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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
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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.
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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
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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.
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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
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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.
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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
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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.
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- 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
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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.
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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
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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:
http://www.csep.ca/CMFiles/GAQ_CSEPPATHReadinessForm_2pages.pdf.
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.
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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
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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:
- Underlying contributors such as ischemic heart disease, hypertension, and type 2 diabetes, obesity
- Prevalence of musculoskeletal conditions in patients with heart disease, e.g., arthritis
- 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.
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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
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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.
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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
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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.
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