Journal of Aging and Physical Activity, 1994, 2, 261-272 O 1994 Human Kinetics Publishers, Inc.

The Revolution in Aging: Implications for Curriculum Development and Professional Preparation in Physical Education

C. Jessie Jones and Roberta E. Rikli

Despite dramatic increases in the older adult population, curriculum develop- ment in the area of physical activity and aging has been minimal or nonexistent in most physical education departments in higher education. As a conse- quence, many practitioners leading programs for older adults have had to rely primarily on self-study and on-the-job training for the knowledge and skills they need. The purpose of this paper is to suggest minimum competen- cies for preparing specialists in the field of physical activity and aging and to recommend corresponding curriculum development. Suggested core offerings for a concentration in physical activity and aging are presented, including specific course content for three specialty courses: physical activity and aging, physical assessment and exercise programming for older adults, and therapeutic exercise for age related chronic conditions. In view of the fact that many departments are faced with declining budgets and program cutbacks, alternative strategies for curricular revision and for integrating gerontological content into the existing physical education curriculum are dis- cussed.

Key Words: competencies, exercise programming, agism

For the first time in history there are more Americans over 50 than under 20 years of age. It is further estimated that the population over 65 will more than double by the year 2030. More specifically, between the years 2010 to 2030 the over-65 population is expected to grow by 73%, compared to a 3% decrease in the under-65 population (Bureau of the Census, 1992). This revolution in aging brings with it many serious challenges as well as numerous opportunities, particularly for people in the field of fitness and health promotion. Although life expectancy has increased by almost 60% since the early 1990s, for many people the increased quantity of years may not result in increased quality unless there is a change in their lifestyle behaviors. The field of physical education can play a major role in increasing both life expectancy and quality of life by educating

C.J. Jones and R.E. Rikli are with the Department of Kinesiology and Health Promotion, California State University, Fullerton, Fullerton, CA 92634.

262 Jones and Rikli

the public as to the importance of active, healthy lifestyles and by providing physical fitness and activity programs for people of all ages-youth through older adults.

A growing body of scientific research documents the contributions of physical activity to health promotion and disease and disability prevention in later years. In the Healthy People 2000 report, physical activity is identified as a "key ingredient" in healthy aging (Department of Health and Human Services, 1991). The report emphasizes the major role of physical activity in maintaining functional independence as a result of its preventive and therapeutic effect on numerous conditions including coronary heart disease, hypertension, diabetes, osteoporosis, and depression. It has been estimated that physical training can "effectively postpone physical deterioration for some 10-20 yrs" (Astrand, 1992, p. 159). In addition, epidemiological studies indicate that even moderate levels of physical activity help postpone morbidity and mortality for several years (Blair et al., 1989; Paffenbarger, Hyde, Wing, & Hsieh, 1986; Paffenbarger et al., 1993).

Despite the dramatic increases in the older adult population and the recog- nized value of physical activity in sustaining health and independent functioning, curriculum development in the area of physical activity and aging has been minimal or nonexistent in many physical education departments in institutions of higher education. As previously reported (Jones & ~ i k l i , 1993), less than 20% of the more than 600 health, physical education, and recreation (HPER) programs in the United States offer even one course related to physical activity and aging, with even fewer departments offering opportunities for specialization in this area. Furthermore, judging from the minimal coverage given to issues on aging in most major textbooks in the field of physical education, it is presumed that the regular core curriculum focuses little attention on the older adult.

Because physical education traditionally has focused on younger popula- tions, professionals working in the growing number of senior programs have had to rely primarily on self-study and on-the-job training for the knowledge and skills they need. Unfortunately, principles that apply to human performance in younger populations do not always generalize to older people. With age, people become increasingly more diverse relative to medical, psychological, and physical status, which in turn requires specialized knowledge in planning programs to meet their needs. As Shephard (1990) has pointed out, programming physical activity for older adults requires more care and expertise than for any other age group, with only a fine line separating effective from dangerous exercise pro- grams.

Whereas credentialing requirements in areas such as teacher education, athletic training, and adapted physical education clearly dictate curriculum content in physical education, there are no comparable standards to suggest competencies and coursework needed to prepare professionals to work with older adult pro- grams. In the absence of such guidelines, departments have no "road map" to follow or directives to use in designing the needed programs in this area. The purpose of this paper, then, is to suggest minimum competencies for preparing specialists in the field of physical activity and aging and to recommend corre- sponding curriculum development. Further, to better meet the changing needs of society, it will be suggested that "agism" be eliminated from the core curriculum in physical education by assuring that basic principles be applied throughout the life span-to the older adult as well as to the younger population.

Curriculum Development 263

Throughout this paper all suggestions are based on input from a combination of sources: our own personal experiences, recommendations from a national standards committee on physical activity and aging, examination of existing programs in adult fitness and aging, and feedback from a network of practitioners currently working in senior physical activity and fitness programs. Information presented is in no way intended to be definitive or complete, but rather should be viewed as a working draft that we hope will lead to further discussion and improved guidelines for preparing physical educators to serve an aging society.

Standards for Program Development

Without professional standards, programs being developed may lack critical components that employers view as essential to job related knowledge and skills. Standards, or guidelines, are policy recommendations (considered by a general consent of authorities) for curricular and related matters of program development. They are not designed to be a mold into which all programs must be poured, but rather they should help focus attention on knowledge and skills critical to the development of quality professional preparation programs. Also, such recommendations should be viewed as evolutionary and must be tempered by the mission of the department and institution, the availability of resources, and the needs within the community. Adherence to formalized standards would serve to inform older persons, their families, senior service providers, state and federal agencies, administrators and faculty in higher education, and the general public that students have successfully completed at least minimum competencies for employment in the field of physical activity and aging.

Although there are no published standards or guidelines for program devel- opment in the field of physical activity and aging, a former Standards Committee of the Council on Aging and Adult Development within AAHPERD (the Ameri- can Alliance for Health, Physical Education, Recreation and Dance) did initiate guidelines in this area.' However, because the committee's work was never published, it has had little impact on cumculum development in higher education. We have reviewed the original work of the committee, made several changes based on additional input, and present the following recommended competencies as guidelines for designing a program for students preparing for careers in the field of physical activity and aging.

Students preparing for careers in the field of physical activity and aging should demonstrate scientific knowledge and application technique in the fol- lowing:

Core content areas of physical education-anatomy, exercise physiology, kinesiology, biomechanics, motor learning, measurement and evaluation, sport/exercise psychology, movement education, and program management and evaluation:

'Committee members contributing to the original guidelines were: Marie Boarman (Chair), Dean Gorman, Rose Lyon, Saundra Modisett, Margaret Smith, and Robert Wiswell.

264 Jones and Rikli

Basic concepts in gerontology-social, psychological, and physiological issues relative to the aging process; The influence of the aging process on participation in physical activity and exercise and, conversely, the effect of physical exercise on the aging pro- cess; Procedures for adapting physical activities and assessments for both healthy and frail older adults, including the effects of pharmacological interventions on physical performance; Issues related to health and physical assessments, including risk factor identification, health appraisal, behavior modification, and exercise pre- scription and monitoring; Major health concerns of older adults, including such topics as mental and physical chronic and acute diseases and disabilities, access to health care, caregiving, long-term care, abuse, and death and dying; Health promotion programs, including self-care, nutrition and weight con- trol, physical fitness, substance abuse, stress management, consumer aware- ness, goal setting, and behavioral modification; Human relations skills, including communication, counseling, motivation, and social interaction; Teaching methodology, including group dynamics, feedback, reinforce- ment, making activities and fitness fun, empowering others, and designing and leading individualized and group exercise and physical activity pro- grams; Community relations skills, including networking with senior service agen- cies and other allied health professionals; Specific needs related to gender differences and culturally and ethnically diverse populations; First aid, CPR, and other emergency procedures;

e Special research design considerations, including implications for future research in physical activity and aging.

Curriculum Development

In most cases, providing curricula to meet these competencies would require a combination of new course development and revision of existing courses. De- scribed in Appendices A through C are examples of three specialty courses designed to meet many of the competencies needed by specialists in adult fitness and aging.

The course on Physical Activity and the Aging Process (Appendix A) is primarily a theoretical course that should be required of all students planning to work with older adults. This course also would be valuable for physical education teacher educators as background knowledge for teaching lifelong concepts to younger people. Equally important, a course of this type should be part of the basic core within the general field of gerontology. Considering that physical activity level is well documented as a critical factor relative to lifelong health and well-being, it is important that all professionals working with or administering programs for older adults understand the relationship between physical activity and aging.

Cumculum Development 265

Unfortunately, physical activity and fitness has not been recognized as important subject matter in the field of gerontology. In a 1980 report, a team of gerontology experts ranked "physical fitness and physical functioning" 55th out of 60 topics in order of their importance within the gerontology curriculum (Johnson et al., 1980). A decade later there continues to be no mention of "physical activity" or "fitness" as recommended subject matter content in the published Standards and Guidelines for Gerontology Programs (Rich, Con- nelly, & Douglass, 1990). Perhaps part of the reason for this serious omission in gerontology cumculum is the lack of curriculum development within our own field relative to fitness and aging, thus limiting the availability of such course content.

The course on Physical Assessment and Exercise Programming for Older Adults (Appendix B) presents assessment and programming information generally not found in other physical education courses. As mentioned earlier, programming exercise for older adults requires special knowledge and skills due to the diverse physical, psychological, health, and medical conditions and concerns of older people. This course might be viewed as a counterpart to the curriculum and methods courses required of students preparing for careers in teaching younger people.

Information presented in the course Therapeutic Exercise for Age Related Chronic Conditions (Appendix C) is imperative for developing the knowledge and skills needed to adapt exercises for various chronic diseases and disabling conditions that are common among older adults. Without an understanding of effective therapeutic interventions, and of the risks involved and precautions needed for people with special conditions, exercise programs can result in more harm than good.

CONCENTRATION IN PHYSICAL ACTIVITY AND AGING

To round out core offerings for a concentration in physical activity and aging and to meet other aspects of the competency requirements discussed earlier, two additional gerontology courses plus a supervised practicum and an internship are recommended. The additional courses are Health Issues and Aging, and Introduction to Gerontology, both of which, with careful planning, might be taken as part of the student's general education requirement. An understanding of health issues and aging is important for senior exercise leaders because of the numerous medical conditions present within typical senior groups, and for increased knowledge of the many ways that health status can be influenced by exercise and other lifestyle behaviors.

An introduction-to-gerontology course generally provides a multidiscipli- nary overview of the characteristics, strengths, and problems of older persons, the development of gerontology as a field of study, services to older adults, career options involving working with older persons, and relevant public policy issues affecting older adults. In addition, this course typicaIIy covers basic issues on aging from a social, psychological, biological, and human services point of view.

Finally, just as observation and practice teaching are required of students going into the field of education, both a practicum and internship should be

266 Jones and Rikli

required of all students planning careers in physical activity and aging. In sum- mary, then, in addition to the typical foundations courses required of all physical education majors, the following set of courses are suggested as a reasonable core for preparing specialists in the field of physical activity and aging:

Physical activity and the aging process Physical assessment and exercise programming for older adults Therapeutic exercise for age related chronic conditions

* Health issues and aging Introduction to gerontology Practicum and internship.

Since much of the demand for fitness leaders for older adult programs are generally entry level positions, the above described concentration would be most appropriate at the undergraduate level. However, it is suggested that any specialty courses in fitness and aging, such as those described in the appendices, be structured so that they also can be taken as electives by graduate students interested in fitness and aging.

Although the purpose of this article is to discuss competencies and curricu- lum development for preparing specialists in the field of physical activity, we would be remiss not to recognize the pressing need for basic training of people who are already working in the field. Many of these paid and volunteer leaders have no academic background in the field of adult fitness and aging (Peterson, 1988). Therefore, some departments also may want to consider offering training workshops or developing a nondegree certificate in adult fitness and aging, perhaps through the university's extended education program.

In most communities, to provide both affordable and quality fitness pro- grams, it may be desirable to have a two-tiered certificate program. A Level I certificate might be developed for exercise technicians who have a specified amount of training in senior fitness but no degree in the field. Potential candidates for this type of training would include senior center activity directors, part-time employees, or volunteer senior instructors. Their major responsibility would be to teach or to assist with the teaching of physical activity and exercise classes for older adults. A Level I1 certificate would require at least a bachelor's degree, with a specialization in the field of physical activity and aging. Level I1 profession- als would have additional responsibilities such as planning and directing health promotion and fitness programs for older adults, supervising Level I exercise technicians, and serving as instructor trainers and exercise consultants.

CURRICULUM DEVELOPMENT AND LIMITED RESOURCES

Declining budgets and program cutbacks may present formidable challenges as well as golden opportunities. They often provide the catalyst needed to reassess curriculum and refocus programs based on shifting needs in a society. If a department recognizes the need to make curriculum changes, limited resources alone should not deter program revisions. When budget restrictions prevent expanding curricular offerings to accommodate new course content, adjustments can be made in other ways such as revising existing courses, eliminating courses

Curriculum Development 267

in some areas, and/or reducing the number of sections or frequency of existing course offerings.

An obvious strategy for adding courses in physical activity and aging to the cumculum without increasing the total number of courses in a program would be to reduce or consolidate current courses that are devoted to younger age groups. Surely, with the demographic shift to more older versus younger Americans, and with the decreasing (unfortunate, but realistic) demands for physical education teachers in many states, departments may need to consider shifting some of their emphasis from the younger to the older client. As mentioned, additional space (resources) for new courses might also be made available by reducing the number or frequency of course sections offered, particularly in areas of decreasing de- mand. If student demand does not justify less frequent offerings, an option may be to schedule some sections through the university's extended education program.

The alternative to developing new courses such as those described in the appendices is to expand or revise existing ones to address the entire life span, thereby applying to older adults as well as to other age groups. For example, content from the course on the physical assessment and exercise programming for older adults (Appendix B) could be included, with proper planning, within existing courses in the department such as exercise physiology, measurement and evaluation, principles of conditioning, physical activity for special populations, physical performance testing and counseling, and program organization and ad- ministration courses. Similarly, the content suggested in the other two courses on physical activity and aging (Appendices A and C) would need to be blended into various other courses in the existing physical education curriculum if in fact students are to be prepared to work with older adults.

A LIFE SPAN APPROACH

Common sense suggests that knowledge of the aging process and factors related to successful aging are important not only in working with older adults but also in educating people of all ages. Understanding the health behaviors and attitudes associated with successful aging should be part of the total health and physical education curriculum from elementary school through higher education. In fact, issues in physical activity and aging should be relevant to virtually all physical education emphasis areas-teacher education as well as areas such as sports medicine, personal training, prephysical therapy, sport management, and sport psychology.

Regardless of whether a department offers a specialization in the field of physical activity and aging, proportionate application should be made to adult development and aging within all appropriate courses--exercise physiology, biomechanics, motor learning, sport psychology, sociocultural perspectives, adapted physical education, athletic training, and measurement and evaluation. Course content, catalog descriptions, and perhaps even titles might be revised to reflect a life span approach. A course on prevention and care of athletic injuries, for example, might be retitled Prevention and Care of Musculoskeletal Injuries and redesigned to apply to movement related injuries in people of all types and ages, not just athletes. In fact, even in the traditional athletic setting, the athletic trainer and the athlete might benefit by a better understanding of certain issues such as injury prevention and treatment choices relative to implications for

268 Jones and Rikli

lifelong functioning. In order to avoid curriculum chaos, when revising curricula, it obviously is important to assess how any changes in course content might affect other courses.

Conclusion

Offering quality professional preparation programs in the field of physical activity and aging requires more than standards development and curricular revisions. Because few faculty in physical education have had formal instruction in gerontol- ogy or experience working with older adults, the issue of faculty development may need to be addressed. Administrators are encouraged to provide incentives for faculty retooling-taking courses, 0bse~ ing fitness programs for older adults, and attending conferences, training seminars, and workshops. Departments may want to consider hiring experienced senior fitness practitioners to assist with curriculum development and course instruction.

In addition, it will be necessary to network with senior fitness leaders and program directors at various community settings to develop training sites for student practicum and internship experiences. For optimum community/university interaction, departments are encouraged to explore partnership opportunities with community agencies to support mutually beneficial senior fitness and health promotion activities. For example, the Department of Kinesiology and Health Promotion at CSU Fullerton is receiving financial support from an HMO (PacifiCareISecure Horizons) to develop a Lifespan Wellness Clinic on campus. The clinic will provide fitness assessment and enhancement programs for seniors, an on-campus training site for students, and a laboratory for conducting research related to health promotion and diseaseldisability prevention.

We hope we have provided some direction for program development in the field of physical fitness and aging. We encourage reactions and feedback from our colleagues related to the issues discussed. Comments and suggestions can be sent to us at California State University at Fullerton, Department of Kinesiology and Health Promotion, Fullerton, CA 92634.

References

Astrand, P. (1992). Why exercise? Medicine and Science in Sports and Exercise, 24, 153-162.

Blair, S.N., Kohl, H.W., Paffenbarger, R.S., Clark, D.G., Cooper, K.H., & Gibbons, L.W. (1989). Physical fitness and all-cause mortality: A prospective study of healthy men and women. Journal of the American Medical Association, 262, 2395-2401.

Bureau of the Census. (1992). Sixty-five plus in America (Series P-23, No. 178). Washington, DC: U.S. Department of Commerce.

Department of Health and Human Services. (1991). Healthy people 2000: National health promotion and disease prevention objectives. Washington, DC: U.S. Government Printing Office.

Johnson, H.R., Britton, J.H., Lang, C.A., Seltzer, E.P., Yancik, R., Maklan, C.W., & Middleswarth, A.B. (1980). Foundations for gerontological education. The Geron- tologist, 20, 1-61.

Cumculum Development 269

Jones, C.J., & Rikli, R.E. (1993). The gerontology movement-Is it passing us by? Journal of Physical Education, Recreation and Dance, 64, 17-26.

Paffenbarger, R.S., Hyde, R.T., Wing, A.L., & Hsieh, C.C. (1986). Physical activity, all cause mortality and longevity of college alumni. New England Journal of Medicine, 314, 605-613.

Paffenbarger, R.S., Hyde, R.T., Wing, A.L., Wing, I.M., Dexter, L.J., & Kampert, J.B. (1993). The association of changes in physical activity level and other lifestyle characteristics with mortality among men. New England Journal of Medicine, 328, 538-545.

Peterson, D.A. (1988). Personnel to serve the aging in the field of health, physical education, recreation, and dance. Los Angeles: University of Southern California, and Washington, DC: Association for Gerontology in Higher Education.

Rich, T.A., Connelly, J.R., & Douglass, E.B. (1990). Standards and guidelines for gerontology programs. Washington, DC: Association for Gerontology in Higher Education.

Shephard, R.J. (1990). The scientific basis of exercise prescribing for the very old. Journal of American Geriatric Society, 38, 62-70.

Appendix A

PE 400 (Upper divisionlgraduate level course)

Physical Activity and the Aging Process

Course Description: Examination of scientific evidence concerning the relationship be- tween physical activity level and physical, mental, and social-psychological well- being during aging. Specifically, the course will address "usual" changes that oc- cur during aging, changes related to inactive lifestyles (functional mobility and health declines), and the positive effects of an active lifestyle on successful aging and prevention of disease and disability.

Course Objectives: Upon completion of this class, students will demonstrate an under- standing of:

1. Current demographic trends; the health, disability, and disease status of older adults

2. Physiological, biological, and psychosocial theories of aging 3. Individual differences in physical aging: premature, usual, and successful 4. "Usual" age related changes such as cardiovascular, respiratory, nervous, mus-

culoskeletal, and psychomotor 5. Changes related to inactivity-physiological, mental, social-psychological, and

functional 6. Declines that are controllable through exercise and other lifestyle habits 7. The role of exercise in increased health span and decreased diseaseldisability 8. Special research design considerations in gerontology.

Course Content: Introduction

Gerontology: an emerging discipline Demographic trends and health status of older adults

270 * Jones and Rikli

Quantity and quality of life: premature, usual, and successful aging * Socioeconomic impact of disease and disability

Overview of the theories of aging

Experimental Design and Research Methods in Gerontology Problems with research in the field of gerontology

* Cross-sectional, longitudinal, and complex research designs Measurement concerns

* Implications for future research

Age Related Changes Cardiovascular/respiratory systems - normal changes; declines related to physical inactivity; role of exercise in

preventing disease and disability * Musculoskeletal system

- normal changes; declines related to physical inactivity; role of exercise in preventing disease and disability

* Nervous system - normal changes; declines related to physical inactivity; role of exercise in

preventing disease and disability Motor control and coordination (balance, posture, response speed, functional mobility) - normal changes; influence of exercise Social/psychological characteristics (cognition, emotional function, well-being) - normal changes; influence of exercise.

Appendix B

PE 401 (Upper divisionJgraduate level course)

Physical Assessment and Exercise Programming for Older Adults

Course Description: The application of physiological, biomechanical, and motor learn- ing principles to the development of physical activity programs for older adults. The course will include development of technical and personal skills related to functional fitness assessment, exercise prescription, exercise leadership, and pro- gram management. Special emphasis will be placed on human relations and com- munication skills needed to effectively work with older adults.

Course Objectives: Upon completion of this class, students will demonstrate knowl- edge and application techniques in:

1. Principles of program design, exercise prescription, and effective exercise leadership

2. Selection and administration of appropriate tests for functional fitness assess- ment

3. How to design and lead exercise classes for older adults 4. Human relations and communication skills for gender differences and diverse

populations 5. Principles related to exercise compliance and motivation 6. Program management and evaluation principles.

Cumculum Development 27 1

Course Content: Introduction

Demographics; population characteristics Types of programs-senior center, retirement housing, institutional, at-home, etc. Healthy People 2000

Program Development/Management Needs assessment; objectives Budgetlmarketing Facility/equipment considerations Leadership training/characteristics Participant consent/medical release forms Health/physical activity profiles Legal responsibilities; safety and emergency procedures

Program Content Program components - functional mobility (assessment, exercise prescription, safety precautions,

demonstration/practice) - flexibility (assessment, exercise prescription, safety precautions,

demonstration/practice) - aerobic endurance (assessment, exercise prescription, safety,

demonstration/practice) - strength conditioning (assessment, exercise prescription, safety,

demonstrationJpractice) Exercise prescription-mode, frequency, intensity, duration Monitoring for signs of exertion Use of creative movement, music, props, and special equipment Exercise leadership skills, including social interaction, group dynamics, feed- back, reinforcement, and human relations and communication skills Strategies to enhance program compliance and motivation Program evaluation Recreational gameslsports Special considerations-chronic conditions / diseases / nonambulatory, gender differences, and culturally and ethnically diverse populations.

Field Assignment Observe selected exercise programs within community Design and conduct exercise classes.

Appendix C

PE 402 (Upper divisionlgraduate level course)

Therapeutic Exercise for Age Related Chronic Conditions

Course Description: An examination of the benefits, risks, and special precautions as- sociated with exercise programs for people with selected chronic conditions and diseases. Specifically, exercise assessment and prescription will be addressed for people with cardiovascular disease, musculoskeletal disorders, sensory deprivation,

272 0 Jones and Rikli

eating disorders, cognitive/nervous system disorders, respiratory disease, GI tract disturbances, diabetes, and pain.

Course Objectives: Upon completion of this class, students will demonstrate knowl- edge and application techniques in: 1. The prevalence, symptoms, and cause of major chronic conditions and diseases

of the older adult population 2. The personal trauma and socioeconomic cost associated with these conditions,

as well as the potential for prevention/rehabilitation 3. The implications of these conditions relative to exercise benefits, risks, and spe-

cial precautions 4. Medical, physical, and functional assessments 5. Identification and prescription of specific exercises for common chronic condi-

tions, as well as specific limitations and safety precautions 6. Common medical treatments and interventions associated with these conditions 7. Identification of common medicineldrug treatments and potential drug/exercise

interactions 8. Assessing and evaluating progress relative to exercise effects 9. How to work with the medical community and caregiver.

Course Content: Introduction

Overview of major chronic conditions/diseases of older people - prevalence, symptoms, and causes - personal trauma and socioeconomic costs of these conditions Lifestyle effects relative to health, mobility, and disease

Preprogram Consideration Medical clearancelparticipant consent Safety and emergency procedures Legal considerations Health profile/current medications Potential medication/exercise interactions Physical and functional assessment

Exercise Programming Special precautions, benefits, and exercise adaptations for: - cardiovascular diseaseslconditions (coronary artery disease, congestive heart

failure, arrhythmias, peripheral vascular disease, hypertension, angina, varicose veins)

- musculoskeletal disorders (osteoporosis, arthritis, bursitis, kyphosis, lordosis, muscular dystrophy, myasthenia gravis, hip and knee replacements, back and postural problems

- sensory deprivation, including visual, hearing, and perceptual disorders - weight problems (obesity and underweight) - cognitive disorders (dementias, Alzheimers, depression) - neurological disorders (Parkinson disease, stroke, Bell's palsy, cerebral palsy,

etc.) - respiratory diseaseldisorders (COPD-emphysema, bronchitis, asthma) - GI tract disturbances (colitis, diverticulosis, constipation, hernia, ulcers) - diabetes, urinary incontinence, and pain Program evaluation/reassessment.