Physiotherapy Theory and Practice, 25(5):330–353, 2009

Copyright r Informa Healthcare

ISSN: 0959-3985 print/1532-5040 online
DOI: 10.1080/09593980802668027

Physical therapy in the 21st century (Part I): Toward

practice informed by epidemiology and the crisis of
lifestyle conditions
Elizabeth Dean, PhD, PT
Professor, Department of Physical Therapy, Faculty of Medicine, University of British Columbia,
Vancouver, BC, Canada

Part I of this two-part introduction to this Special Issue on the practice of physical therapy in
the 21st century outlines the epidemiological basis and rationale for evidence-informed physical
therapy practice for addressing contemporary health priorities. This evidence emanates from the
definition of health by the World Health Organization (WHO) and the International Classification
of Functioning (ICF), and WHO and other international databases on the prevalence of lifestyle
conditions. Lifestyle conditions include ischemic heart disease, smoking-related conditions, hyperten-
sion and stroke, obesity, diabetes, and cancer. Epidemiological data combined with evidence supporting
the effectiveness of noninvasive interventions related to physical therapy to address these priorities
(e.g., health education and exercise) are highly consistent with the promotion of health and wellness
and the ICF. Given their commitment to exploiting effective noninvasive interventions, physical
therapists are in a preeminent position to focus on prevention of these disabling and lethal conditions
in every client or patient, their cure in some cases, as well as their management. Thus, a compelling
argument can be made that clinical competencies in 21st century physical therapy need to include
assessment of smoking and smoking cessation (or at least its initiation), basic nutritional assessment
and counseling, recommendations for physical activity and exercise, stress assessment and basic stress
reduction recommendations, and sleep assessment and basic sleep hygiene recommendations. The
physical therapist can then make an informed clinical judgment regarding whether a client or patient
needs to be referred to another professional related to one or more of these specialty areas. The
prominence of physical therapy as an established health care profession and its unique pattern of
practice (prolonged visits over prolonged periods of time) attest further to the fact that physical
therapists are uniquely qualified to lead in the assault on lifestyle conditions. Evidence-based physical
therapy practiced within the context of epidemiological indicators (i.e., evidence-informed practice)
maximally empowers clinicians to promote lifelong health in every person and in turn, the health of
communities. This vision of physical therapy’s leading role in health promotion and health care in the
21st century holds the promise of reducing the need for invasive health interventions (drugs and
surgery). Part II of this introduction describes evidence-based physical therapy practice within this
context of evidence-informed practice.

Accepted for publication 13 October 2008.

Address correspondence to Elizabeth Dean, PhD, PT, Department of Physical Therapy, Faculty of Medicine, University of
British Columbia, 212-Friedman Building, 2177 Wesbrook Mall, Vancouver, BC, Canada V6T 1Z3. E-mail: elizabeth.dean@ubc.ca

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331 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
Introduction
The purpose of this article, Part I of a two-part
introduction to this special issue on 21st century
physical therapy practice, is to outline the ratio-
nale for a contemporary evidence-informed prac-
tice framework that is strongly indicated this
century. In this series, evidence-informed practice
refers to practice that is aligned with epidemio-
logical evidence and health care needs, whereas
evidence-based practice is used to refer to specific
evidence-supported interventions that are needed
to address the epidemiological priorities of the
21st century (see Part II).
An evidence-informed framework for practice
largely reflects a focus on lifestyle conditions
and is consistent with the World Health Orga-
nization (WHO)’s vision of health and well
being. Contemporary lifestyle conditions include
ischemic heart disease (IHD), cancer, smoking-
related conditions (e.g., the multisystem effects
of smoking), and pulmonary conditions such as
chronic bronchitis and emphysema, and some
types of asthma, and cancer of the structures of
the respiratory tract as well as other organs),
hypertension and stroke, obesity, and diabetes.
Threats to musculoskeletal health (e.g., osteo-
porosis and arthritis) and psychosocial health
can also be influenced by lifestyle choices; thus,
these conditions may be subsumed within life-
style conditions. Over the past 25 years, HIV/
AIDS has emerged as an infectious condition of
global concern that is highly amenable to con-
trol through lifestyle modification, specifically,
safe sex practices. Although HIV/AIDS is a
global health priority and clearly warrants
attention by physical therapists, this article
focuses on noncommunicable lifestyle condi-
tions that have been associated with global
economic development.
The description of the framework for physical
therapy practice in the 21st century begins with
an overview of the construct of health and well-
being. The epidemiology of the noncommunic-
able lifestyle conditions is presented followed by
a description of their modifiable risk factors.
Importantly, clients and patients may present
with one or more risk factors of lifestyle condi-
tions or the manifestations of one or more life-
style conditions irrespective of the primary reason
for referral, be it self-referral or by a physician.
Multipronged strategies to reduce these risks and
prevent these conditions are then described. The
role of facilitators and barriers to people acquir-
ing healthy lifestyles need to be considered in
designing individualized lifelong health plans.
Because lifestyle is central to acquiring lifestyle
conditions and lifestyle change is central to their
prevention and risk factor modification, the role
of racial, ethnic, and cultural factors in effecting
such change in a multicultural society is consi-
dered. The rationale for physical therapists to be
culturally competent in working with people from
various cultures as well as awareness of their
own ethnocentricity is presented. Finally, the
implications of such a contemporary practice
framework for physical therapists in the 21st
century are outlined and described in detail in
Part II of this series.
The construct of health and wellness
Health is not merely the absence of impair-
ment or disease; rather, it refers to mental and
social as well as physical well-being (World
Health Organization, 2008). Although physical
well-being can contribute to the status of the
other dimensions of health, it does not ensure
this as illustrated in the WHO International
Classification of Function (ICF) (World Health
Organization, 2002). Thus, mental and social
well-being warrants being assessed as system-
atically as physical well-being, in a model of care
based on health and its mediating environmental
and personal influences. Collectively, these
domains of health translate into an individual’s
capacity to perform activities that enables him
or her to participate fully in life as illustrated in
the ICF, which is being adopted worldwide and
recently by the American Physical Therapy
Association (2001). The WHO’s definition of
health has existed for over 50 years, yet it
remains to be fully integrated into contemporary
health care.
The primary determinants of improved health
this past century have been the provision of
clean water, waste management, sanitation,
basic nutrition, shelter, security, and the civility
of the society in which people live. Education,
socioeconomic, and employment status are also
powerful independent determinants of health.
These pillars are reflected in contemporary
models of health and health care.
 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
Throughout the 20th century, biomedicine
was the dominant model of medical care and
focused on an impairment model. Its best out-
comes have been reported for controlling infec-
tion, relieving acute symptoms and signs of
impairments, and emergent care. With respect to
the prevention, cure, and management of life-
style conditions, biomedicine’s outcomes have
been less impressive. Because of their remark-
able association with lifestyle practices and that
their prevention and resolution are more effec-
tively addressed with noninvasive interventions
(i.e., nondrug and nonsurgical solutions),
chronic conditions that are hallmarking the 21st
century could be effectively prevented, at times
cured as well as managed by physical therapists
who are preeminently well positioned to fill this
critical health care niche in the 21st century.
To fill this role, physical therapists need an
understanding of health and well-being with
respect to its multiple dimensions consistent with
the determinants of health, the WHO definition
(World Health Organization, 2008), and the ICF
(World Health Organization, 2002). Health can
be defined as the capacity of an individual to
perform and engage in life in a way that is
consistent with that individual’s needs and
wants. This capacity to engage in life, and the
degree to which one performs one’s roles,
reflects limitations of structure and function,
limitations in activities, and restrictions in life
participation, all of which can reflect personal
and environmental factors. Mediating environ-
ment factors include psychosocial and attitu-
dinal barriers as well a physical barriers. Some
would argue that it is the environment or society
in which people live that is disabling rather than
the individual being disabled. With respect to
health and wellness, prevention, and risk factor
reduction, contemporary physical therapists
need related clinical competencies including
proficiency in promoting self-efficacy, a funda-
mental attribute to effecting positive health
behavior choices or change. This aspect of care
is described in detail in Part II of this intro-
duction, which specifically addresses aligning
physical therapy practice with current health
care needs.
Because the determinants of health are
strongly influenced by social and public policy
and legislation in addition to individual health
choices, physical therapists need to assume a
332
visible role in public health initiatives. Although
social and urban planners have focused on
creating health-conducive communities for seve-
ral decades, as illustrated in Jacobs’ seminal work
(1961), our communities are far from being
exemplary health-promoting environments. Such
communities emphasize walking and cycling
rather than reliance on automobiles. They pro-
mote small businesses and commercial operations
to foster human interaction within the commu-
nity. Economic advancement through big busi-
ness is antithetical in many ways to the creation
of healthy communities and human interaction
and loyalties fostered at an interpersonal level.
Physical therapists can work with social planners
and legislators to create healthy spaces, including
socially and physically safe and esthetically
pleasing walking and cycling areas and parks for
family and recreational activities and walking
dogs. These public spaces need to be designed
so that they are inclusive of people of all ages
and abilities. The unique perspective of physical
therapists is needed at forums on health planning
and policy making.
Epidemiology of lifestyle conditions
Over the 20th century, health care priorities
shifted from the prevention, cure, and manage-
ment of acute infectious conditions to the
present-day focus on the prevention, cure, and
management of lifestyle conditions in high-
income countries and increasingly in middle- and
low-income countries (Figure 1). Although there
have been some downward trends over recent
decades in the prevalence of some lifestyle
conditions in high-income countries (e.g., IHD
and stroke [World Health Reports, 2000 and
2006]), these conditions remain among the lead-
ing causes of morbidity, disability, and premature
death. Hypertension, obesity, and metabolic
syndrome are examples of conditions that have
escalated to epidemic proportions and are asso-
ciated with severe life-threatening consequences
(Kahn, Ferrannini, Buse, and Stern, 2005). The
combination of increased life expectancy this past
century and prevalence of lifestyle conditions,
end-of-life morbidity, and disability are being
prolonged. This trend has created a crisis for the
health care systems in high-income countries.
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Dean /Physiotherapy Theory and Practice 25 (2009) 330–353

Figure 1. Comparative incidence and prevalence of the lifestyle conditions for Canada, China, India, the United States, and the United Kingdom.
 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353 334

No longer can lifestyle conditions be considered
only adult conditions. In high-income countries,
such as the United States and Canada, most
children have one or more risk factors for one or
more lifestyle conditions. Risk factors for these
conditions have become pediatric priorities, given
that lifestyle attitudes and preferences vis-à-vis
food and physical activity are established early.
Family lifestyle practices influence childhood pre-
ferences, which will manifest as either good or
poor health in adulthood. Fifty years ago, condi-
tions such as heart disease emerged in people in
late middle age or older. The manifestations of
these conditions today have become common in
individuals in their young adulthood or early
middle age. Although life expectancy has increased
this past century, some authorities argue that
today’s children will not live as long as their
parents because of their injurious lifestyles
(Mokdad, Marks, Stroup, and Gerberding, 2004).
To address the discrepancy between know-
ledge about lifestyle choices and health status
(Steptoe, Kerry, Rink, and Hilton, 2002), a
societal commitment to reducing the incidence of
lifestyle conditions through prevention/public
health efforts, rather than treating people once
they are sick, is no more urgent than at present.
Those individuals who present clinically with
lifestyle conditions can be viewed as being at the
tip of the iceberg in that for each individual who
requires care, there are innumerable others who
are at risk. An assault on lifestyle conditions can
only be achieved by addressing their causes rather
than a primary focus on symptom reduction with
drugs and surgery (Engel, 1977, 1980). Further-
more, addressing their causes extends beyond
understating molecular genetic mechanisms to
explain how the human body adapts to lifestyle
choices and the life-threatening manifestations
of these choices. Addressing the causes of life-
style conditions needs to be tackled systemati-
cally through aggressive prevention and, where
possible, reversal strategies at the societal and
individual levels.
A summary of eight major risk factors related
to lifestyle and their documented impact on
several leading lifestyle conditions is shown in
the Table 1. Lifestyle behavioral choices have
given rise to a dramatic increase in the newly
defined, life-threatening condition, metabolic
syndrome, which includes elevated blood sugar,
blood pressure, triglycerides, and cholesterol;
and obesity (Scott, 2003). Despite their pre-
valence, however, lifestyle conditions are largely

Table 1. Modifiable risk factors of the lifestyle conditions (modified from Bradberry, 2004; Charkoudian and Joyner, 2004;
Heart and Stroke Foundation of Canada, 2003).

Condition

Cardiovascular Obstructive
Risk factor disease Cancer lung disease Stroke Diabetes Osteoporosis

Smoking X X (m risk of all- X X X X

cause cancer*)
Physical X X X X X
inactivity
Obesity X X X X X
Nutrition X X X X X
High BP X X X
Dietary Fat**/ X X X X
Blood Lipids
Elevated X X X X
glucose levels
Alcohol*** X X ? X X

*Smoking is not only related to cancer of the nose, mouth, airways, and lungs, but smoking increases the risk of all-cause cancer.
**Partially saturated, saturated, and trans-fats are the most injurious to health.
***Alcohol can be protective in moderate quantities, red wine in particular.
335 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
preventable through lifestyle modification as
mentioned (Sebregts, Falgar, and Bar, 2000;
World Health Report, 1999), and in some cases,
reversible.
Modifiable risk factors of lifestyle
conditions
Lifestyle behaviors, including one or more of
the following: smoking, poor nutritional choices,
physical inactivity, stress, and poor-quality sleep,
constitute common risk factors that impact an
individual’s potential for phenotypic expression
of one or more of the following: ischemic heart
disease, cancer, hypertension and stroke, obesity,
and diabetes and metabolic syndrome. Lifestyle
behavior also impacts musculoskeletal health
and psychosocial health particularly as we age.
Contemporary perspectives of prevention and
management of lifestyle conditions are focusing
on multiple health behaviors and simultaneous
health behavior change (Allegrante et al, 2008;
Noar, Chabot, and Zimmerman, 2008). Although
reports of simultaneous vs. individual health beha-
vior risk factor change are emerging and demons-
trating favorable results (Hyman et al, 2007), the
literature largely focuses on lifestyle morbidity
individually rather than in combination; thus,
this reflects a limitation of the literature, our
knowledge, and potential strategies for addressing
multiple risk factor health behavior change.
Cardiovascular disease
The risk factors for IHD are well established
(Manson et al, 1992; Williams et al, 2002), and they
contribute to atherosclerotic deposits through-
out the systemic vasculature and vascular wall
injury including inflammation (Bradberry, 2004).
Nonmodifiable risk factors include age, gender,
and family history as well as the individual’s his-
tory. Modifiable risk factors include increased
cholesterol, increased homocysteine, smoking,
inactivity, high blood pressure, diabetes, weight,
and stress (Keller and Lemberg, 2003; Twisk,
Kemper, van Mechelen, and Post, 1997). Less
recognized contributing factors include elevated
C-reactive protein, a marker of inflammation
(Anonymous, 2003); sharing the lifestyle of some-
one with IHD (Macken, Yates, and Blancher,
2000); and having overweight parents (Paterno,
2003). Other factors include passive smoking, level
of education, depression, anger coupled with
hostility, and social isolation (Graves and Miller,
2003; Panagiotakos et al, 2002).
Information regarding the degree of risk
factor change needed to effect a change in health
status is now emerging. A 1% reduction in
cholesterol, for example, can reduce IHD risk
by 3%, and a long-term reduction in diastolic
blood pressure of 5–6 mmHg reduces this risk
by 20–25% (Sleight, 1991). Thus, even modest
changes can have an appreciable health impact.
IHD risk factors are prevalent in the general
population. When a large cross section of late,
middle-aged people was screened, atherosclerosis
involving the femoral artery affected two thirds
(Leng et al, 2000). A direct relationship existed
between the degree of atherosclerosis and cardio-
vascular and circulatory health. Individuals with
peripheral artery disease have a severalfold
increased IHD risk; thus, peripheral artery disease
can be considered a marker of systemic athero-
sclerosis. Cardiac events related to atherosclerosis
could be reduced by 70–80% with an optimal
lifestyle. Atherosclerosis can be reversed with
lifestyle change, thereby minimizing associated
cardiac events (Haskell et al, 1994; Niebauer et al,
1997; Ornish et al, 1998; Srinath et al, 1995).
Of all lifestyle behaviors, other than not
smoking, physical activity has the greatest health
protective effect. Regular walking reduces IHD
risk as least as much as vigorous activity (Bauman,
2004). In men with compensated left ventricular
hypertrophy, moderate physical activity reduces
the risk of stroke by 49%, compared with seden-
tary men without left ventricular hypertrophy
(Pitsavos et al, 2004). Self-reported fitness is inde-
pendently related to fewer IHD risk factors and
angiographic evidence of IHD in women under-
going coronary angiography for suspected ische-
mia (Wessel et al, 2004). Measures of obesity are
not independently associated with these outcomes.
Thus, fitness appears more important than body
weight for cardiovascular risk in women.
Moderate and high physically intense leisure
time predicts 28% and 44% less mortality, respec-
tively, compared with little activity (Mozaffarian
et al, 2004). Low, moderate, and high levels of
exercise are associated with 30%, 37%, and 53%
more years of healthy life, respectively. In addition,
aerobic training has a direct effect on reducing
 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
serum lipids even in older individuals. High-
density lipoproteins increase and low-density
lipoproteins decrease (Park et al, 2003). Finally,
hospitalized patients with acute coronary syn-
drome have better outcomes if they have been
physically active (Pitsavos et al, 2008). Specifically,
the severity of symptoms is less, mortality rates are
lower, and short-term prognosis is improved.
Nutrition is a well-established independent
risk factor for health and disease. People who
consume fish twice a week have a 47% reduced
risk of cardiac mortality compared with those
who eat fish less than once a month (Mozaffarian
et al, 2004). Daily cereal fiber consumption (two
whole-grain slices) is associated with a 14%
reduced risk of myocardial infarction or stroke,
and this effect is apparent even late in life
(Mozaffarian et al, 2003).
Psychosocial factors are also established risk
factors for IHD. Difficulty managing anger
and hostility is one such risk factor, irrespective
of whether someone has a type A (active-
extrovert) or type B (passive-introvert) personality
(Anonymous, 2004). Stress is a risk factor that
can be classified as cumulated daily stresses or
hassles vs. the negative impact of life events.
Lipoprotein levels increase with both; however,
coping style and subjective appraisal of stressors
are powerful mitigating factors (Twisk, Snel,
Kemper, and van Mechelen, 1999). Cumulative
daily hassles may be underestimated in terms of
their impact on health compared with life event
stressors. After an individual’s first coronary
event, avoidance strategies are negatively asso-
ciated with healthy lifestyles, whereas positive
reappraisal and problem solving are positively
associated (Henrichon and Robichaud-Ekstrand,
2002). Positive reappraisal/problem solving, pro-
gram participation, and the avoidance of distanc-
ing and escape strategies predict adaptation to
lifestyle changes after a coronary episode. The
role of spirituality and religiosity may also reduce
health risk. Further research is needed to eluci-
date this relationship because religiosity may be
associated with confounding lifestyle practices.
The risk of a cardiac event after the first
one is high (Hannan, Kilburn, O’Donnel, 1990;
Weintraub et al, 1997). Thus, the prevalence
of repeated revascularization procedures and
need for more potent drugs to offset worsening
pathology is high. Ornish (1998) reported that
194 individuals with previous revascularization
336
procedures were able to avoid repeat procedures
for at least 3 years (the study duration) with
participation in a comprehensive lifestyle change
program. Compared with individuals who had
had a previous revascularization procedure and
did not participate in the lifestyle change pro-
gram, participants reported less angina.
The role of lifestyle modification programs
related to cardiovascular and cerebrovascular
health is especially strong in several areas. First,
the seminal work of Ornish (1998) has established
the reversibility of atherosclerosis, which has
been implicated in IHD, cerebrovascular disease,
hypertension, renal disease, diabetes, sexual dys-
function, and Alzheimer’s syndrome. Further-
more, physical activity can independently reduce
the risk of stroke (Endres et al, 2003), and the
combination of optimal nutrition and exercise has
been shown to markedly reduce IHD risk
(Kromhout, Menotti, Keseloot, and Sans, 2002;
Luedemann et al, 2002; Naslund, Fredrikson,
Hellenius, and de Faire, 1996; Shapiro, 2000).
Modification of vascular risk factors warrants
being better targeted to enable people to realize
their full health potential and minimize risk
of morbidity, disability, and premature death
(Ebrahim, 2000). Community programs for indi-
viduals in health and those with specific condi-
tions have demonstrated positive health outcomes
and warrant being exploited, given the need to
maximize the health of communities and reduce
the incidence of disease at the lowest cost (Eng
et al, 2003; Jones, Dean, and Scudds, 2005).
Cancer
Risk factors for many cancers are well estab-
lished and include well-established environmental
and behavioral factors (e.g., nutrition [low fiber
and fats], inactivity, poor air quality, smoking,
ingestion and inhalation of chemicals, and
psychological factors). An inverse relationship
between many cancers and a low antioxidant (low
in servings of vegetables and fruit) diet has been
well established (World Cancer Research Fund
and American Institute for Cancer Research,
2008). Cancer, hallmarked by unusual cell proli-
feration, eventually compromises organ function.
The specialty of cancer prevention and rehabili-
tation requires an integrated knowledge of
pathophysiology; environmental and behavioral
337 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
contributing factors; psychosocial implications;
and management interventions (Brennan,
DePompolo, and Garden, 1996; Rashbaum,
Walker, and Glassman, 2001). To date, evidence
for walking as a preventive strategy for cancer has
been best established for colon cancer (Bauman,
2004) and suggested for breast cancer. The degree
to which lifestyle choices can reverse cancer in
terms of disease remission, retard its progress,
and offset biomedical treatment of side effects
warrants elucidation.
Hypertension and stroke
Hypertension, which has become pandemic, is
a serious condition associated with life-threatening
complications. Prolonged elevation of blood
pressure is no longer viewed as acceptable under
any circumstance, including aging. Atherosclerosis
and IHD are commonly associated with high
blood pressure (Cucchiara and Kasner, 2002).
Manifestations of IHD are increased in people
with hypertension and include abnormal lipid
profiles, hyperglycemia, increased fibrinogen,
obesity, and dysrhythmias (Kannel, 1990). These
risks can be further accentuated by cigarette
smoking, elevated cholesterol, glucose intolerance,
and inactivity (Shinton, 1997). Increased sympa-
thetic reactivity can explain hypertension, thus has
been implicated in the etiology of stroke (Everson
et al, 2001). The prevention of hypertension
requires more than normalizing blood pressure if
the deadly manifestations of high blood pressure
including IHD are to be avoided. Because of the
dire consequences of hypertension, the American
Heart Association now advocates more stringent
blood pressure limits, specifically, below 130/
85 mmHg irrespective of age (American Heart
Association, 2005; Heart and Stroke Foundation
Canada, 2003). Risk assessment for hypertension
is an important component of each patient’s
assessment. The management strategy should be
based on an analysis of the overall risk assessment
rather than on blood pressure alone.
In the adult population, age range of 60–74
years, almost 75% of African Americans have
high blood pressure and 50% of Caucasians
(Chobanian et al, 2003). Comparable to IHD,
risk factors consist of both nonmodifiable and
modifiable risk factors. Nonmodifiable risk
factors include age, gender, race, and other
genetic factors. Modifiable risk factors include
diets with high sodium intake and low potassium
intake, alcohol consumption, reduced physical
activity, and being overweight (Slama, Susic,
and Frolic, 2002). Obesity is a strong predictor
of hypertension (Shaper, 1996). Although
reduction of hypertension has been attributed
to low-dose thiazide diuretics and b-blockers,
the first line of defense for preventing high
blood pressure or normalizing blood pressure
should be established evidence-based nutritional
approaches, weight reduction, and exercise
(Hamilton and Hamilton, 1997). The so-called
DASH (Dietary Approaches to Stop Hyperten-
sion) diet has demonstrated unequivocal blood
pressure-lowering effects as a primary inter-
vention and warrants being exploited in every
person presenting with hypertension or for its
prevention (Appel et al, 1997; Sacks et al, 1995).
In individuals whose hypertension is controlled,
the combination of a Mediterranean diet (typi-
cally including plentiful servings of fruit and
vegetables, fish and fiber sources, and low
hydrogenated and trans fats, and sugar) and
physical activity can reduce overall health risk
(Pitsavos et al, 2002).
Although weight reduction is an essential
component of hypertension prevention and
management, the protective effect of physical
activity may be unrelated to degree of obesity (Hu
et al, 2004). A 4–8% reduction in body weight can
reduce blood pressure by 3 mmHg, and physical
activity conditioning can reduce blood pressure
by 5/3 mmHg (Costa, 2002). In normotensive
African American men, aerobic exercise can
attenuate an exaggerated blood pressure response
(Bond et al, 2002). Similarly, normotensive fit
African American women have a blunted blood
pressure response to experimental stressors
(Jackson and Dishman, 2002). However, one
study reported no relationship between physical
activity and hypertension, flow-mediated dila-
tation of the brachial artery, and an index of
angiogenesis assessed with plasma vascular
endothelial growth factor (both indicators of
endothelial dysfunction) (Felmeden et al, 2003).
Physical activity was based on self-report in a
questionnaire rather than fitness outcomes; thus,
the results of this study are difficult to interpret.
Hypertension has become a common pedia-
tric condition often combined with abnormal
blood lipids and obesity (McCrindle, 2001;
 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
Misra, 2000). Risk factor assessment for the
lifestyle conditions should now be considered
fundamental to the pediatric physical therapy
assessment (National Institutes of Health, 2004).
Stroke is a preventable tragedy for almost
750,000 Americans annually with compromised
cerebral perfusion and hypertension as the
most common risk factors (Kirschner, 2003).
Although lowering blood pressure below 130/
85 mmHg is well accepted across ages, the
success of blood pressure control has been
reported to be less than 25% in the hypertensive
population (Chalmers and Chapman, 2001).
Therefore, despite our knowledge and consi-
derable understanding of its etiology, stroke risk
and other risks associated with hypertension
are far from being well controlled; hence,
hypertension remains a major but preventable
health threat to many people. Risk factors for
stroke include previous stroke, hypertension,
IHD, atrial fibrillation, hyperlipidemia, dia-
betes, abnormal ankle-to-brachial pressure
index, reduced exercise endurance, retinopathy,
albuminuria, autonomic neuropathy, smoking,
alcohol consumption, and lack of exercise
(Cohen et al, 2003; Hart and Halperin, 1999;
Kirschner, 2003; Kurl et al, 2003; Kurth et al,
2003). Walking as little as 2 hours a week can
reduce stroke risk by 50% (Costa, 2002). With
respect to nutrition, high sodium and low
potassium as well as lipids have been implicated
in hypertension and stroke. Low plasma vitamin
C is associated with a severalfold increased
stroke risk, particularly in men who are over-
weight and hypertensive (Kurl et al, 2002).
A minimal reduction in diastolic blood pressure
(5–6 mmHg) reduces the risk of stroke by
35–40% (Sleight, 1991). Thus, weight control,
regular exercise, a diet rich in fruits, vegetables,
and whole grain cereals, smoking cessation,
and blood pressure control are central to
stroke prevention as well as its comprehensive
management.
To impact population health, stroke preven-
tion depends on the dissemination of these well-
established and widely available interventions to
a large number of people. Advice given by a
health provider to individuals with stroke for the
purpose of secondary prevention has a major
impact. In one study, individuals were given
the simple advice to ‘‘eat fewer high fat/high
cholesterol foods’’ and to ‘‘exercise more’’
338
(Greenlund et al, 2002). Compared with the
control group who received no advice, those
who received advice reported fewer days with
limited activity, fewer days that ‘‘were not good
physically’’ and more ‘‘healthy’’ days. The
results of this study are compelling in that even
simple advice by a health care provider may
have an impact on critical health behaviors and
potential health outcomes.
Physical activity not only can reduce stroke
risk but can provide a potent prophylactic
strategy for increasing blood flow and reducing
brain injury during cerebral ischemia (Endres
et al, 2003). A possible mechanism is augmented
endothelium-dependent vasodilation. Aerobic
exercise three times a week reduces cerebral
infarct size and functional deficits in a mouse
model and improves endothelium-dependent
vasorelaxation (Endres et al, 2003). Evidence is
mounting that supports an additional role for
exercise during stroke rehabilitation, namely,
stroke prophylaxis.
Recommendations by the American Heart
Association on physical activity and exercise
guidelines for survivors of stroke concur that
physical conditioning is a primary goal in these
individuals who have to contend with both the
pathology of stroke, above average risk for
further cardiovascular or cerebrovascular events,
and the effects of deconditioning (Gordon et al,
2004). Improved conditioning may help reduce
limitations of activity and social participation,
hence improve quality of life. The burden of
disease and disability and their risk factors may
be correspondingly reduced.
Obesity
Obesity has become a global pandemic rivaling
malnutrition as a health priority in some low-
income countries (World Health Organization,
1998) and contributes to health risk related to
most lifestyle conditions or minimally worsening
their manifestations. Obesity is pandemic in the
United States where almost 70% of people are
overweight (Keller and Lemberg, 2003). Obesity is
frequently linked with insulin resistance and high
blood pressure, which may reflect reduced activity
and exercise. Reduced physical activity is a signi-
ficant predictor of obesity (Wenche, Holmen,
Kruger, and Midthjell, 2004). Insulin resistance
339 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
associated with lack of exercise in people who
are overweight may be further compounded by
insulin resistance associated with chronic inflam-
mation observed in fat cells (Xu et al, 2003).
Abdominal obesity, lipid metabolism, and insulin
resistance are interrelated markers for coronary
artery disease (Frayne, 2002). In addition to
cardiovascular and general health risk, being
overweight negatively impacts quality of life
(Eckel and Krauss, 1998; Trakas et al, 2001).
Obesity is a major risk factor for other lifestyle
conditions and contributes to disability through
cardiopulmonary restriction, musculoskeletal
impairment, and psychosocial factors. In turn,
obesity is associated with lifelong impaired
health and disability and significant social and
economic burdens.
Type 2 diabetes and metabolic syndrome
Early detection of glucose intolerance allows
for intensive dietary and exercise modifications,
which have been shown to be more effective than
drug therapy in normalizing postprandial glu-
cose and inhibiting progression to diabetes
(Singleton, Smith, Russell, and Feldman, 2003).
Diabetic autonomic neuropathy as an indepen-
dent risk factor for stroke may reflect increased
vascular damage and effect on the regulation of
cerebral blood flow in individuals with diabetes
(Cohen et al, 2003).
Individuals with type 2 diabetes mellitus have
increased risk of cardiovascular and cere-
brovascular disease compared with individuals
without diabetes; thus, early detection and strict
control are mandatory. Moderate physical
activity with a faster walking pace (Hu et al,
2001) along with weight loss is a powerful
combination to reduce the risk of type 2 diabetes
as well as reverse it. These interventions with
a balanced diet can reduce the risk of developing
diabetes among those who are at high risk by
50–60% (Srinath et al, 1995). Cigarette smoking
is an independent risk factor for type 2 diabetes
(Wannamethee, Shaper, and Perry, 2001) and is
particularly dangerous for an individual with
diabetes (Abraham, 2004). Diabetes has been
reported to be a strong risk factor and hyper-
tension a less strong risk factor for IHD in
women compared with men (Burkman, 1991).
Cardiovascular and cerebrovascular risk factors
are often delayed in being detected and are
undertreated in people with diabetes.
Insulin sensitivity is largely predicted by body
mass index, smoking, age, and physical activity.
Weight reduction counters the effects of meta-
bolic syndrome and may counter the associated
hypertension and dyslipidemia as well. Early
detection of glucose intolerance allows for
intensive dietary and exercise modifications,
which have been shown to be more effective
than drug therapy in normalizing postprandial
glucose and inhibiting progression to diabetes
(Singleton, Smith, Russell, and Feldman, 2003).
Diabetic autonomic neuropathy as an indepen-
dent stroke risk factor may reflect increased
vascular damage and effect on the regulation
of cerebral blood flow in individuals with dia-
betes (Cohen et al, 2003). Diet and exercise
are primary components of the multifactorial
approach to prevention and management of this
lethal multisystemic condition.
Musculoskeletal health
Osteoporosis and arthritis may lead to con-
siderable morbidity and disability, and seconda-
rily, premature death particularly in older people.
Lifestyle has been implicated in their etiology or
as a contributing factor (Ng et al, 2006; Roddy
and Doherty, 2006); thus, a risk factor review
needs to be included in the initial assessment of
every perimenopausal woman or older person,
including men, to provide a baseline. Moderate
levels of physical activity, including walking, are
associated with a substantially lower risk of hip
fractures in postmenopausal women (Feskanich,
Willett, and Colditz, 2002). Thus, risk factor
assessment of both nonmodifiable and modifiable
risks is a major component of the health assess-
ment to help minimize associated morbidity and
potential mortality (American Physical Therapy
Association, 2001). Establishing baseline infor-
mation on bone health in every older patient is
prudent, given the relationship between lifestyle
behaviors (e.g., smoking, low activity, and sub-
optimal nutrition including low calcium con-
sumption, and heavy meat, caffeine, and alcohol
consumption) and bone health. Although post-
menopausal women have been the focus of bone
health studies, other groups are at risk of osteo-
porosis and should not be overlooked (e.g.,
 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
inactive children [particularly girls], older men
and individuals with chronic conditions who may
be less able to engage in weight-bearing activities
and physical activity; and those on long-term
steroids or having been so at any point in their
lives). In a study of the development of bone mass
and strength in girls and young women, only
exercise (and not daily calcium intake) was asso-
ciated with bone density and strength (Lloyd,
Petit, Lin, and Beck, 2004). This finding stresses
the singular importance of bone health assess-
ment and bone building in young people to offset
osteoporosis later in life.
Psychosocial health
The accumulation of daily irritants or life
struggles has been reported to have greater
impact on psychological and physical well-being
than major life events (Eliot, 1994). Such stress
has been documented to contribute to risk of
some lifestyle conditions or complicate their
presentation. Psychological distress has been
related to poor health and potentially poorer
health outcomes in patients entering cardiac
rehabilitation programs, for example (Jette and
Downing, 1996). Thus, the detection of undue
stressors and instruction regarding their identi-
fication and management is a prudent compo-
nent of physical therapy workup, assessment,
management, and evaluation. Comparable to
other interventions, tangible outcomes of stress
reduction need to be assessed over time to detect
clinically important changes (i.e., those that
impact physical health, function, participation,
and subjective well-being).
The incidence of mental health problems and
depression is prevalent within contemporary Wes-
tern society (Saxena, Jane-Llopis, and Hosman,
2006). Furthermore, people with mental health
challenges may have increased risk of lifestyle
conditions. On the basis of one descriptive study,
individuals with mental health conditions, such
as schizophrenia, have poor physical healthy
and die prematurely from cardiovascular disease
(McCreadie, 2003). Compared with women with
schizophrenia, men with the condition have been
reported to consume less fruits, vegetables, whole
grains, and carbohydrates than recommended.
Furthermore, the incidence of smoking and obesity
for both sexes are higher than for the general
340
population. Cholesterol has been shown to be high
and activity levels low. This study raised concern
for the physical well-being of individuals with
mental health problems as well as their psycho-
social well-being and the need for further investi-
gation of the physical health and well-being of
persons with mental health challenges.
Dementia and Alzheimer’s disease appear to
be increasing. This trend may reflect the aging of
the population, lifestyle factors, and improved
awareness and detection of these conditions.
The factors that have been associated with
Alzheimer’s disease also decrease cerebral blood
flow (Krill and Halliday, 2001). Understanding
the vascular component of this condition will be
an important advance in terms of its prevention
and management. In a cohort of older African
Caribbean individuals, vascular risk has been
associated with cognitive impairment, and
physical activity is inversely related to impaired
cognition (Stewart, Richards, Brayne, and Mann,
2001). Exercise training has been reported to
improve physical health and depression in indi-
viduals with Alzheimer’s disease (Teri et al, 2003).
Whether this reflects a vascular component of the
pathoetiology of the condition that is offset with
exercise warrants study. Cognitive capacity has
been rated among the three most important
contributors to healthy aging along with mobility
and capacity to perform activities of daily living
(Ramos, Simoes, and Albert, 2001).
Rationale for multipronged strategies
to reduce lifestyle conditions
Given most people have one or more risk
factors or manifestations of lifestyle conditions,
strategies to address these conditions in the 21st
century include multiple health behavior change
strategies and evidence-based interventions that
are targeted to the individual based on assess-
ments of health and risk factors (Greenland
et al, 2003). The findings of these assessments
constitute the vital signs of people in the 21st
century, hence, warrant being included in the
assessments and ongoing evaluation of all clients
or patients irrespective of their primary diag-
nosis or reason for referral. In the management
of these individuals, indices and measures of
health and well-being are legitimate outcomes
341 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
for the contemporary physical therapist along
with risk factor reduction.
Assessment of psychosocial factors is neces-
sary to establish readiness to change injurious
lifestyle behaviors; barriers and facilitators of
changing; and cultural factors to understand
that individual’s beliefs about health and well-
being, illness and disability, and the role of
lifestyle factors on health, and self efficacy; and
the individual’s confidence in changing his or
her lifestyle practices. To be equipped to address
contemporary health issues as a client’s or
patient’s primary problems or when these pre-
sent secondarily, the contemporary physical
therapist needs sufficient clinical competencies,
knowledge, and expertise as the primary care-
giver for clients or patients with respect to
smoking cessation, basic nutritional recommen-
dations, weight control, regular physical activity
guidelines, exercise prescription, stress and sleep
management, and recommendation for mode-
rate rather than excessive alcohol consumption;
or minimally to initiate such strategies and work
collaboratively with other team members
depending on the individual’s needs.
Smoking cessation
Smoking is the leading cause of preventable
death in the United States (Mokdad, Marks,
Stroup, and Gerberding, 2004). Despite its
well-documented health hazards, smoking
remains prevalent in both industrialized and
nonindustrialized countries (Peto et al, 1992)
and is estimated to shorten life by 11 minutes
for each cigarette smoked (Shaw, Mitchell, and
Dorling, 2000). Twenty-five percent of men
and 20% of women smoke. The danger of
smoking extends beyond chronic obstructive
pulmonary disease (COPD) and cancer or
asthma irritant. Overall systemic morbidity and
all cause mortality including cancer of organs
other than the respiratory tract are increased
in smokers (Report of the Surgeon General,
2000a, 2000b). Smokers also have longer hospi-
tal stays and more health complications than
nonsmokers. In addition, the health hazards of
second-hand or passive smoking by nonsmokers
have been well established (Glantz and Parmley,
1996). Furthermore, passive smoking is additive
in the smoker.
Of the leading causes of mortality worldwide,
COPD is typically within the top killers and is
associated with the loss of a million years of life
each year (Calverley and Walker, 2003; Pierson,
2004). In the United States, COPD ranks fourth
behind IHD, cancer, and stroke; thus, smoking
leads to life-threatening conditions that are
systemic and not only related to the respiratory
tract (Mozaffarian et al, 2004). Former and
current smokers have 25% and 44% fewer
healthy years of life, respectively, compared
with lifelong nonsmokers. Smoking cessation
is a priority for all individuals not only those
with lung disease, regardless of disease severity
(Paterno, 2003; Yohannes and Hardy, 2003).
Smoking in children remains a societal concern.
Individuals who do not experiment with smoking
until adulthood have the highest probability of
being a lifelong nonsmoker (Cote, Godin, and
Gagne, 2006). Health policies are therefore aimed
at reducing young people’s exposure to smoking
advertising and images and access to cigarettes.
These policies may explain the reduction in
boys who smoke; however, the proportion of girls
who smoke appears to be increasing (Centers for
Disease Control and Prevention, 2006). Young
girls constitute a unique group to which anti-
smoking campaigns need to be targeted in that the
outcomes of women with smoking-related condi-
tions are worse than for men.
Physical therapists in the 21st century need
knowledge of smoking effects and clinical com-
petence in initiating smoking cessation in their
patients for purposes of both health and well-
being, risk factor reduction, as well as the impact
of smoking on the outcomes for the problems
being managed, including smoking’s negative
impact on healing, repair, and immunity in
general. See the systematic review by Bodner
and Dean in this special issue regarding the role
of brief advice in smoking cessation.
Nutrition and weight control
Nutrition, a distinct issue to weight control, has
been implicated in IHD, cancer, hypertension and
stroke, diabetes, musculoskeletal health, and
potentially psychosocial well-being. In addition,
obesity, which is frequently associated with these
lifestyle conditions, often complicates the clinical
picture of patients presenting to physical therapists.
 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
Nutrition has a major role in these conditions
independent of an individual being overweight.
Although nutrition is a primary focus of an ath-
lete’s training regimen, in patient care this essential
component of health is relatively ignored. Patients
with chronic as well as acute conditions are
dependent on nutrition for immunity, healing, and
repair, as well as energy for resting metabolism and
functional performance. Physical therapists require
patients to perform physically in the presence of
ongoing pathology (chronic or acute); thus, atten-
tion to nutrition may augment management goals
and outcomes in much the same way as optimal
nutrition enhances athletic performance.
Complications and risks for which each client or
patient who is obese needs to be assessed include
1) IHD, peripheral vascular disease, cardiac myo-
pathy, and chronic heart failure; 2) hypertension
and stroke; 3) some cancers; 4) insulin insensiti-
vity and type 2 diabetes mellitus; 5) gallbladder
disease; 6) dyslipidemia; 7) osteoarthritis and gout;
and 8) pulmonary diseases, including COPD,
asthma, alveolar hypoventilation, and sleep apnea
(Anonymous, 2000; Grundy, 2002; Hu, 2003;
Kannel, Wilson, Nam, and D’Agostino, 2002;
Racette, Deusinger, and Deusinger, 2003; Tanaka
and Nakanishi, 1996).
The shear number of weight loss strategies
marketed to the public attests to their failure.
Levine (2004) and Levine et al (2005) have repor-
ted that the activity levels between lean people and
those who are overweight are substantially differ-
ent. Lean people engage in more spontaneous
activity resulting in greater nonexercising thermo-
genesis. These investigators argue that being lean
predisposes an individual to being more active and
burn more calories when inactive. They attribute
the current pandemic obesity levels primarily to
declining physical activity and sitting. Nutritional
habits during childhood are associated with life-
style conditions in adulthood (Caballero, 2001).
Obesity in children is strongly associated with
parental obesity (Paterno, 2003). Maintaining
weight within a healthy range throughout life is
recommended for optimal health advantage. This
health advantage includes increasing the threshold
for chronic conditions and reducing the rate of
disease progression if it manifests. In this way, life
and its quality could be prolonged and end-of-life
morbidity reduced.
Health statistics from cultures that consume
a diet largely of plant-based foods support
342
superior health outcomes. The diets of octogena-
rians in Asia and centenarians tend to be low in
saturated fat, trans-fat, and refined sugar and
high in fiber compared with Western dietary
habits (Sanders, 2003). The Mediterranean diet,
including fruits and vegetables, fish, and vegetable
oil, has shown health benefit and is associated
with less chronic disability and premature death
compared with the Western diet (Pitsavos et al,
2002, 2004). These cultures also tend to have
higher activity levels that influence metabolism
and people’s physiological responses to the food
they consume.
Nutritional guidelines have been revised by
the United States Department of Health and
Human Services (2008) and Health Canada
(2008). Compared with previous versions, the
revision is more aligned with the literature than
with the interest of lobby groups from the food
industry, dairy and meat producers, nutrient
supplementation businesses and organic food
producers. Some authorities have argued that
the current pandemic of lifestyle conditions
reflects adherence to guidelines over which food
industry lobby groups had significant influence
rather than lack of adherence by the consumer.
Current levels of fat and refined food con-
sumption and vegetable consumption as exam-
ples fail to meet the recommended dietary
guidelines. Both high fat and low vegetable
consumption have been strongly implicated in
the lifestyle conditions.
An optimal nutrition food pyramid on
which the revised American nutrition guidelines
are based is shown in Figure 2. These guidelines
closely parallel those of Health Canada (2008).
The pyramid illustrates general guidelines for
optimizing health in the general public, and
these guidelines have been associated with
offsetting the lifestyle conditions (Polidori,
2003). In general, each individual’s diet needs
to be aligned with these guidelines for optimal
lifelong health. Individuals vary with respect
to their metabolic nutritional needs based on
stage of life, health status, and ethnicity
and commensurate with increased metabolic
demands of healing and repair following
injury or during illness. In the absence of an
objectively identified deficit, there is no evidence
to support that nutrient supplementation pro-
vides added benefit to a daily nutritious diet of
wholesome foods.
343 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353

Figure 2. Nutrition food pyramid. Limit: high glycemic foods, e.g., sugar and added sugar, pastries, sweets, refined carbo-
hydrates, trans-fats, highly preserved and highly processed foods. Include: 5 to 8 glasses of water. Other components of a
healthy lifestyle include: Physical activity, exercise, and rest. Daily physical activity—10,000 steps a day. Minimum of
accumulated 30 minutes of aerobic exercise 3
/wk. 2 to 3 sessions/wk of 20 to 30 min of strength training. Management of
daily stress. Breathe clean air (no active or passive smoking). Several hours of restful sleep daily.

Regular physical activity and exercise
prescription
With increased physical activity, the risks of
IHD, stroke, and colon cancer are reduced. The
precise dose-response relationships between phy-
sical activity and health, and physical fitness and
health, however, have yet to be clarified and may
differ from one person to the next (Blair, Cheng,
and Holder, 2001). Current evidence supports
that moderate physical activity is sufficient for
health and does not need to be strenuous or
prolonged. Leisure activities, such as walking
and gardening, for example, are associated
with marked health benefit (Wannamathee and
Shaper, 2001). Even light to moderate physical
activity in middle to older age confers signi-
ficant benefit for cardiovascular health and is
protective for all cause mortality (Astrand, 1992;
Gunnarsson and Judge, 1997; Katzmarzyk,
Gledhill, and Shephard, 2000). The Surgeon
General (Report of the Surgeon General, 2000a)
recommends at least 20 minutes of moderately
intense exercise on 3 or more days of the week
with an accumulated duration of 180 minutes a
week. Of clinical relevance is that small gains in
exercise capacity (e.g., from being physically
dependent to being independent) or increased
maximal capacity from three to four METs
can translate into marked gains in activities of
daily living.
Exercise has a profound effect on the endo-
thelial function of blood vessels, which has been
implicated in atherosclerosis, IHD, cerebrovas-
cular disease, and gastrointestinal conditions and
could explain its multisystem benefits. Moderate
levels of physical activity reduce the risk of stroke
independent of other factors (Lee and Blair,
2002). In addition to dietary habits, reduced
physical activity has been implicated in all life-
style conditions, including osteoporosis and
dementia and Alzheimer’s disease, and is recog-
nized as an essential component in their primary
prevention. Even physical activity that is mild has
an important role in the primary prevention of
type 2 diabetes mellitus through its direct effect
on increasing tissue sensitivity to insulin (Sato,
2000). Nonpharmacological interventions for the
prevention and management of hypertension
have been strongly advocated to maximize their
therapeutic benefit and to minimize the need
for medication and its potential risks (Orozco-
Valero, 2002). Regular physical activity has a
particularly important role in preventing or
mitigating chronic conditions and reducing end-
of-life incapacity in the older population and
 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
Figure 3. Physical activity/exercise pyramid. Source: U.S. Department of Agriculture and the U.S. Department of Health and
Human Services, 2005.
their associated social and economic burdens
(Messinger-Rapport and Sprecher, 2002).
The physical activity and exercise pyramid is
shown in Figure 3. This pyramid has a physically
active lifestyle at the base, followed by aerobic
exercise 3–5 times weekly, followed by strength-
ening exercise and flexibility, and with inactivity
at the top, thus to be engaged in sparingly.
Generally, 10,000 steps a day is consistent with
an active lifestyle and good health in an adult
(Tudor-Locke and Bassett, 2004). Fewer than
5,000 steps a day is consistent with a sedentary
lifestyle, and 7,500–9,999 steps a day is consistent
with a somewhat active lifestyle. Over 12,500
steps a day is consistent with a highly active
lifestyle. The physical activity pyramid and the
food pyramid are effective visual reminders of
the priority and components of each for optimal
health (Foss and Keteyian, 1998). Although
physical activity and optimal nutrition can
reduce the risk of early atherosclerosis in lifelong
344
nonsmokers, this protection is not as apparent
in smokers (Luedemann et al, 2002).
Promotion of moderate alcohol
consumption
Light to moderate alcohol consumption has
been reported to have some health benefit
(Barefoot et al, 2002; Lopez-Velez, Martinez-
Martinez, and Del Valle-Ribes, 2003). Red wine
has been reported to be rich in plant phenolics,
which are present in fruit and vegetables. These
substances are antioxidants, which may mediate
their health benefit. The type of alcoholic drinks
people prefer and the amount consumed are
confounded by other differences in health beha-
vior; thus, interpreting the literature is difficult.
Whether health-related benefits of alcohol are
more marked in people with poorer health
habits, for example, or the benefit is additive in
345 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
individuals with healthy diets and who are
physical activity is unknown.
Stress and sleep management
Stress from life events, whether they negative
or positive, has been the focus of the literature for
several decades (Holmes and Rahe, 1967). In the
1970s, Benson (1997) focused attention on the
cumulative effect of daily stressors on autonomic
arousal (i.e., the fight, flight, fright mechanism),
which in more recent years has received increased
attention regarding the impact of cumulative
stress from daily hassles on the lifestyle condi-
tions (Twisk, Snel, Kemper, and van Mechelen,
1999). Finally, anger (e.g., intermittent explosive
disorder), repressed emotion, and hostility have
been considered particularly important in terms
of their deleterious impact on health. This aspect
of lifestyle is addressed in the article by LeMyre
in this Special Issue.
Sleep deprivation is a common occurrence in
contemporary life; see article by Coren in this
special issue. Although often viewed as trivial or
a luxury, quality and quantity of sleep are essen-
tial to health and well-being and physiologically
to healing and repair, self-healing, and recovery.
Assessment of sleep quality and quantity can
direct attention to this as a problem and be reme-
diated. Remediation of sleep issues may address
an individual’s problem directly, or augment
outcome of interventions.
Implications for physical therapy
in the 21st century
Physical therapists have a 100-year tradition
of prescribing education and therapeutic exercise
to address health, illness, injury, and disability.
As noninvasive practitioners, they are uniquely
qualified and positioned to promote healthy
communities through the health of its indivi-
duals. Biomedicine’s outcomes with respect to
the prevention, cure, and management of the
lifestyle conditions have been less dramatic
than in the management of acute particularly
emergent conditions, are costly and even dele-
terious, and warrant being used more judiciously
(Angell, 2004; Boodman, 2002; Engel, 1980,
1992; Hewa and Hetherington, 1995; Riegelman,
1991). Factors to explain the discordance
between health care needs and optimal care
extend beyond the scope of this series. Suffice it
to say that the factors driving the health care
agenda today or perhaps the illness care agenda
are complex and include powerful economic and
political influences that extend beyond what is
necessarily in people’s lifelong health interests
(Angell, 2004; Boodman, 2002). Engel, a long-
time proponent of dismantling the biomedical
model, has attributed the deficiencies of con-
temporary biomedicine in addressing contempo-
rary health problems to historical influences,
specifically, a persisting ‘‘seventeenth century
world view’’ (Engel, 1992, 1997). The 1970s
witnessed a systematic bias toward hospital-
based care. This bias has shifted over the past
20 years toward doctor-based care and treat-
ments marketed for profit, neither of which has
been shown to produce optimal health outcomes
(Angell, 2004).
The profession of physical therapy is com-
mitted to health, wellness, prevention, and the
‘‘cure,’’ as well as the remediation of disease and
disability. This is achieved through a commit-
ment to empowering people to self-heal, serving
as coaches in the wellness, prevention, or reha-
bilitation process, minimizing harm through
minimizing iatrogenic (medical care) risks, and
providing cost-effective, low-cost care. It is a
primary professional and ethical responsibility of
every physical therapist to ensure that non-
invasive interventions including education (e.g.,
smoking cessation, basic nutrition counseling,
weight control, guidelines for regular physical
activity, stress and sleep management, and alco-
hol management) and structured exercise pro-
grams are being maximally exploited in the
provision of lifelong health in every person,
patient, and client across all settings. Physical
therapy expertise needs to extend beyond the
clinic, facility, or hospital. The physical thera-
pist’s expertise is needed in a consultation role
to legislators, community planners, businesses,
schools, and other public and private institutions
particularly where a large number of people, and
secondarily their families, will be reached through
public health messages.
Given health and health care priorities in the
21st century, patient education needs to be
viewed as a distinct clinical competence and
implemented in every interaction between an
 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
individual and a physical therapist. Each
patient’s education needs and style must be
addressed so that the educational content and
delivery are tailored to that individual. Family
participation may help strengthen the outcome
of the health education. Education program
development must include a structure that
ensures sustainability of health behavior change.
Adopting a systematic approach to health and
wellness within the profession is consistent with
the leading health priorities of our time, and the
need to exploit the substantial evidence base in
terms of knowledge translation to each person
and, in turn, the community. In this special
issue, Rhodes and Fiala address health behavior
change with special emphasis on physical acti-
vity and exercise.
Industrialized countries are becoming
increasing ethnically and culturally diverse, with
massive migration of people across the globe
particularly to high-income countries—countries
with pandemics related to lifestyle, the lifestyle
conditions. With birth rates on the decline in
these countries, immigration is being encour-
aged. Thus, the role and impact of ethnicity and
culture as important factors influencing health,
ill health, utilization of health care services, and
the types of health education that are needed
and ways it should be disseminated, need to be
understood (Kromhout, Menotti, Keseloot, and
Sans, 2002). The delivery of culturally sensitive
care is needed to augment health outcomes
across culturally diverse groups.
The prevalence of and mortality associated
with COPD increase with age, and Caucasians
have higher rates than other ethnic groups in
North America (Chatila, Wynkoop, Vance,
and Criner, 2004). Among people with advanced
COPD, however, African Americans and
women are more prone to adverse effects of
tobacco smoke than their counterparts. Cardio-
vascular disease in Mexican Americans and
Native American Indians is a particular concern,
which has implications for optimal care and
service delivery (Luepker, 2001; North et al,
2003; Storey et al, 2003). Obesity, hypertension,
and the metabolic syndrome are also more
prevalent in these groups; thus, the special needs
of these groups warrant being targeted by phy-
sical therapists. Currently, Eastern Europe, the
Middle East, and Asia have the highest smoking
prevalence in the world.
346
The health advantage that people from some
other cultures enjoy in their homeland, e.g.,
Asians, is compromised when they immigrate to
Western countries and adopt Western dietary
and exercise habits (Egusa et al, 2002; Goel,
McCarthy, Phillips, and Wee, 2004; Wahlqvist,
2002). Although they may benefit from
improved health services and access, the lifestyle
conditions exact a toll on new immigrants with
each passing year. The physical therapist has a
unique role as health educator in promoting
optimal lifestyle practices in new immigrants.
Cultural awareness and sensitivity are attributes
needed by the contemporary physical therapist
to ensure culturally competent care, which is
a function of the practitioner and the patient
(Campinha-Bacote, 1999; Suh, 2004).
Although people from Utah, 72% Mormon by
faith, who follow a strict lifestyle code, have
among the best health indexes in the country and
some of the lowest rates of chronic conditions
(LaMonte et al, 2000), ethnic minorities are at
increased risk of heart disease and stroke among
other conditions. Designing preventive and
management strategies requires responding to the
needs of different groups. A training program
designed specifically for African Americans with
stroke and complex co-morbidities can be highly
effective in improving fitness and reducing risk of
further disease and disability (Rimmer, Riley,
Creviston, and Nicola, 2000). Racial differences
have been documented with respect to the inter-
action of obesity, hypertension, and diabetes
between African American and European
American women (Dubbert et al, 2002). Greater
emphasis needs to be placed on targeting risk
factors in different ethnic and cultural groups.
For example, alcohol consumption in Caucasian
Americans and weight control in African Ameri-
cans and Caribbean groups are among targeted
priorities (Dundas et al, 2001). For each indivi-
dual, the severity of the problem, the risks, and
readiness to change needs to be assessed to
effectively target management strategies. Sensi-
tivity to cultural as well as individual differences
in targeting health education strategies is essential
to the long-term success of the intervention.
Cultural differences in self-reported function
have been described (Owens et al, 2002). These
differences as well as low education status have
explained overreporting functional status when
self-reports are compared with objective measures
347 Dean /Physiotherapy Theory and Practice 25 (2009) 330–353
of performance. These observations support the
need for greater cultural sensitivity and awareness
in the clinic particularly when the patient is from a
minority group and the therapist from the domi-
nant Caucasian American group. These findings
support the need for objective functional assess-
ment in addition to self-reported functional status.
Another important cultural factor in health
care is the reporting of discomfort and pain that
impacts activity and participation. Studies have
been conducted on pain expression and the
responses of health care providers to the pain
expressed by people from cultures different from
the health care provider. In addition to cultural
differences in pain expression, patients from
cultures that are highly expressive in expressing
discomfort and pain have been reported to receive
less analgesia and pain control interventions than
individuals who are less expressive, a characteristic
consistent with the dominant culture (Cleeland
et al, 1997).
Cultural factors impact substantially the
beliefs and responses of people when healthy or
ill. Culture also may impact on self-efficacy and
other attributes that underlie self-responsibility
for health and recovery. Thus, prescribing health
education or exercise needs to be tailored to the
needs of each individual with particular atten-
tion to their cultural needs.
Implications of evidence-informed practice
in the 21st century for physical therapy are
described in detail in Part II of this introduction
to this Special Issue on 21st Century Physical
Therapy Practice. To address 21st century health
issues, a bold change in the qualitative direction
and priorities of physical therapy practice is
indicated. The good news is that the evidence-
based interventions to address these priorities
are well-documented. Thus, by such practice, the
leading causes of morbidity and mortality can be
substantially reduced if not the least causes of
morbidity and mortality.
Conclusion
The profession of physical therapy has had a
100-year tradition and value system of exploiting
noninvasive interventions to address impair-
ment, disease, injury, and disability. In the past
50 years, the unequivocal role of these inter-
ventions as powerful preventive measures has
emerged in the literature. The profession has
been shifting from models of impairment and
chronic disease to a model based on the WHO
ICF, which is consistent with people’s overall
health and well-being and is consistent with
health care needs and contemporary definitions
of physical therapy. As a leading contemporary
health care profession in the 21st century,
physical therapy can address the health care
challenges of our day at a systemic level in
society by being responsive and doing its part in
ensuring participation as well as ‘‘health for all’’
and in partnership with each individual and
other health care team members. Such commit-
ment to the exploitation of the largely non-
invasive practices of physical therapy with a
commensurate reduction of the need for and
reliance on biomedicine, the truest sense of
health care, is highly consistent with the Hippo-
cratic code of ethics, i.e., ‘‘First do no harm,’’
and ‘‘The function of protecting and developing
health must rank even above that of restoring
it when it is impaired’’ (Adams, 1946).
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