5 A’s if ready to change and 5 R’s if not ready to change
  • Assess facilitators and barriers
  • Adherence to sleep hygiene initiatives and provide judicious support and reinforcement

Promote sleep hygiene initiatives, provide related resources, and support initiatives of other health professionals
Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539-1552.

Morin CM, Benca R. Chronic insomnia. Lancet. 2012 March 24;379(9821):1129-1141.

van de Water AT, Eadie J, Hurley DA. Investigation of sleep disturbance in chronic low back pain: an age- and gender-matched case-control study over a 7-night period. Man Ther. 2011 Dec;16(6):550-556.

Knowles OE, Drinkwater EJ, Urwin CS, et al. Inadequate sleep and muscle strength: Implications for resistance training. J Sci Med Sport. 2018 Sep;21(9):959-968.

Chun MY, Cho BJ, Yoo SH, et al. Association between sleep duration and musculoskeletal pain: The Korea National Health and Nutrition Examination Survey 2010-2015. Medicine. 2018;97(50):e13656. doi: 10.1097/MD.0000000000013656.

O’Donoghue GM, Fox N, Heneghan C, et al. Objective and subjective assessment of sleep in chronic low back pain patients compared with healthy age and gender matched controls: a pilot study. BMC Musculoskelet Disord. 2009 Oct 2;10:122.

Haack M, Scott-Sutherland J, Santangelo G, et al. Pain sensitivity and modulation in primary insomnia. Eur J Pain. 2012 Apr;16(4):522-533.

Kundermann B, Krieg JC, Schreiber W, et al. The effect of sleep deprivation on pain. Pain Res Manag. 2004 Spring;9(1):25-32.

Schuh-Hofer S, Wodarski R, Pfau DB, et al. One night of total sleep deprivation promotes a state of generalized hyperalgesia: a surrogate pain model to study the relationship of insomnia and pain. Pain. 2013 Sep;154(9):1613-1621.

Tang NK, Wright KJ, Salkovskis PM. Prevalence and correlates of clinical insomnia co-occurring with chronic back pain. J Sleep Res. 2007 Mar;16(1):85-95.

Simpson N, Dinges DF. Sleep and inflammation. Nutr Rev. 2007 Dec;65(12 Pt 2):S244-52.

Pittsburgh Sleep Index (PSQI). https://www.med.upenn.edu/cbti/assets/user-content/documents/Pittsburgh%20Sleep%20Quality%20Index%20(PSQI).pdf.

Refer to chapter section on ‘Lifestyle Medicine Competencies in Physical Therapist Practice: Assessment and Interventions’ for specific evidence-based lifestyle behavior change strategies.
Managing Stress
Assessment and Evaluation

  • Stressors’ status, past and present; and interventions that reduced stress in the past
  • Readiness to change*; 5 A’s if ready to change and 5 R’s if not ready to change
  • Facilitators and barriers
  • Adherence to structured stress management initiatives and provide judicious support and reinforcement

Promote stress management initiatives, provide related resources, and support initiatives of other health professionals
Eriksson S, Gard G. Physical exercise and depression. Phys Ther Rev. 2011;16(4):261-268.

Lemyre L, Lalonde-Markon MP. Psychological stress measure (PM-9): integration of an evidence-based approach to assessment, monitoring, and evaluation of stress in physical therapy practice. Physiother Theory Pract. 2009;25(5-6):453-462.

Lloyd C, Waghorn G, McHugh C. Musculoskeletal disorders and comorbid depression: implications for practice. Aust Occup Ther J. 2008;55(1):23-29.

Marazziti D, Castrogiovanni P, Rossi A, et al. Pain threshold is reduced in depression. Int J Neuropsychopharmacol. 1998;1(1):45-48.

Centers for Disease Control and Prevention. Prevalence of disabilities and associated health conditions among adults--United States, 1999.JAMA. 2001;285(12):1571-2.

Krishnan KRR, France RD, Pelton S, McCann UD, Davidson J, Urban BJ. Chronic pain and depression. II: symptoms of anxiety in chronic low back pain patients and their relationship to subtypes of depression. Pain. 1985;22(3):289-294

Melloh M, Elfering A, Käser A, et al. Depression impacts the course of recovery in patients with acute low-back pain. Behav Med. 2013;39(3):80-89.

de Mello Franco FG, Laurinavicius AG, Lotufo PA, et al. Persistent depressive symptoms are Independent predictors of low-grade inflammation onset among healthy individuals. Arq Bras Cardiol. 2017;109(2):97–102

Refer to chapter section on ‘Lifestyle Medicine Competencies in Physical Therapist Practice: Assessment and Interventions’ for specific evidence-based lifestyle behavior change strategies.

*Intervention includes health competencies in which the physical therapist assesses each lifestyle practice, then initiates indicated lifestyle change strategies and/or refers to other established health professional(s). The physical therapist is responsible for assessing the patient’s interest and willingness to change behaviors and, if so, the degree of adherence to the recommendations, even when a patient is referred to other health professionals to support and reinforce their initiatives.

*5 A’s - Ask about the target health behavior, Advise to change the behavior, Assess willingness to attempt to change the behavior, Assist in changing the behavior, Arrange follow-up; a 6th ‘A’ is accountability of the clinician to support the patient through the defined health behavior change goals, and accountability of the patient in reporting back to the clinician. Such feedback enables the clinician and patient to progress, maintain or revisit the goals to ensure they are realistic and achievable.

5 R’s - Determine the Relevance of changing behavior to patient, Discuss the Risks of patient’s continued deleterious behavior, Explore Rewards of changing behavior, Examine possible Roadblocks to changing behavior, Continue Repetition of the discussion

** Activity and exercise are conducted in accordance with the patient’s medication regimen which need to be modified as lifestyle behavior changes are effected

Chapter 15 (References and Supplemental Materials)


LaVerene Garner, PT, DPT
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Supplemental Materials
Table 1. Screen for nervous system overall well-being
Behavior Screening Tool Physical Therapist Action
Sleep Pittsburgh Sleep Quality Index1 Education on sleep hygiene and refer to physician for potential sleep study
Smoking Cessation Do you smoke?
If yes, complete:
Fagerstrom Test for Cigarette Dependence (FTCD)2
Motivational interviewing to promote behavior change related to smoking

Educate on increased risk of cancer as well as Alzheimer’s Disease and Multiple Sclerosis

Refer to smoking cessation program
Vitamin D and E Blood work through primary care physician Refer to physician for screening and remediation
Physical Activity Godin Leisure-Time Exercise Questionnaire3,4 Address physical activity engagement through SMART goals and behavior change
Self-efficacy for PA Marcus Self-efficacy for physical activity5 Utilize SMART goal setting to facilitate mastery
Nutrition 7 day food journal

Start The Conversation Screen6

AUDIT-C (Alcohol Screening)7
Educate on benefits of plant based diet

Refer as necessary
Relationships Perform the 3 item loneliness scale8 or the UCLA Loneliness Questionnaire 9 Refer to behavioral health provider

Encourage positive relationships through church, physical activity groups, and other social group settings such as book clubs

Refer older adults to community based programs
Relationships Perform the 3 item loneliness scale8 or the UCLA Loneliness Questionnaire 9 Refer to behavioral health provider

Encourage positive relationships through church, physical activity groups, and other social group settings such as book clubs

Refer older adults to community based programs
Accident and fall prevention In individuals over the age of 65 screen for fall risk:

Falls Efficacy Scale - International10,11

Have you fallen in the last 6 months?
Are you taking psychotropic medications?12

Do you require assist with ADL’s?12

Are you afraid of falling?12
Do you use an assistive device to walk?12

Objective Screeners:

Timed Up and Go:13,14

Five Time Sit to Stand15,16
If the questions to the left indicate increased risk of falling, then one or all of the following should occur:

Perform balance test such as the Mini-BESTest17 to determine what is contributing to balance problems.

Refer to MD for medication changes as needed

Ensure client is having vision checked regularly
References for Supplemental Materials (Table 1)
  1. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193-213. doi:10.1016/0165-1781(89)90047-4
  2. Fagerstrom K. Determinants of Tobacco Use and Renaming the FTND to the Fagerstrom Test for Cigarette Dependence. Nicotine Tob Res. 2012;14(1):75-78. doi:10.1093/ntr/ntr137
  3. Godin G, Shephard RJ. A simple method to assess exercise behavior in the community. Can J Appl Sport Sci. 1985;10(3):141-146.
  4. Godin G. The Godin-Shephard Leisure-Time Physical Activity Questionnaire. Health Fit J Cananda. 2011;4(1):18-22.
  5. Marcus BH, Selby VC, Niaura RS, Rossi JS. Self-Efficacy and the Stages of Exercise Behavior Change. Res Q Exerc Sport. 1992;63(1):60-66. doi:10.1080/02701367.1992.10607557
  6. Paxton AE, Strycker LA, Toobert DJ, Ammerman AS, Glasgow RE. Starting the conversation performance of a brief dietary assessment and intervention tool for health professionals. Am J Prev Med. 2011;40(1):67-71. doi:10.1016/j.amepre.2010.10.009
  7. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998;158(16):1789-1795. doi:10.1001/archinte.158.16.1789
  8. Hughes ME, Waite LJ, Hawkley LC, Cacioppo JT. A Short Scale for Measuring Loneliness in Large Surveys. Res Aging. 2004;26(6):655-672. doi:10.1177/0164027504268574
  9. Russell D, Peplau LA, Cutrona CE. The revised UCLA Loneliness Scale: concurrent and discriminant validity evidence. J Pers Soc Psychol. 1980;39(3):472-480. doi:10.1037//0022-3514.39.3.472
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  11. Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C. Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age Ageing. 2005;34(6):614-619. doi:10.1093/ageing/afi196
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  15. Whitney SL, Wrisley DM, Marchetti GF, Gee MA, Redfern MS, Furman JM. Clinical Measurement of Sit-to-Stand Performance in People With Balance Disorders: Validity of Data for the Five-Times-Sit-to-Stand Test. Phys Ther. 2005;85(10):1034-1045. doi:10.1093/ptj/85.10.1034
  16. Buatois S, Miljkovic D, Manckoundia P, et al. Five Times Sit to Stand Test Is a Predictor of Recurrent Falls in Healthy Community-Living Subjects Aged 65 and Older. J Am Geriatr Soc. 2008;56(8):1575-1577. doi:10.1111/j.1532-5415.2008.01777.x
  17. Franchignoni F, Horak F, Godi M, Nardone A, Giordano A. Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest. J Rehabil Med. 2010;42(4):323-331. doi:10.2340/16501977-0537
Table 2. Intervention Guide and Screening Tools for People with PD
Early (Hoehn and Yahr I and II) Middle (Hoehn and Yahr II and II) Late (Hoehn and Yahr IV and V)
High intensity exercise when possible (80-85%)1,2

Moderate intensity if high intensity not appropriate (60-65%)1,2

*Bike, treadmill, or overground walking are acceptable examples of exercise modalities3
High intensity exercise when possible (especially in earlier stages)1,2

Moderate intensity if high intensity not possible (60-65% HRR)1,2

*Bike, treadmill, or overground walking are acceptable examples of exercise modalities3
Low to moderate intensity exercise
Strength training: 2-3x/wk at moderate intensity4 Strength training: 2-3xwk at moderate intensity4 Seated strength training as tolerated
Flexibility/Stretching most days of the week5 Flexibility/stretching most days of the week5 Flexibility/stretching ALL days of the week5
Combine postural control activities with strength training (walking lunges with or without rotation, windmills) Postural control may still be combined with strength training if safe, however, if not progress to strength and postural control separately Those at Hoehn and Yahr IV may perform standing postural control activities. Those at Hoehn and Yahr V are primarily bed and wheelchair bound, so seated postural control exercise is most appropriate.
Postural control tests

  • Mini BESTest6
  • Functional Gait Assessment7

Other tests and measures appropriate for individuals with PD can be found in the PD Edge Documents developed by the APTA – neurology.8
Postural Control tests

  • Mini BESTest6
  • Functional Gait Assessment7

Other tests and measures appropriate for individuals with PD can be found in the PD Edge Documents developed by the APTA – neurology.8
Postural Control tests

  • Hoehn and Yahr IV - Berg Balance Test9
  • Hoehn and Yahr V - Seated balance test

Other tests and measures appropriate for individuals with PD can be found in the PD Edge Documents developed by the APTA – neurology.8
Community Based Exercise programs:

Boxing programs

Programs focusing on large, powerful movements

Tai Chi10
Community Based Exercise programs:

Boxing programs
Programs focusing on large, powerful movements
Tai Chi10
Can engage in community-based exercise programs if seated:
Consistent appointments (monthly, quarterly, biannually) with PT to assess any improvement or decline in function; modify exercise program. Consistent appointments (monthly, quarterly, biannually) with PT to assess any improvement or decline in function; modify exercise program. Consistent appointments (monthly, quarterly, biannually) with PT to alter exercise program and assess any improvement or decline in function; modify exercise program. Consistent appointments (monthly quarterly, biannually) with PT to alter exercise program and assess any improvement or decline in function; modify exercise program.
Caregiver training
Assistive devices
References for Supplemental Materials (Table 2)
  1. Schenkman M, Moore CG, Kohrt WM, et al. Effect of High-Intensity Treadmill Exercise on Motor Symptoms in Patients With De Novo Parkinson Disease: A Phase 2 Randomized Clinical Trial. JAMA Neurol. 2018;75(2):219-226. doi:10.1001/jamaneurol.2017.3517
  2. Kolk NM van der, Vries NM de, Kessels RPC, et al. Effectiveness of home-based and remotely supervised aerobic exercise in Parkinson’s disease: a double-blind, randomised controlled trial. Lancet Neurol. 2019;18(11):998-1008. doi:10.1016/S1474-4422(19)30285-6
  3. Ellis T. Exercise in Parkinson’s disease: are we narrowing in on the essential elements? Lancet Neurol. 2019;18(11):982-983. doi:10.1016/S1474-4422(19)30348-5
  4. Chung CLH, Thilarajah S, Tan D. Effectiveness of resistance training on muscle strength and physical function in people with Parkinson’s disease: a systematic review and meta-analysis. Clin Rehabil. 2016;30(1):11-23. doi:10.1177/0269215515570381
  5. Rawson KS, McNeely ME, Duncan RP, Pickett KA, Perlmutter JS, Earhart GM. Exercise and Parkinson disease: Comparing tango, treadmill and stretching. J Neurol Phys Ther JNPT. 2019;43(1):26-32. doi:10.1097/NPT.0000000000000245
  6. Franchignoni F, Horak F, Godi M, Nardone A, Giordano A. Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest. J Rehabil Med. 2010;42(4):323-331. doi:10.2340/16501977-0537
  7. Reliability, Internal Consistency, and Validity of Data Obtained With the Functional Gait Assessment - ProQuest. Accessed November 25, 2020. https://www-proquest-com.libproxy.uncg.edu/docview/223109292?accountid=14604
  8. Parkinson Disease. Accessed November 25, 2020. https://neuropt.org/practice-resources/neurology-section-outcome-measures-recommendations/parkinson-disease
  9. Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the elderly: validation of an instrument. Can J Public Health Rev Can Sante Publique. 1992;83 Suppl 2:S7-11.
  10. Song R, Grabowska W, Park M, et al. The impact of Tai Chi and Qigong mind-body exercises on motor and non-motor function and quality of life in Parkinson’s disease: A systematic review and meta-analysis. Parkinsonism Relat Disord. 2017;41:3-13. doi:10.1016/j.parkreldis.2017.05.019

Chapter 16 (References)


Kerstin Palombaro, PT, PhD
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Chapter 17 (References)

Obesity, Diabetes, and Cardiometabolic Health

Ericka N. Merriwether, PT, DPT, PhD
Rupal M. Patel, PT, PhD
Nola Peacock, PT, DSc
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Chapter 18 (References)


Mary Lou Galantino, PT, MS, PhD, FAPTA
Nicole L. Stout, PT, DPT, FAPTA
Lisa VanHoose, PT, PhD
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Chapter 19 (References)

Women’s Health

Wendy Farnen Price, PT, DPT
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Chapter 20 (References)

Health Disparities

Karla A. Bell, PT, DPT
Chris W. Condran, PT, DPT, MBA
Melissa Hofmann, PT, MSPT, PhD
Alexis Ortiz, PT, PhD
Rosa Elena Torres-Panchame, PT, DPT
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  119. Blashill AJ, Pagoto S. Skin Cancer Risk in Gay and Bisexual Men: A Call to Action. JAMA Dermatol. 2015;151(12):1293-4. doi: 10.1001/jamadermatol.2015.3125. PubMed PMID: 26445402; PMCID: PMC4852690.

Chapter 21 (References)

Technology and Telehealth

Ben Cornell, PT, MPT, PhD
Alan C. Lee, PT, DPT, PhD
  1. What is telehealth? How is telehealth different from telemedicine? HealthIT.gov website. https://www.healthit.gov/faq/what-telehealth-how-telehealth-different-telemedicine Accessed August 26,2020.
  2. Telemedicine. Medicaid.gov website. https://www.healthit.gov/faq/what-telehealth-how-telehealth-different-telemedicine Accessed August 26, 2020.
  3. APTA Definitions and Guidelines on Telehealth. American Physical Therapy Association website. https://www.apta.org/apta-and-you/leadership-and-governance/policies/telehealth Accessed August 26, 2020.
  4. Telepractice. American Speech-Language-Hearing Association website. https://www.asha.org/practice-portal/professional-issues/telepractice/ Accessed August 28, 2020.
  5. Brennan D, Tindall L, Theodoros D, et al. A Blueprint for Telerehabilitation Guidelines. International J Telerehab. 2010;2(2):31-34.
  6. Lee AC. COVID-19 and the advancement of digital physical therapist practice and telehealth. Phys Ther. 2020;100(7):1054-1057.
  7. Nesbitt TS. The role of telehealth in an evolving health care environment: workshop summary. Chapter 3 – The evolution of telehealth: Where have we been and where are we going? Board on Health Care Services: Institute of Medicine. Washing (DC): National Academies Press (US); 2012 Nov 20. https://www.ncbi.nlm.nih.gov/books/NBK207141/
  8. Silva GS, Farrell S, Shandra E, Viswanathan A, Schwamm LH. The status of telestroke in the United States: A survey of currently active stroke telemedicine programs. Stroke. 2012;43:2078-2085.
  9. AMA adopts new guidance for ethical practice in telemedicine. American Medical Association website. https://www.ama-assn.org/press-center/press-releases/ama-adopts-new-guidance-ethical-practice-telemedicine Accessed August 28, 2020.
  10. Richardson JK. Tipping the scales of Time. Phys Ther. 2000;80(11):1121-1124.
  11. Shaw DK. Telemedicine and cardiopulmonary rehabilitation: Where do we stand? J Cardiopulm Rehabil. 1999;19(1):59-61.
  12. Marshall SG, Shaw DK, Honles GL, Sparks KE. Interdisciplinary approach to the rehabilitation of an 18-year-old patient with bronchopulmonary dysplasia, using telerehabilitation technology. Respir Care. 2008;53(3):346-350.
  13. Lee AC and Harada N. Telehealth as a means of health care delivery for physical therapist practice. Phys Ther. 2012;92:463-468.
  14. Impact of COVID-19 on the Physical Therapy Profession. American Physical Therapy Association website. https://www.apta.org/contentassets/15ad5dc898a14d02b8257ab1cdb67f46/impact-of-covid-19-on-physical-therapy-profession.pdf Accessed August 30, 2020.
  15. Lam K, Lu AD, Shi Y, Covinsky KE. Assessing telemedicine unreadiness among older adults in the United States during the COVID-19 pandemic. JAMA Intern Med. Published online August 3, 2020. doi:10.1001/jamainternmed.2020.2671.
  16. COVID-19 Updates: Jurisdiction telehealth laws/guidance for PTs and PTAs. The Federation of State Boards of Physical Therapy website. https://www.fsbpt.org/Portals/0/documents/news-events/Jurisdiction_Telehealth_LawsGuidance_for_PTs_and_PTAs.pdf Accessed August 30, 2020.
  17. Physical therapy compact. PT Compact website. http://ptcompact.org/ Accessed August 30, 2020.
  18. First major insurer adopts a permanent telehealth benefit. American Physical Therapy website. https://www.apta.org/news/2020/05/15/first-major-insurer-adopts-a-permanent-telehealth-benefit Accessed 30, 2020.
  19. Shigekawa E, Fix M, Corbett G, Roby DH, Coffman J. The current state of telehealth evidence: a rapid review. Health Affairs. 2018;37(12):1975-1982.
  20. Cottrell MA, Galea OA, O’Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clin Rehabil. 2017;31(5):625-638.
  21. Ownsworth T, Arnautovska U, Beadle E, Shum DHK, Moyle W. Efficacy of telerehabilitation for adults with traumatic brain injury: a systematic review. J Head Trauma Rehabil. 2018;33(4):E33-46.
  22. Steele L, Lade H, McKenzie S, Russell TG. Assessment and diagnosis of musculoskeletal shoulder disorders over the internet. Int J Telemed Appl. 2012;2012:1-8. doi:10.1155/2012/945745
  23. Laskowski ER, Johnson SE, Shelerud RA, et al. The telemedicine musculoskeletal examination. Mayo Clin Proc. 2020;95(8):1715-1731. doi:10.1016/j.mayocp.2020.05.026
  24. Durfee WK, Savard L, Weinstein S. Technical feasibility of teleassessments for rehabilitation. IEEE Trans Neural Syst Rehabil Eng. 2007;15(1):23-29. doi:10.1109/TNSRE.2007.891400
  25. Tanaka MJ, Oh LS, Martin SD, Berkson EM. Telemedicine in the era of COVID-19: The virtual orthopaedic examination. J Bone Joint Surg Am. 2020;102(12):e57. doi:10.2106/JBJS.20.00609
  26. Cabana F, Boissy P, Tousignant M, Moffet H, Corriveau H, Dumais R. Interrater agreement between telerehabilitation and face-to-face clinical outcome measurements for total knee arthroplasty. Telemed e-Health. 2010;16(3):293-298. doi:10.1089/tmj.2009.0106
  27. Palacín-Marín F, Esteban-Moreno B, Olea N, Herrera-Viedma E, Arroyo-Morales M. Agreement between telerehabilitation and face-to-face clinical outcome assessments for low back pain in primary care. Spine (Phila Pa 1976). 2013;38(11):947-952. doi:10.1097/BRS.0b013e318281a36c
  28. Harris-Hayes M, Steger-May K, Koh C, Royer NK, Graci V, Salsich GB. Classification of lower extremity movement patterns based on visual assessment: Reliability and correlation with 2-dimensional video analysis. J Athl Train. 2014;49(3):304-310. doi:10.4085/1062-6050-49.2.21
  29. Russell TG, Jull GA, Wootton R. Can the Internet be used as a medium to evaluate knee angle? Man Ther. 2003;8(4):242-246. doi:10.1016/S1356-689X(03)00016-X
  30. Russell TG, Blumke R, Richardson B, Truter P. Telerehabilitation mediated physiotherapy assessment of ankle disorders. Physiother Res Int. 2010;15(3):167-175. doi:10.1002/pri.471
  31. Russo RR, Burn MB, Ismaily SK, et al. Is digital photography an accurate and precise method for measuring range of motion of the shoulder and elbow? J Orthop Sci. 2018;23(2):310-315. doi:10.1016/j.jos.2017.11.016
  32. Russo RR, Burn MB, Ismaily SK, et al. Is digital photography an accurate and precise method for measuring range of motion of the hip and knee? J Exp Orthop. 2017;4(1). doi:10.1186/s40634-017-0103-7
  33. Truter P, Russell T, Fary R. The validity of physical therapy assessment of low back pain via telerehabilitation in a clinical setting. Telemed e-Health. 2014;20(2):161-167. doi:10.1089/tmj.2013.0088
  34. Venkataraman K, Morgan M, Amis KA, et al. Tele-assessment of the Berg Balance Scale: Effects of transmission characteristics. Arch Phys Med Rehabil. 2017;98(4):659-664.e1. doi:10.1016/j.apmr.2016.10.019
  35. Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: A systematic review and meta- analysis. BMC Geriatr. 2014;14(1). doi:10.1186/1471-2318-14-14
  36. Palsbo SE, Dawson SJ, Savard L, Goldstein M, Heuser A. Televideo assessment using Functional Reach Test and European Stroke Scale. J Rehabil Res Dev. 2007;44(5):659-664. doi:10.1682/JRRD.2006.11.0144
  37. Camarri B, Eastwood PR, Cecins NM, Thompson PJ, Jenkins S. Six minute walk distance in healthy subjects aged 55-75 years. Respir Med. 2006;100(4):658-665. doi:10.1016/j.rmed.2005.08.003
  38. Mylius CF, Paap D, Takken T. Reference value for the 6-minute walk test in children and adolescents: a systematic review. Expert Rev Respir Med. 2016;10(12):1335-1352. doi:10.1080/17476348.2016.1258305
  39. Bohannon RW, Crouch R. Minimal clinically important difference for change in 6-minute walk test distance of adults with pathology: a systematic review. J Eval Clin Pract. 2017;23(2):377-381. doi:10.1111/jep.12629
  40. Bohannon RW, Bubela DJ, Wang Y-C, Magasi SS, Gershon RC. Six-minute walk test versus three-minute step test for measuring functional endurance (alternative measures of functional endurance). J Strength Cond Res. 2015;29(11):3240. doi:10.1519/JSC.0000000000000253
  41. Erikson L, Lindstrom B, Gard G, Lysholm J. Physiotherapy at a distance: A controlled study of rehabilitation at home after a shoulder joint operation. J Telemed Telecare. 2009;15:215-220.
  42. Russell TG, Buttrum P, Wootton R, Jull FA. Internet-based outpatient telerehabilitation for patients following total knee arthroplasty: a randomized controlled trial. JBJS 2011;93:113-120.
  43. Tousignant M, Moffet H, Boissy P et al. A randomized controlled trial of home telerehabilitation for post-knee arthroplasty. J Telemed Telecare 2011;17:195-198.
  44. Lee ACW, Billings M. Telehealth implementation in a skilled nursing facility: Case report for physical therapist practice in Washington. Phys Ther. 2016;96:252-259.
  45. Telemedicine: Risk management issues, strategies and resources. Healthcare Perspective (Issue 14). A Risk Management Resource to Manage Liability in the Healthcare Practice. HPSO website. http://www.hpso.com/Documents/Risk%20Education/Businesses/CNA_HP17-14_060117_CF_PROD_SEC.pdf. Accessed September 27, 2020.
  46. Informed consent resources for telehealth. Agency for Healthcare Research and Quality website. https://www.ahrq.gov/news/telehealth-consent.html. Accessed September 28, 2020.
  47. American Physical Therapy Association. Guide to Physical Therapist Practice. Second Edition. American Physical Therapy Association. Phys Ther. 2001;81(1):9-746.
  48. COVID-19 Updates and Resources. Health Policy & Administration Section website. https://www.aptahpa.org/general/custom.asp?page=COVID19. Accessed September 28, 2020.
  49. Boissonnault WG, Ross MD. Physical therapists referring patients to physicians: A review of case reports and series. J Orthop Sports Phys Ther. 2012;42(5):446-454. doi:10.2519/jospt.2012.3890
  50. Salawu A, Green A, Crooks MG, Brixey N, Ross DH, Sivan M. A proposal for multidisciplinary tele-rehabilitation in the assessment and rehabilitation of COVID-19 survivors. Int J Environ Res Public Health. 2020;17(13):1-13. doi:10.3390/ijerph17134890
  51. Pani D, Barabino G, Dessì A, Uras S, Raffo L. The challenge of collaborative telerehabilitation: Conception and evaluation of a telehealth system enhancement for home-therapy follow-up. Concurr Comput Pract Exp. 2015;27(11):2889-2906. doi:10.1002/cpe.3441
  52. Reegaard K, Nystad E, Fernandes A, Rindahl G. Anticipated challenges for cross-organisational distributed collaboration in reactive telemedicine. 11th Hum Factors Organ Des Manag 46th Nord Ergon Soc Annu Conf. 2014;(January):481-486.
  53. Kamsu-Foguem B, Tiako PF, Fotso LP, Foguem C. Modeling for effective collaboration in telemedicine. Telemat Informatics. 2015;32(4):776-786. doi:10.1016/j.tele.2015.03.009
  54. Galea MDF. Telemedicine in rehabilitation. Phys Med Rehabil Clin N Am. 2019;30(2):473-483. doi:10.1016/j.pmr.2018.12.002
  55. Hall JL, Mcgraw D. For telehealth to succeed, privacy and security risks must be identified and addressed. Health Aff. 2014;33(2):216-221. doi:10.1377/hlthaff.2013.0997
  56. Becker CD, Dandy K, Gaujean M, Fusaro M, Scurlock C. Legal perspectives on telemedicine part 1: Legal and regulatory issues. Perm J. 2019;23:1-3. doi:10.7812/TPP/18-293
  57. Webb C, Orwig J. Expanding our reach: Telehealth and licensure implications for psychologists. J Clin Psychol Med Settings. 2015;22(4):243-250. doi:10.1007/s10880-015-9440-9
  58. Lustgarten SD, Colbow AJ. Ethical concerns for telemental health therapy amidst governmental surveillance. Am Psychol. 2017;72(2):159-170. doi:10.1037/a0040321
  59. Steele L, Lade H, McKenzie S, Russell TG. Assessment and diagnosis of musculoskeletal shoulder disorders over the internet. Int J Telemed Appl. 2012;2012. doi:10.1155/2012/945745
  60. Hwang R, Mandrusiak A, Morris NR, Peters R, Korczyk D, Russell T. Assessing functional exercise capacity using telehealth: Is it valid and reliable in patients with chronic heart failure? J Telemed Telecare. 2017;23(2):225-232. doi:10.1177/1357633X16634258
  61. Cox NS, Alison JA, Butto BM, Wilson JW, Holland AE. Assessing exercise capacity using telehealth: A feasibility study in adults with cystic fibrosis. Respir Care. 2013;58(2):286-290. doi:10.4187/respcare.01922

Chapter 22 (References)

Building a Lifestyle Medicine Practice

Ginger GarnerName, PT, DPT, ATC/L
Karen LitzyName, PT, DPT
  1. Lifestylemedicine.org. 2020. Core Competencies. [online] Available at: <https://www.lifestylemedicine.org/ACLM/Lifestyle_Medicine/What_is_Lifestyle_Medicine/ACLM/About/What_is_Lifestyle_Medicine_/Core_Competencies.aspx?hkey=26f3eb6b-8294-4a63-83de-35d429c3bb88> [Accessed 16 September 2020].
  2. Who.int. 2018. Non Communicable Diseases. [online] Available at: <https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases> [Accessed 16 September 2020].
  3. Global strategy for the prevention and control of noncommunicable diseases. World Health Organization. https://www.who.int/nmh/publications/wha_resolution53_14/en/. Published 2000. Accessed September 16, 2020.
  4. Health and Economic Costs of Chronic Diseases | CDC. Cdc.gov. https://www.cdc.gov/chronicdisease/about/costs/index.htm. Published 2020. Accessed September 16, 2020.
  5. Bodai B. Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival. Perm J., 2017. doi:10.7812/tpp/17-025
  6. System | Definition of System by Oxford Dictionary on Lexico.com also meaning of System. Lexico Dictionaries | English. https://www.lexico.com/en/definition/system. Published 2020. Accessed September 29, 2020.
  7. Hayashi R. https://paymentdepot.com/blog/average-credit-card-processing-fees/. Published 2020. Accessed September 29, 2020.
  8. Michalowicz M. Profit First. [Place of publication not identified]: Penguin Publishing Group; 2017.
  9. Outsourcing Payroll and Third-Party Payers | Internal Revenue Service. Irs.gov. https://www.irs.gov/businesses/small-businesses-self-employed/outsourcing-payroll-and-third-party-payers. Published 2020. Accessed September 30, 2020.
  10. Gallucci G, Swartz W, Hackerman F. Impact of the wait for an initial appointment on the rate of kept appointments at a mental health center. Psychiatr Serv. 2005;56(3):344-346. doi:10.1176/appi.ps.56.3.344
  11. Festinger DS, Lamb RJ, Marlowe DB, Kirby KC. From telephone to office: intake attendance as a function of appointment delay. Addict Behav. 2002 Jan-Feb;27(1):131-7. doi: 10.1016/s0306-4603(01)00172-1. PMID: 11800219.
Supplemental Materials
  1. 3 financial sisters
  2. Media attention for your practice
    • How to create your message to reinforce a lifestyle medicine platform
      • Copy on your website
      • Social media presence
    • How to develop solid partnerships
      • Reach out to fellow lifestyle medicine practitioners in your area to create a team approach with your client in the center. (How to make the first move.)
      • How to nurture those partnerships over time
    • Media attention for your practice
      • How to pitch the media (local, national, international)
      • Refining your message for the media
      • Clarity around your core topics and how to break them down into bite-size offers
      • How to leverage media attention to grow your practice, expand your message, and make a more significant impact on your community.
  3. What do you want your legacy to be?
    • How do you want you and your practice to be remembered?
    • Succession planning