ACSM (2010) Article: Medical Exercise Positioning

This article was published over a year ago in the ACSM Health and Fitness Journal, vol. 14/NO. 1, January 2010. For those who missed the publication, here it is.....


Medical Exercise Positioning: A Business Toolkit
By Wendy A. Williamson, PhD


Positioning exercise professionals to service advanced medical conditions is gaining more attention and reaching a demand as a result of many factors, including the increase health care costs, and possibly the reduced allowable visits per insurance coverage, i.e. physical therapy. As the skill sets and education of the fitness professional are evaluated, is the average fitness professional prepared, and positioned to provide this service? Do fitness professionals have the professional relationships and respect with the medical community to service medical conditions? Can synergy be created to enhance reciprocation and can skills be advanced to enhance quality service and provide a significant return on investment (ROI)?

Many questions exist but the potential and possibility are endless. Medical fitness has been around for years. Since 1994, the American Academy of Health, Fitness, and Rehabilitation Professionals (AAHFRP) has offered the oldest certification: Medical Exercise Specialist. Dr. Michael Jones, PhD, PT, and President indicates that over 9,000 students have become certified across six continents (Africa, Australia,Europe, Asia, and North and South America) .

According to Dr. Jones, the demand for MES has been growing for years. Why? Several possible reasons might be because our population is getting older and there truly are not enough medical professionals to manage all of these folks. “Everyone is taking advantage of this shift and opportunity,” says Dr. Jones(Regarding MES)

Corporate wellness has existed for some time as well. Currently, nearly two-thirds of U.S. companies offer some sort of wellness program to lower the health insurance costs, combat absenteeism and boost productivity. (Wulfhorst, 2009) Are fitness professionals positioned to provide wellness programs?

Amanda Harris, Vice President of ACAC Fitness and Wellness Centers, shares that their three centers have a supervised exercise area for members whose physician has highly recommended exercise for their overall health. Their approach for these members is to provide a semi-private area that introduces basic and simple exercise instruction. Through general supervision, it has served as a springboard for more direct programming for their specific needs, whether it is small group sessions or individualized attention.

As a result, fitness professionals can be positioned to address simple lifestyle choices. It appears that the majority of adults believe that the health care dollars should assist. In 2007, Partnership for Chronic Disease (PFCD) reported that 81% of adults believed that the U.S. should prioritize our health care dollars to “invest more in preventative measures to ensure that diseases are prevented or kept from becoming more serious,” while 12 % say the dollars should be spent “more to treat diseases once they have happened.”

A few years ago (2007), PFCD reported that chronic disease represented more than 75% of health care costs and more than 70% of the deaths in the U.S. They also indicated that over 133 million Americans have a chronic disease and only 56% of the chronically ill patients receive the recommended health care services. (PFCD, 2007)

“Chronic diseases afflict 100 million Americans, which cause seven out of 10 deaths and consume $2 out of every $3 spent on health care, but much of the burden can be prevented with simple lifestyle choices because a “major contributing factor is physical inactivity.” (Leavitt, 2008)

What are the medical conditions? Are there medical conditions beyond chronic condition? Looking at Parkinson’s Disease, in 2006, Crizzle and Newhouse conducted a study to review existing studies evaluating the effectiveness of physical exercise on mortality, strength, balance, mobility, and activities of daily living (ADL) for sufferers of Parkinson’s disease (PD). Seven studies met the established criteria and were evaluated. The results of the research “up to this time,” support the hypothesis that patients with Parkinson ’s disease improved their physical performance and activities of daily living through exercise. (Crizzle and Newhouse, 2006)

Do we need to provide individual fitness programming in all cases? Many individuals may need individualized attention depending upon their condition, but there are other options such as specialized fitness groups that establish accountability, socialization, and the opportunity to create a group setting for medical conditions. Small group fitness programming can also reach more people, enable cost controlling measures, and still reach goals

Programs such as these are delivered in-house, hospitals, community-based centers, YMCAs and private fitness facilities. All of these centers provide equipment, classes, and general instruction for exercise. Some hospitals and private fitness centers can provide rehabilitation and then continue post-rehabilitation with appropriate personnel “in-house”. For fitness professionals, it has become more common to receive hand-offs from the medical community, such as physical therapy, sports medicine physicians, etc.

The all inclusive one-stop-“medical”-shopping has also become common, especially in orthopedic conditions where the orthopedic surgeon is in a medical building, while the CNRP, PA, Physical Therapist, MES, and personal trainer are also in the same building. Continuation of service can be provided from the surgery to complete discharge. This is convenient for the patient/client and it also creates an advantage for the fitness professional to learn, and advance their respective skills under the direction of the medical professionals.

The International Health, Recreation, and Sport Association (IHRSA) reported that at the conclusion of 2008 there were 30,022 fitness facilities within the U.S. However, when reviewing these numbers, Michael Scott Scudder, owner of CMETO (Club Management Education and Training On-line), stated the following:

“I believe the IHRSA numbers were as accurate as could be ascertained at the end of 2008 (30,022 facilities).”
I also believe there are at least 3,000 “other facilities” that do not show up on the radar that entertain membership options (condos, co-ops, gated communities, retirement communities, hotel facilities, etc.).
There seems to be enough in the greater metropolitan areas to have “enough” facilities to service and position fitness professionals to manage post rehabilitation or medical exercise servicing (MES). Do we have an adequate number of advanced fitness professionals to manage the needs at these facilities? If we look at the most common conditions seen by the advanced professional, perhaps we would know the answer to this question.

Table 1:
Common Medical Conditions

1. Orthopedic
2. Neruologic
3. Cardiovascular
4. Metabolic
5. Mental Disorders
6. Auto-immune disease
What are the most common conditions (Table 1) that the fitness professional receives for post-rehabilitation? They are as follows: Orthopedic (knee and hip replacements, torn ACL, meniscus tears, rotary cuff, kyphosis, lordosis), Neurologic (spinal cord injuries, strokes, cerebral palsy, etc), cardiovascular (heart attack, heart surgery, elevated cholesterol, high blood pressure, etc.), Metabolic (obesity, diabetes, thyroid condition, etc), mental disorders (dementia, Alzheimer’s) , and auto-immune disease (fibromyalgia, chronic fatigue syndrome, lupus, scleroderma, rheumatoid arthritis), etc.)

As a result of these conditions, we have an array of medical professionals from which we seek direction. These professionals will include: (Table 2) massage therapists, physical therapists, physician assistants, registered dietitians, nurse practitioners, family physicians, sports medicine doctors, surgeons, etc.) Interaction with these professionals is a must and can be challenging. However, see the suggestions below for the best success in interaction.

Table 2:

Medical Professionals

1. Massage therapists
2. Physical Therapists
3. Physician assistants
4. Registered Dieticians
5. Nurse practitioners
6. Family physicians
7. Sports medicine doctors
8. Surgeons
9. Etc.

As clients present themselves for post-rehabilitation or medical exercise servicing, the size of the “toolkit” for the fitness professional may run “large”. However, in recent years, it is very difficult for a fitness professional to be prepared for all conditions that may be presented. Yet, at the same time, it is the responsibility of the fitness professional to academically be prepared as well as have the application experience even if it means through an internship, etc.

In general terms, a caring and compassionate personality is one of the key ingredients. In the past, a college degree may not have been warranted, but along with approved certifications, a related college degree is essential. The National Commission on Certification Agencies http://www.noca.org/NCCAAccreditation/AccreditedCertificationPrograms/tabid/120/Default.aspx is the gatekeeper for the fitness professional and criteria must be met to be recognized as an accredited certification agency. The list changes from time to time. Most often, this list is utilized as a determining factor in hiring practices.

The personality of fitness professionals is also a key ingredient that ranks closely to skill sets. The fitness professional needs to be able to interact positively and effectively with the client. Within the development of the fitness professional, once the necessary education is acquired, and an approved certification, there may be specialty training or a second certification that may be necessary to address medical fitness. As mentioned, specialty study can also be achieved through internships, interacting with medical professionals through observation, accompanying client to appointments, and attending local seminars provided by the medical community.

Secondly, being a team player defining each of the “teams’” rolls is very critical. Dr. Jones reports that the fitness professional must understand their roll and how to communicate effectively. Communication with the medical professionals can often be a challenge. Networking with the assistants, front desk staff, nurse practitioners or whomever the fitness professional can get to respond may be the only answer, and truthfully, some medical professionals may not ever respond via letter, phone, etc. Our dialogue with the medical community is critical. Our professionalism, terminology, confidentiality, etc. is necessary to achieve respect, reciprocation, and referrals. If our homework is done, we understand the respective condition enough to address the situation without “hick-up”. Our discussion via letter, phone, and internet will be respected and addressed.

For three years via telephone calls and formal letters, I attempted to communicate with a family physician. Once I began working with an incomplete paraplegic whose daughter just happened to be this physician’s nurse. This daughter shared her interaction with me regarding her father. She shared that information with the physician and the rest was history. The process was long and difficult, especially seeking medical releases and seeking input; however, it did pay off. Over the years, I have continued to provide service to more than a dozen of this physician’s patients.

As mentioned, establishing relationships, referrals, and reciprocation with the medical community may be difficult; however, don’t give up, it can be done. By attending appointments with clients, establishing relationships with staff, attending open houses, social events, and sporting events just may assist the fitness professional in crossing “paths” with the medical professional. Always be prepared since you never know when or if you will interact with a medical professional.

Positioning for Medical Exercise Servicing

1. Establishing relationships with medical community
2. Communicate with ALL medical staff
3. Provide potential program design for client/patient
4. Accompany client to Dr. appointment
5. Observe medical professionals
6. Have medical professional present already existing presentation
7. Create medical advisory team
8. Provide up-dated fitness progression
9. Follow-up correspondence via e-mail, telephone calls
10. Attend social/professional functions
When communicating via letters, I highly recommend “doing the homework” and providing the medical professional with the results of the assessment, and create a potential program design for the approval after or along with the medical release. Why? The potential program design establishes the fitness professional’s expertise, research and process thought regarding the condition of the client. The majority of the work has been done. All that is being sought is further direction, a signature, so the client may begin an exercise program.

The medical professional often is involved with educational seminars, and workshops, etc., and probably has several “canned” presentations. Attempt to secure a time for the medical professional to come and present to your staff. Since the presentation has already been prepared, the medical professional doesn’t have to ‘reinvent’ the wheel and is prepared to present when called upon, if interested. The fitness facility can negotiate benefits such as membership, especially, if this professional is providing more than one “talk”.

Perhaps, a medical advisory team is needed at your facility. Fitness services (personal training, yoga, Pilates, etc.) could be provided as a benefit and an opportunity for the medical professional to experience what is being offered. Too often, the medical professional doesn’t have a good understanding what can be offered by the fitness professional and until they see first-hand, they never will have a true understanding.

Follow-up correspondence is an effective way to show client progression of the client, their patient, and an opportunity to illustrate skill-sets and to continue to keep the ‘open-door’ to the respective medical professional. In some cases, the medical professional may provide a summary of a follow-up visit in his/her office for the client, via telephone, e-mail, etc.

Positioning takes time, energy and skill. It may not only be the medical professional. The client who presents themselves for medical exercise servicing wants quality return, improved daily activity, a return to their normal life. Regardless of the economic times or the health care options, the Return on Investment for this special population will continue. The reciprocation of service and referral will increase exponentially. The fitness professional’s position must take special populations into account for growth and opportunity.

Keep in mind, that for every new client that presents to the fitness professional, the opportunity for establishment exists, the opportunity for further networking exists, and the opportunity for advancing skills and business exists as well. Advancing skills and positioning ourselves only creates more business, more ROI, and quite honestly more income. However, Dr. Jones reiterates that as fitness professional, it is key that we have complete understanding of our 1) scope of practice, 2) know the criteria for post rehabilitation, and 3) Recognize when there is a red flag.

By maintaining our professionalism, creating relationships with the medical community, and offering quality care and service, the potential is enormous. Positioning the fitness professional will require a lot of work and truthfully, some of the medical community may be skeptical of the potential. Rightly so, as so many fitness professionals may not be willing to put the incredible effort forward to achieve MES or Post Rehabilitation status. However, the “fittest” will survive and the “willing” will be rewarded both professionally and personally. Medical Exercise Servicing is here to stay, and the fitness professional toolkit must be strategically “packed and prepared” to address the business demand.



Americans want presidential candidates to address chronic disease in health reform proposals: 75 percent more likely to support a candidate who makes preventing and managing chronic disease a primary part of their health proposal. (2007) Partnership to Fight Chronic Disease (PFCD), www.fightchronic disease.org, June 1, 2007.

Crizzle, A and I Newhouse. (2006) Is Physical Exercise Beneficial for Persons with Parkinson’s Disease?, Clinical Journal of Sport Medicine, 16, 5, pp. 442-425, September 2006.

Leavitt, M. (2008) Regular exercise can help prevent chronic illness, reduce health care costs, Lexington Herald-Leader, October 13, 2008.

O’Connor, D., A. Jackson. (2001) Predicting physical therapy visits needed to achieve minimal functional goals after arthroscopic knee surgery, Journal of Orthopaedic and Sports Physical Therapy, 31(7), 340-358.

Wulforst, E. (2009) Healthcare reform could impact wellness programs, Reuters, www.reuters.com, July 7, 2009.