World Physical Therapy Day2014

Resources on why physical therapy matters

World Confederation for Physical Therapy | 1

Contents

Introduction ............................................................................................................................... 2

About physical therapy ............................................................................................................... 3

Facts and figures about physical therapists .................................................................................. 4

Article by WCPT President ............................................................................................................. 5

About physical therapy, independence and participation ...........................................................6

About physical activity and child obesity .................................................................................... 8

About physical activity and cardiovascular disease ...................................................................... 11

About physical activity and diabetes ......................................................................................... 13

About physical activity and active ageing .................................................................................... 15

About physical activity and cancer ............................................................................................ 18

Journal articles about physical therapy ...................................................................................... 20

Notes about this bookletThe terms physical therapy and physiotherapy refer to the same profession – some countries use one term, some the other. When the words physical therapy and physical therapist are used in this document, they also refer to physiotherapy and physiotherapist.

The information in this booklet may be reproduced without charge. It is designed as a resource, and does not necessarily represent an official WCPT view or policy.

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Introduction

This booklet provides facts, research findings, statistics and articles to help you demonstrate the contribution of

physical therapists, as part of your World Physical Therapy Day events and campaigns.

World Physical Therapy Day falls on 8th September every year. It is an opportunity for physical therapists (known

in some countries as physiotherapists) all over the world to raise awareness about the crucial role their profession

plays in making and keeping people well, mobile and independent. The day was established in 1996, by the World

Confederation for Physical Therapy – the profession’s global body representing over 350,000 physical therapists in

106 countries.

WCPT has compiled this information for you to use freely. If you’re not sure what to organise for World Physical

Therapy Day yet, there are plenty of suggestions in the complementary booklet “World Physical Therapy Day: what

to do, how to do it, how to get noticed”.

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Here is some basic information about physical therapy for you to copy and use in any material you produce to educate the public. If you refer to “physiotherapists” rather than “physical therapists” in your country, do change the text appropriately.

Physical therapists are experts in developing and maintaining people’s ability to move and function throughout their lives. With an advanced understanding of how the body moves and what keeps it from moving well, they promote wellness, mobility and independence. They treat and prevent many problems caused by pain, illness, impairments and disease, sport and work related injuries, ageing and long periods of inactivity.

Physical therapists work with people affected by a wide range of conditions and symptoms, for example:

• painful conditions such as arthritis, repetitive strain injury, neck and back pain

• cancer

• strokes, Parkinson’s disease and spinal cord injury

• heart problems

• lung disease

• trauma, such as road traffic accidents and landmines

• incontinence

They work in a variety of settings, including hospitals, health centres, sports facilities, education and research centres, hospices and nursing homes, rural and community settings.

Here are some examples of how physical therapists make a difference. They:

• use their skills to treat the underlying causes of pain

About physical therapy

and limitations in movement and function

• use many treatment approaches to help individuals regain their mobility and maximise their potential

• promote healthy lifestyles and exercise

• treat each patient/client as an individual and thoroughly assess them to identify their needs

• treat sports injuries

• promote safe and healthy activities

• work with children with coordination, balance and other movement problems to improve and maximise their independence.

To achieve all this, physical therapists are educated over several years, giving them a full knowledge of the body’s systems and the skills to treat a wide range of problems. This education is usually university-based and at a level that provides full professional recognition and allows them to practise independently. Continuing education ensures that they keep up to date with the latest advances in research and practice. Many physical

therapists are engaged in research themselves.

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Facts and figures about physical therapists

Physical therapists work with people of all ages to bring about improvements in their health and independence.

Physical therapists provide exercise prescriptions to help people keep fit and achieve/maintain a healthy weight.

Around 500 million people are obese worldwide. Physical activity is one of the best means of countering obesity.

Children and young people under the age of 18 need 60 minutes of moderate to vigorous physical activity each day to promote and maintain health.

Adults need 30 minutes of moderate physical activity five days a week, or 20 minutes of vigorous physical activity three days a week to maintain health. Plus they need to do muscle strengthening exercises at least twice a week.

Research has shown that physical therapy exercise prescriptions help women who experience incontinence, osteoporosis or breast cancer surgery.

Studies have indicated that physical therapy treatments have a major impact on conditions such as back and neck pain.

Physical activity provided under the guidance and supervision of a physical therapist reduces the risk of heart attack, stroke, type 2 diabetes, colon cancer and breast cancer.

Despite limited numbers of physical therapists in some countries around the world, they have proved their effectiveness at getting and keeping people healthy.

Physical therapists provide exercise programmes for

conditions that affect the bones and muscles, such as arthritis, back and neck pain, osteoporosis, joint replacements, and urinary incontinence.

More detailed information about what physical therapists do can be found in WCPT’s Description of Physical Therapy at www.wcpt.org/policy/ps-descriptionPT.

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Article by WCPT President

This article by WCPT’s President, Marilyn Moffat, can be published in newsletters, magazines and journals, or passed to other publications as background information.

If you are making any changes they should be checked with the WCPT Secretariat info@wcpt.org.

People with disabilities and long-term illnesses have the right to lead full and fulfilled lives as part of society. But many do not, because they have not received the right kind of support. This waste of human potential has a huge cost beyond personal hardship.

Several studies indicate that lack of participation by people with disabilities costs some countries 7% of their gross domestic product – reflecting both the loss of so many people not contributing economically and the cost of supporting them.

On top of mobility and independence problems, low incomes, higher living costs and restricted employment combine to limit the life chances of people with disabilities. This denies a large proportion of the world’s population their fundamental freedoms.

It needn’t be like that. This year, to mark World Physical Therapy Day, WCPT is highlighting the role of physical therapists in supporting people with long-term illness and disability to participate fully in society. Their role is to help people fulfil their potential by maximising movement and functional ability.

Physical therapists specialise in human movement and physical activity. They identify physical and other factors that prevent people from being as active and independent as they can be, and then find ways of overcoming them through rehabilitation, science-based exercise prescription, and promotion of physical activity.

Every year on 8th September, physical therapists around the world use World Physical Therapy Day to draw attention to the contribution the profession can make to the health and well-being of individuals and nations. The message is “Movement for Health”. This year we’re promoting the message that people with chronic illness and disability have a basic human right to be able to participate in society and that physical therapists can play a key part in helping them be “Fit to take part”.

The United Nations Convention on the Rights of Persons with Disabilities says “...the importance of accessibility to the physical, social, economic and cultural environment, to health and education and to information and communication, in enabling persons with disabilities to fully enjoy all human rights and fundamental freedoms...”

Physical therapists can help make that happen – and the message has to go out to politicians and other policy makers that they are worth the investment. The World Health Organization and the World Bank have said in a joint report: “Rehabilitation is a good investment because it builds human capacity. It should be incorporated into general legislation on health, employment, education, and social services and into specific legislation for people with disabilities.”

I can only echo those words. Physical therapy, including the rehabilitation services we provide, is a good investment because its builds human capacity. More than that, it allows people to fulfil their true potential.

Marilyn Moffat, WCPT President

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About physical therapy, independence and participation

The facts

People with disabilities are more likely to be unemployed. An Organization for Economic Co-operation and Development study of working age people with disabilities in 27 countries found that their rate of employment (44%) was almost half that of people without disabilities (75%). Source: Sickness, disability and work: breaking the barriers. A synthesis of findings across OECD countries. Paris, OECD, 2010 http://ec.europa.eu/health/mental_health/eu_compass/reports_studies/disability_synthesis_2010_en.pdf

“Low incomes, higher living costs and restricted employment opportunities often combine to limit the life chances of disabled people far beyond the restrictions of the disability itself.” Source: Masse, B. (1994). The Commission on Social Justice: Disabled People and Social Justice. London: Institute for Public Policy Research p.13 www.nhsemployers.org/Aboutus/Publications/Pages/RapidAccesstoTreatmentandRehabilitationforNHSstaff.aspx

Physical therapy brings participation

A United Kingdom Hospital introduced early access to physiotherapy services for NHS staff who were off sick with musculoskeletal problems, or reporting MSK problems. This resulted in more staff remaining in work, absent staff returning quicker, and a saving to the hospital of £586,000 over six months as a result of not having to bring in temporary staff. Source: NHS Employers, Rapid access to treatment and rehabilitation for NHS staff. London 2012

Research shows that rehabilitation at home after a stroke is cost-effective and reduces long-term dependency. The total economic cost of stroke to the UK in 2006/07 was £4.5 billion. Sources: Saka O, Serra V, Samyshkin Y, McGuire A, Wolfe CC. Cost-effectiveness of stroke unit care followed by early supported discharge. Stroke. 2009 Jan;40(1):24-9 http://stroke.ahajournals.org/content/40/1/24.abstract

Scarborough P, peto V, Bhatnagar P, Kaur A, Leal J, Luengo-Fernandez R, et al. Stroke statistics. Oxford: University of Oxford 2009 www.bhf.org.uk/publications/view-publication.aspx?ps=1001548

Multidisciplinary interventions involving physical components such as physical therapy alongside psychological and vocational components have been shown to lead to higher return to work rates. Source: de Boer A, Taskila T, Tamminga S, Frings-dresen M, Feurstein M, Verbeek J (2011), Interventions to enhance return-to-work for cancer patient, Cochrane Database of Systematic Reviews, Feb (2)CD007569 www.thecochranelibrary.com/details/file/1018207/CD007569.html

Participation benefits economies

According to the World Health Organisation and the World Bank, the economic cost of disability comes mainly from “loss of productivity from insufficient investment in educating disabled children, and exits from work or reduced work related to the onset of disability, and the loss of taxes related to the loss of productivity.” Source: World Report on Disability 2011 www.who.int/disabilities/world_report/2011/en/

A Canadian analysis estimated that the national economic cost caused by the loss of productivity due to short and long-term disability was 6.7% of gross domestic product. Source: The Economic Burden of Illness in Canada,1998. Ottawa, HealthCanada, 2002 http://publications.gc.ca/collections/Collection/H21-136-1998E.pdf

An Australian study has concluded that increasing participation by disabled people and reducing their unemployment by one third over a decade would result in a cumulative increase in Australia’s GDP of AUD 43 billion. Source: The Economic Benefits of Increasing Employment for People with Disability, by Deloitte Access Economics for Australian Network on Disability, 2011 www.deloitte.com/view/en_AU/au/industries/Lifesciencesandhealth/b147a016d0b47310VgnVCM2000001b56f00aRCRD.htm

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The economic cost of disability in Africa is between 3% of GDP in Malawi, and 7% of GDP in South Africa. In Asia, the costs lie between 3% of GDP in Vietnam and 4.6% of GDP in Thailand.

Source: The Price of Exclusion, International Labour Office, Geneva 2009 www.ilo.org/wcmsp5/groups/public/@ed_emp/@ifp_skills/documents/publication/wcms_119305.pdf

A UK study has shown that if just half of breast cancer survivors who initially return to work but then leave were helped to stay in work the economy could save £30 million every year. Source: Making it Work, Macmillan Cancer Support, London 2010 www.macmillan.org.uk/Documents/GetInvolved/Campaigns/Campaigns/Working_through_cancer/WorkingThroughCancer2010/MakingitWork.pdf

What the World Health Organization and the World Bank say

In their World Report on Disability (2011) The World Bank and the World Health Organization support rehabilitation as an effective means to help people participate and fulfil their potential.

They say:

“Rehabilitation is a good investment because it builds human capacity. It should be incorporated into general legislation on health, employment, education, and social services and into specific legislation for people with disabilities.”

Providing assistive technology – the responsibility of rehabilitation professionals such as physical therapists – “increases independence, improves participation, and may reduce care and support costs”.

“Convincing evidence shows that some therapy measures improve rehabilitation outcomes. For example, exercise therapy in a broad range of health conditions – including cystic fibrosis, frailness in elderly

people, Parkinson’s disease, stroke, osteoarthritis in the knee and hip, heart disease, and low back pain...”

“Unmet rehabilitation needs can delay discharge, limit activities, restrict participation, cause deterioration in health, increase dependency on others for assistance, and decrease quality of life. These negative outcomes can have broad social and financial implications for individuals, families, and communities.”

“Many countries – particularly low-income and middle-income countries – struggle to finance rehabilitation, but rehabilitation is a good investment because it builds human capital. Financing strategies can improve the provision, access, and coverage of rehabilitation services, particularly in low-income and middle-income countries.”

Source: www.who.int/disabilities/world_report/2011/en/

What the United Nations Convention on the Rights of Persons with Disabilities says

“...the full enjoyment by persons with disabilities of their human rights and fundamental freedoms and of full participation by persons with disabilities will result in their enhanced sense of belonging and in significant advances in the human, social and economic development of society and the eradication of poverty...”

“...the importance of accessibility to the physical, social, economic and cultural environment, to health and education and to information and communication, in enabling persons with disabilities to fully enjoy all human rights and fundamental freedoms...”

One of the eight general principles of the convention is “Full and effective participation and inclusion in society”.

Source: www.un.org/disabilities/convention/conventionfull.shtml

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According to the World Health Organization, childhood obesity “is one of the most serious public health challenges of the 21st century“ Source: www.who.int/dietphysicalactivity/en/

Obesity in childhood is linked with asthma, musculoskeletal problems, hypertension, early signs of cardiovascular disease, low self-esteem and depression. In the long-term, it can increase the likelihood of being an obese adult, and having a greater risk of cancer, type 2 diabetes and cardiovascular disease. Encouraging children and their families to reach recommended levels of physical activity is a cornerstone of obesity treatment and prevention.

Participation in physical activity helps prevent many chronic diseases. All physical therapists are experts in movement and exercise, and the ways in which it promotes health. Some physical therapists, called paediatric physical therapists, specialise in working with children. A physical therapy assessment is particularly important for children who are obese. The assessment can screen for musculoskeletal impairments and guide therapeutic exercise and physical activity prescription.

Childhood obesity facts

Globally, over 40 million preschool children were overweight in 2008. More than 75% of overweight and obese children live in low-and middle-income countries. Source: WHO www.who.int/features/factfiles/obesity/en/

Childhood obesity affects people regardless of their income. The problem is global and is steadily affecting many low-and middle-income countries, particularly in urban settings. Source: WHO www.who.int/mediacentre/factsheets/fs311/en/

Children’s choices, diet and physical activity habits are influenced by their surrounding environment. Source: WHO www.who.int/features/factfiles/obesity/en/

Children who are obese have a high incidence of musculoskeletal impairments. Source: http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1754.2011.02102.x/abstract

Rising levels of childhood obesity are being caused mainly by a shift towards energy-dense foods high in fat and sugars, and decreasing levels of physical activity. Source: WHO www.who.int/dietphysicalactivity/childhood/en/

Defining child obesity

The World Health Organization defines childhood obesity as having a body mass index (BMI) standardised deviation score (SDS) above 2.0. Childhood growth and BMI should be plotted on WHO age and gender specific charts in tandem with national growth reference charts. Measures of body composition such as waist circumference should be used to describe obesity. Source: WHO www.who.int/growthref/who2007_bmi_for_age/en/index.html

Child obesity and physical activity

The World Health Organization recommends 60 minutes of moderate to vigorous intensity physical activity every day for children aged 5-18. Moderate activity includes activities that raise the heart rate and cause some breathlessness. Vigorous activity is exercise that makes people huff and puff – and could include dancing, household chores and sports like running and football. Activities for children should be fun and age-appropriate. In addition, families should be active together because parents are the most important agents of lifestyle change. Source: WHO www.who.int/dietphysicalactivity/childhood_what_can_be_done/en/index.html

About physical activity and child obesity

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Physical activity recommendations

Children from birth to age five should engage in daily physical activity that promotes skill in movement and lays the foundations of health-related fitness. Source: National Association for Sport and Physical Education guidelines on physical activity for children www.shapeamerica.org/standards/guidelines/pa-children-5-12.cfm

Infants should interact with caregivers in daily physical activities that are dedicated to exploring movement and the environment and that promote skill development in movement. Source: National Association for Sport and Physical Education guidelines on physical activity for children www.shapeamerica.org/standards/guidelines/pa-children-5-12.cfm

Toddlers should engage in a total of at least 30 minutes of structured physical activity and at least 60 minutes per day of unstructured physical activity and should not be sedentary for more than 60 minutes at a time, except when sleeping. Source: www.shapeamerica.org/standards/guidelines/pa-children-5-12.cfm

Children under five should be physically active daily for at least 180 minutes spread throughout the day. Source: WHO recommendations 2010 in WCPT Active and Healthy. The role of the physiotherapist in physical activity. General Meeting of European Region of the WCPT 2012. Pages 13-14.

Children should accumulate at least 60 minutes, and up to several hours, of age-appropriate physical activity on all or most days of the week. This should include moderate and vigorous physical activity with most of the time being spent on activities where exercise is intermittent. Children should participate in several bouts of physical activity lasting 15 minutes or more each day. Periods of inactivity of two or more hours are discouraged for children, especially during the daytime hours.

Source: National Association for Sport and Physical Education guidelines on physical activity for children www.shapeamerica.org/standards/guidelines/pa-children-5-12.cfm

The role of the physical therapist

In cases of childhood obesity, a physical therapy assessment covers: 1) parental beliefs around healthy childhood growth and development; 2) cardiorespiratory (exercise testing); 3) musculoskeletal (including assessment of range of movement; strength; flexibility; balance; coordination; posture; gait and bony alignment); 4) sedentarism (eg screen-time); 5) sleep; 6) physical activity levels and perceived barriers to reaching recommended levels.

Treatment includes: 1) general health literacy education for child and parent 2) management of any associated conditions (eg painful flat fee, knee pain, weak core) identified in physical assessment; 3) age-appropriate and fun exercise training to increase physical fitness; 4) assisting parent/s to make changes at home to prevent obesity developing or progressing; 5) providing education and practical strategies to improve sleep and energy balance; 6) liaison and onward referral within the interdisciplinary team.

Positive communication between the therapist and family is essential. Many parents may not be aware that their child’s weight is a problem. Ensuring that a holistic assessment is used to identify areas where the child may have functional difficulties (eg balance or low cardiorespiratory fitness) may help the therapist discuss the child’s health without solely focusing on shape or size. In order to facilitate a child’s lifestyle change, it is recommended that the full family works towards this. Sources: Júlíusson PB, et al., Overweight and obesity in Norwegian children: prevalence and socio-demographic risk factors.

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Acta Paediatr. 2010 Jun;99(6):900-5. www.ncbi.nlm.nih.gov/pubmed/20175763 O’Malley et al., A Pilot study to profiles the lower limb musculoskeletal health in obese children. Pediatric Physical Therapy (in press). www.therapydia.com/articles/12586-a-pilot-study-to-profile-the-lower-limb-musculoskeletal-health-in-children-with-obesity

A review of evidence on the effect of physical activity on the development of pre-school children concluded that the availability of outside playing areas, and the encouragement and involvement of adults, were important in encouraging exercise. Source: Timmons BW et al. Physical activity for preschool children - how much and how? Can J Public Health. 2007; 98 Suppl 2:S122-34. www.ncbi.nlm.nih.gov/pubmed/18213943

Children with illness or disabilities are more restricted in exercise participation, and have higher levels of obesity than their peers. Finding structures that support them to participate brings psychological and social, as well as physical, advantages. Professionals such as physical therapists are well placed to ensure that activities are appropriate. Source: Murphy NA et al. Promoting the participation of children with disabilities in sports, recreation, and physical activities. Pediatrics. 2008; 121(5):1057-61 http://pediatrics.aappublications.org/content/121/5/1057.full

This information was produced with the kind assistance of the International Organisation of Physical Therapists in Paediatrics.

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Cardiovascular disease is the term used to describe diseases affecting the heart and circulatory system, and includes heart disease, stroke and raised blood pressure (hypertension).

Exercise, particularly aerobic conditioning and strength training, is one of the key interventions that can prevent death and disability from cardiovascular disease. Physical therapists are experts in prescribing these as part of a structured, safe and effective programme.

For those already affected by cardiovascular disease, the expert advice provided by physical therapists can help bring a return to usual roles. Physical therapists help people achieve a return to work, education, community participation and fulfilled lives.

Cardiovascular general

Cardiovascular disease is now the leading cause of deaths worldwide. Globally, 17.3 million people died from cardiovascular disease in 2008, 30% of all deaths. 7.3 million were due to coronary heart disease and 6.2 million due to stroke. It is estimated that by 2030, almost 23.6 million people will die from cardiovascular diseases, mainly heart disease and stroke. Source: World Health Organization www.who.int/mediacentre/factsheets/fs317/en/

The death and disability rates caused by heart disease and stroke for every country are available at: http://whqlibdoc.who.int/publications/2011/9789241564373_eng.pdf

It has been estimated that if everyone walked briskly at 4.8-6.4 kph (3-4 mph) on most days of the week, about 30% of deaths from cardiovascular disease would be prevented each year. Sources: Pate R et al. Physical activity and public health. JAMA. 1995;273(5):402-407. www.ncbi.nlm.nih.gov/pubmed/7823386 Wei M, Kampert et al. Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men. JAMA. 1999;282(16):1547-1553. www.ncbi.nlm.nih.gov/pubmed/10546694

Manson JE et al. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. NEJM. 1999;341(9):650-658. content.nejm.org/cgi/content/abstract/347/10/716 Tully M et al. Brisk walking, fitness, and cardiovascular risk: a randomized controlled trial in primary care. Prevent Med. 2005;41:622-628. www.ncbi.nlm.nih.gov/pubmed/15917061

Research involving people at risk of cardiovascular disease has indicated that exercise supervised by physical therapists, along with counselling from a dietician, brings significant improvements in blood pressure, weight, quality of life and other health indicators after one year. Source: Eriksson KM, Westborg CJ, Eliasson MC. A randomized trial of lifestyle intervention in primary healthcare for the modification of cardiovascular risk factors. Scand J Public Health. 2006;34(5):453-61. www.ncbi.nlm.nih.gov/pubmed/16990155

Raised blood pressure

Raised blood pressure, which is a risk factor for heart attack and stroke, can be controlled by exercise. One study has indicated that endurance exercise brings an average reduction of 10mm Hg for both systolic and diastolic blood pressure readings. Source: American College of Sports Medicine’s Guidelines for Exercise Testing and Prescription. 6th Ed. Baltimore MD: Lippincott Williams & Wilkins 2000. www.exrx.net/Store/Other/ACSMGuidelinesExTestingRx.html

The type of strength training prescribed by physical therapists can effectively reduce blood pressure in older men and women. Source: Martel GF et al. Strength training normalizes resting blood pressure in 65- to 73-year- old men and women with high normal blood pressure. J Am Geriatr Soc. 1999 Oct;47(10):1215-21. www.ncbi.nlm.nih.gov/pubmed/10522955

Major analyses of available research have indicated that exercise can reduce resting blood pressure by 3mm Hg for resting systolic blood pressure. Sources: Cornelissen VA, Fagard RH. Effects of endurance training on blood pressure, blood pressure-regulating mechanisms, and

About physical activity and cardiovascular disease

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Heart disease

Systematic reviews of evidence have shown that therapeutic exercise provided by physical therapists is beneficial to people with coronary heart disease, heart failure and chronic obstructive pulmonary disease. Source: Taylor, NF et al. Therapeutic exercise in physiotherapy practice is beneficial: a summary of systematic reviews 2002–2005. Australian Journal of Physiotherapy. 2007, Vol 53(1): 7-15. www.ncbi.nlm.nih.gov/pubmed/17326734

Reviews of evidence have shown that exercise-based cardiac rehabilitation for patients with coronary heart disease significantly improves health outcomes and mortality rates. Sources: Clark et al. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med. 2005; 143:659-672. www.annals.org/cgi/content/abstract/143/9/659 Taylor RS et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004; 116:682– 692. www.ncbi.nlm.nih.gov/pubmed/15121495

A review of evidence has indicated that exercise training in people who have had heart failure is safe and effective. Source: Smart N, Marwick TH. Exercise training for heart failure patients: a systematic review of factors that improve patient mortality and morbidity. Am J Med. 2004; 116: 693-706 www.ncbi.nlm.nih.gov/pubmed/15121496

Telehealth interventions can help reduce cardiovascular disease risk and help increase uptake of a prevention programmes by those who do not access cardiac rehabilitation. Source: Neubeck L et al. Telehealth interventions for the secondary prevention of coronary heart disease: a systematic review. European Journal of Cardiovascular Prevention and Rehabilitation. 2009; Vol 16(3): 281-9 www.ncbi.nlm.nih.gov/pubmed/19407659

This information was produced with the kind assistance of Julie Redfern.

cardiovascular risk factors. Hypertension 2005 Oct; 46(4):667-75. www.ncbi.nlm.nih.gov/pubmed/16157788 Kelley GA, Kelley KS. Progressive resistance exercise and resting blood pressure: a meta- analysis of randomized controlled trials. Hypertension. 2000 Mar; 35(3):838-43. www.ncbi.nlm.nih.gov/pubmed/10720604

This type of blood pressure reduction has been associated with a 5-9% reduction in heart morbidity, and a 8% to 14% reduction in the risk of stroke. Source: Whelton et al. Primary prevention of hypertension: clinical and public health advisory from The National High Blood Pressure Education Program. JAMA. 2002 Oct 16;288(15):1882- 8. www.ncbi.nlm.nih.gov/pubmed/12377087

Stroke

Exercise reduces the risk of stroke. Walking at 4.8 kph (3 mph) for 5 hrs/wk brings a 46% lower risk of stroke, compared with non-exercisers. Sources: Hu F et al. Physical activity and risk of stroke in women. JAMA. 2000; 283(22):2961- 2967. www.ncbi.nlm.nih.gov/pubmed/10865274Lee I et al. Exercise and risk of stroke in male physicians. Stroke. 1999;30(1):1-6. www.ncbi.nlm.nih.gov/pubmed/9880379

Structured exercise also brings improvement in all measures of impairment and disability in people who have had a stroke. Source: Teixeira-Salmela et al. Muscle strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors. Arch Phys Med Rehabil. 1999 Oct; 80(10):1211-8. www.ncbi.nlm.nih.gov/pubmed/10527076

In one study, patients who had had a stroke performed strengthening and functional tasks three times a week for four weeks, and gained significant improvements in strength, walking speed, standing/sitting and endurance. Source: Dean CM et al. Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Arch Phys Med Rehabil. 2000 Apr;81(4):409-17. www.ncbi.nlm.nih.gov/pubmed/10768528

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About physical activity and diabetes

Diabetes mellitus is a condition where the amount of glucose in the blood is too high, causing tissue damage. There are two types. Type 1 diabetes occurs when the body is unable to produce any insulin. It cannot be prevented. Type 2 diabetes develops when the body isn’t producing enough insulin, or becomes resistant to insulin. This type of diabetes can be prevented. Most cases of type 2 diabetes are associated with being overweight.

Exercise is one of the best ways to control or reduce weight, and reduce risk of type 2 diabetes. Physical therapists are experts in prescribing structured, safe and effective exercise programmes.

Their advice can also help people who have health complications as a result of diabetes. For example, they can help those who have lost limbs through diabetes-related amputations recover their mobility and adapt their environment so that they have independence. Physical therapists help people achieve a return to work, education, community participation and fulfilled lives.

Diabetes facts

The World Health Organization (WHO) estimates that 347 million people worldwide have diabetes. This number is expected to double by 2030. Source: World Health Organization factsheet www.who.int/mediacentre/factsheets/fs312/en/

Diabetes was traditionally more common in developed countries, but modernisation and lifestyle changes have meant it is increasingly prevalent in developing countries. According to WHO, almost 80% of diabetes deaths occur in low and middle-income countries. Source: World Health Organization factsheet www.who.int/mediacentre/factsheets/fs312/en/

Diabetes and its complications have a significant economic impact on individuals, families, health systems and countries. For example, WHO estimates that in the period 2006-2015, China will lose $558 billion in national income due to heart disease, stroke and diabetes alone. Source: World Health Organization factsheet www.who.int/mediacentre/factsheets/fs312/en/

The death and disability rates caused by diabetes for every country are available at: www.who.int/entity/cardiovascular_diseases/en/cvd_atlas_29_world_data_table.pdf

Exercise and diabetes

Exercise has a role in preventing and controlling diabetes. According to the World Health Organization, 30 minutes of moderate intensity physical activity on most days, along with a healthy diet, can help reduce the risk of developing type 2 diabetes. Source: World Health

Organization www.who.int/mediacentre/factsheets/fs312/en/

Both resistance exercise and aerobic exercise are effective at reducing glucose intolerance and reducing the risk of diabetes. Sources: Fenicchia LM et al. Influence of resistance exercise training on glucose control in women with type 2 diabetes Metabolism. 2004 Mar;53(3):284-9. www.ncbi.nlm.nih.gov/pubmed/15015138 Castaneda C et al. A randomized controlled trial of resistance exercise training to improve glycemic control in older adults with type 2 diabetes. Diabetes Care. 2002 Dec; 25(12):2335-41. www.ncbi.nlm.nih.gov/pubmed/12453982

High-intensity progressive resistance training, in combination with moderate weight loss, is effective in controlling blood glucose levels in older patients with type 2 diabetes. Source: Dunstan DW et al. High-intensity resistance training improves glycemic control in older patients with type 2 diabetes. Diabetes Care.

2002 Oct;25(10):1729-36. www.ncbi.nlm.nih.gov/pubmed/12351469

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Moderate aerobic exercise alone or with resistance training improves glycemic control, waist circumference, and protects heart in individuals with type 2 diabetes.Source: Chudyk A, Petrella RJ. Effects of exercise on cardiovascular risk factors in type 2 diabetes: a meta-analysis. Diabetes Care. 2011 May;34(5):1228-37. www.ncbi.nlm.nih.gov/pubmed/21525503

Regular, moderate exercise lowers risk of developing diabetes in those who are overweight and with pre-diabetes. Sources: Evans WJ. Effects of exercise on body composition and functional capacity of the elderly. J Gerontol A Biol Sci Med Sci. 1995;50 Spec No:147-50. www.ncbi.nlm.nih.gov/pubmed/7493209 Christakos CN, Fields KB. Exercise in diabetes: minimize the risks and gain the benefits. J Musculoskeletal Med. 1995;12:16–25.

Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEJM. 2002;346(6):393–403. www.ncbi.nlm.nih.gov/pubmed/11832527

A 16 week high-intensity exercise programme results in decreased diabetic medication regimes, lowered systolic blood pressure, decreased abdominal adipose tissue, and increases in strength, physical activity, and lean muscle mass. Source: Castaneda C, Layne JE, Munoz-Orians L, et al. A randomized controlled trial of resistance exercise training to improve glycemic control in older adults with type 2 diabetes. Diabetes Care. 2002;25(12):2335-41. www.ncbi.nlm.nih.gov/pubmed/12453982

Prevalence of diabetes by WHO Region

2000 2030 (predicted)

Africa 7,020,000 18,234,000

Eastern Mediterranean 15,188,000 42,600,000

The Americas 33,016,000 66,812,000

Europe 33,332,000 47,973,000

South-East Asia 46,903,000 119,541,000

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Physical therapists are exercise experts, providing services to optimise physical ability in a wide range of people. They prescribe exercise as part of a structured, safe, and effective programme.

An important part of their role is to help people remain active as they age. More than any other profession, physical therapists prevent and treat chronic disease and disability in aging adults through prescribed activity and movement.

The World Health Organization encourages regular physical activity for older adults, because it has been shown to improve their independence and quality of life (www.who.int/dietphysicalactivity/factsheet_olderadults/en/). It says that older adults should engage in at least 30 minutes of moderate-intensity physical activity five days a week, if appropriate (www.who.int/ageing/active_ageing/en/index.html).

Here is some information demonstrating the contribution of physical therapists in keeping people active as they age – particularly their role in maintaining general health, preventing and treating cardiovascular disease, and countering joint problems.

Improving functional ability

Older adults engaged in regular physical activity demonstrate improved balance, strength, coordination, motor control, flexibility and endurance. As a result, physical activity can reduce the risk of falls – a major cause of disability among older people. Source: World Health Organization, “Physical activity and older adults” www.who.int/dietphysicalactivity/factsheet_olderadults/en/

Participation in regular exercise programmes leads to older adults having higher levels of function, greater independence, and improved quality of life. Source: Ellingson T, Conn VS. Exercise and quality of life in elderly individuals. J Gerontol Nurs. 2000 Mar;26(3):17-25. www.ncbi.nlm.nih.gov/pubmed/11111627

About physical activity and active ageing

Exercise programmes can slow down functional decline. Elderly adults can, with an appropriate exercise programme, be helped to achieve levels of activity that will bring health benefits, and slow the decline in function that might normally be expected with age. Source: Landin RJ, Linnemeier TJ, et al. Exercise testing and training of the elderly patient. Cardiovasc Clin. 1985; 15(2): 201-18. www.ncbi.nlm.nih.gov/pubmed/3912049

Even for those in their 80s and 90s, exercise programmes can increase functional ability, postpone disability and maintain independent living. Sources: Spirduso WW Cronin DL. Exercise dose-response effects on quality of life and independent living in older adults. Med Sci Sports Exerc. 2001;33(6 Suppl):S598-608. www.ncbi.nlm.nih.gov/pubmed/11427784 Hruda KV, Hicks AL, et al. Training for muscle power in older adults: effects on functional abilities. Can J Appl Physiol. 2003;28(2):178-89. www.ncbi.nlm.nih.gov/pubmed/12825328

Physical activity and exercise are inversely associated with mortality and age-related morbidity. Sources: Kushi LH, Fee RM, et al. Physical activity and mortality in postmenopausal women. JAMA. 1997 Apr 23-30; 277(16): 1287-92. www.ncbi.nlm.nih.gov/pubmed/9109466 Nied RJ, Franklin B. Promoting and prescribing exercise for the elderly. Am Fam Physician. 2002 Feb 1;65(3):419-26. www.ncbi.nlm.nih.gov/pubmed/11858624 Gregg EW, Cauley JA, et al. Relationship of changes in physical activity and mortality among older women. JAMA. 2003 May 14; 289(18):2379-86. www.ncbi.nlm.nih.gov/pubmed/12746361

Promoting cardiovascular health

Regular exercise in older adults has many positive effects on cardiovascular health, including increasing cardiac output, maximum heart rate, endurance, and arterial blood flow, and decreasing heart rate, blood pressure, and risk of heart disease. Source: Vincent KR, Braith RW et al. Resistance exercise and physical performance in adults aged 60 to 83. J Am Geriatr Soc. 2002 Jun; 50(6):1100-7. www.ncbi.nlm.nih.gov/pubmed/12110072

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One study found that after eight months of regular training, a group of 85-year-olds had increased walking speed and increased maximal oxygen uptake and decreased blood pressure. This resulted in reduced health risk and improved independence. Source: Puggaard L, Larsen JB, et al. Maximal oxygen uptake, muscle strength and walking speed in 85-year-old women: effects of increased physical activity. Aging (Milano). 2000 Jun;12(3):180-9. www.ncbi.nlm.nih.gov/pubmed/10965376

Walking 10,000 steps is effective in lowering blood pressure and increasing exercise capacity in individuals with hypertension. Source: Iwane M, Arita M, Tomimoto S, et al. Walking 10,000 steps/day or more reduces blood pressure and sympathetic activity in mild essential hypertension. Hyperten Res. 2000;23:573-580. www.ncbi.nlm.nih.gov/pubmed/11131268

Improving joint health

Tai Chi exercise brings improved balanced and physical functioning to people with osteoarthritis. Source: Song R, Lee EO et al. Effects of tai chi exercise on pain, balance, muscle strength, and perceived difficulties in physical functioning in older women with osteoarthritis: a randomized clinical trial. J Rheumatol. 2003 Sep; 30 (9): 2039-44. www.ncbi.nlm.nih.gov/pubmed/12966613

Research indicates that exercise decreases pain, increases function, increases balance, and increases ability to exercise in people with osteoarthritis and rheumatoid arthritis. Sources: Minor MA, Hewett JE et al. Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Rheum. 1989 Nov; 32(11): 1396-405. www.ncbi.nlm.nih.gov/pubmed/2818656 O’Reilly SC, Muir KR et al. Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheum Dis. 1999 Jan; 58(1): 15-9. www.ncbi.nlm.nih.gov/pmc/articles/PMC1752761/

Exercise decreases depression and anxiety in people with osteoarthritis. Source: Minor MA, Hewett JE et al. Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Rheum. 1989 Nov; 32(11):1396-405. www.ncbi.nlm.nih.gov/pubmed/2818656.

Land-based therapeutic exercise programmes have been shown to reduce pain and improve physical function in people with osteoarthritis of the knee. Source: Fransen M, McConnell S. Therapeutic exercise for people with osteoarthritis of the hip or knee. A systematic review. J Rheumatol. 2002 Aug; 29(8):1737-45. www.ncbi.nlm.nih.gov/pubmed/12180738

For people with osteoarthritis of the knee, both high intensity and low intensity aerobic exercise (stationary cycling) are equally effective at improving functional status, gait, pain, and aerobic capacity. Source: Brosseau L, MacLeay L, et al. Intensity of exercise for the treatment of osteoarthritis. Cochrane Database Syst Rev. 2003;(2): CD004259. www.ncbi.nlm.nih.gov/pubmed/12804510

Research indicates that regular exercise by people with arthritis decreases the likelihood of developing disability by 10% and protects against functional decline. Source: Feinglass J, Thompson JA et al. Effect of physical activity on functional status among older middle-age adults with arthritis. Arthritis Rheum. 2005 Dec 15; 53(6): 879-85. www.ncbi.nlm.nih.gov/pubmed/16342096

Research provides strong evidence that for individuals with rheumatoid arthritis exercise from low to high intensity is effective in improving disease-related characteristics, reducing cardiovascular disease, and increasing functional ability Source: Metsios GS, Stavropoulos-Kalinoglou A, et al. Association of physical inactivity with increased cardiovascular risk in patients with rheumatoid arthritis. Eur J Cardiovasc Prev Rehabil. 2009;16:188–94. www.ncbi.nlm.nih.gov/pubmed/19238083

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Improving mental health

Cardiovascular fitness is associated with increases in brain volume, in both gray and white matter and thus sparing of brain tissue in aging humans. Source: Colcombe SJ, Erickson KI, Scalf PE, et al. Aerobic exercise training increases brain volume in aging humans. J Gerontol A BiolSci Med Sci. 2006;61(11):1166-1170. www.ncbi.nlm.nih.gov/pubmed/17167157

Physical activity has been shown to improve mental health and cognitive function in older adults and contributes to the management of disorders, such as depression and anxiety. Active lifestyles often provide older persons with regular occasions to make new friendships, maintain social networks, and interact with other people of all ages. Source: World Health Organisation, “Physical activity and older adults” www.who.int/dietphysicalactivity/factsheet_olderadults/en/

Research has indicated that increased levels of physical activity reduces the risk of Alzheimer’s disease. Exercise, along with cognitively stimulating activities, can reduce some of the symptoms of the disease. Sources: Penrose FK. Can exercise affect cognitive functioning in Alzheimer’s disease? A review of the literature. Activities, Adaptation & Aging 2005:29(4): 15-40. www.tandfonline.com/doi/abs/10.1300/J016v29n04_02 Christofoletti G, Oliani MM et al. A controlled clinical trial on the effects of motor intervention on balance and cognition in institutionalized elderly patients with dementia. Clin Rehabil. 2008 Jul:22(7):618-26. http://cre.sagepub.com/content/22/7/618.abstract

Aerobic exercises significantly reduced depressive symptoms in people over 60. Source: Penninx BW, Rejeski WJ et al. Exercise and depressive symptoms: a comparison of aerobic and resistance exercise effects on emotional and physical function in older persons with high and low depressive symptomatology. J Gerontol B Psychol Sci Soc Sci. 2002 Mar;57(2):P124-32. www.ncbi.nlm.nih.gov/pubmed/11867660

A regular programme of aerobic exercise can slow or reverse functional deterioration, reducing the individual’s biological age by 10 or more years, and potentially prolonging independence. Source: Shephard RJ. Maximal oxygen intake and independence in old age. Br J Sports Med. 2009 May;43(5):342-6. Epub 2008 Apr 10. http://bjsm.bmj.com/content/early/2008/04/10/bjsm.2007.044800.short

This information was produced with the kind assistance of Marilyn Moffat, Professor of Physical Therapy at New York University and President of WCPT.

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Cancer is an umbrella term used to describe more than 100 different diseases with the common characteristic of uncontrolled malignant cell growth. It is a leading and growing cause of death worldwide, with the total number of cases globally increasing, as the world population grows and ages.

The growing global population with cancer faces unique challenges – from their disease and from the treatments they receive. Physical therapists can help them achieve health and quality of life. The prescribed exercises and lifestyle advice that physical therapists provide can also help people reduce their risk of getting cancer.

Cancer facts

Cancer is a leading cause of death worldwide and accounted for 7.6 million deaths (around 13% of all deaths) in 2008. Source: International Agency for Research on Cancer www.iarc.fr

Deaths from cancer worldwide are projected to continue to rise to over 11 million in 2030. More than 30% of cancer can be prevented by modifying or avoiding key risk factors, including:

•being overweight or obese

•physical inactivity.

Other risk factors include:

• tobacco use

• low fruit and vegetable intake

•alcohol use

•HPV-infection

•urban air pollution

• indoor smoke from household use of solid fuels.

Source: World Health Organization www.who.int/mediacentre/factsheets/fs297/en/

About physical activity and cancer

The link between physical activity and cancer

Getting adequate physical activity, maintaining a healthy weight and eating a healthy diet can reduce the chance of recurrence of many cancers and increase the likelihood of disease-free survival after a diagnosis, say new guidelines from the American Cancer Society. Source: American Cancer Society http://onlinelibrary.wiley.com/doi/10.3322/caac.21142/full

Large population studies have identified a strong association between lower levels of physical activity and higher cancer mortality. Walking or cycling an average of 30 minutes per day has been associated with a 34% lower rate of cancer death and a 33% improved cancer survival. Source: Orsini N, Mantzoros C S et al. Association of physical activity with cancer incidence, mortality, and survival: a population based study of men. British Journal of Cancer. 2008 98: 1864-1869. www.ncbi.nlm.nih.gov/pubmed/18506190

Increasing numbers of studies are indicating that physical activity can reduce the incidence of cancer. World Health Organization recommendations say that undertaking 150 minutes of moderate intensity aerobic physical activity a week can reduce the risk of breast and colon cancers. The same amount of exercise can also reduce the risk of diabetes and heart disease. Source: Global Recommendations on Physical Activity for Health, released by the World Health Organization in 2011 www.who.int/dietphysicalactivity/factsheet_recommendations/en/index.html

According to the International Agency for Research on Cancer: “Physical activity is one risk factor for non-communicable diseases which is modifiable and therefore of great potential public health significance. Changing the level of physical activity raises challenges for the individual but also at societal level.” www.un.org/apps/news/story.asp?NewsID=37467&Cr=cancer&Cr1

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Physical activity helps people with the effects of treatment for cancer

A systematic review of controlled trials of physical activity interventions in cancer survivors, during and after treatment, showed that physical activity had a significant effect. A large effect was shown on upper and lower body strength, and a moderate effects on fatigue and breast- cancer-specific concerns. Exercise was generally well-tolerated during and after treatment, with minimal adverse events. The study abstracted data from over 82 studies. Source: Speck RM, Courneya KS et al. An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. J. Cancer Surviv. 2010 Jun;4(2):87-100. www.ncbi.nlm.nih.gov/pubmed/20052559

A panel of experts convened by the American College of Sports Medicine concluded that exercise training is safe during and after cancer treatments and results in improvements in physical functioning, quality of life and cancer-related fatigue in several cancer survivor groups. Source: Schmitz KH, Courneya KS et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010 Jul;42(7):1409-26. www.ncbi.nlm.nih.gov/pubmed/20559064

Physical activity helps improve outcomes for people with cancer

Studies have indicated a relationship between higher physical activity levels and lower mortality in cancer survivors. A recent meta-analysis reported that, post-diagnosis, physical activity reduced breast cancer deaths by 34%, all causes mortality by 41% and disease recurrence by 24%. Source: Ibrahim EM, Al-Homaidh A. Physical activity and survival after breast cancer diagnosis: meta-analysis of published studies. Med Oncol. 2010 Apr 22. www.ncbi.nlm.nih.gov/pubmed/20411366

Studies also indicate the volume of exercise necessary to bring benefits. The Nurses’ Health Study reported 50% fewer cancer recurrences in women who exercised

more than three hours per week. Among people who have had colo-rectal cancer, a study found a 50% lower rate of recurrence and related death in those who exercised more than six hours per week. Sources: Holmes, MD, Chen WY et al. Physical activity and survival after breast cancer diagnosis. JAMA 2005 293: 2479-2486. www.ncbi.nlm.nih.gov/pubmed/15914748Meyerhardt J A, Giovannucci E L et al. Physical Activity and Survival After Colorectal Cancer Diagnosis. Journal of Clinical Oncology 2006 Vol 24, No 22 (August 1): 3527-3534. http://jco.ascopubs.org/content/24/22/3527.abstract

Current lack of physical activity among people with cancer

Generally, cancer survivors display low levels of physical activity. A study has reported that in Canada less than 22% of cancer survivors are physically active. Source: Courneya KS, Katzmarzyk PT et al. Physical activity and obesity in Canadian cancer survivors: population-based estimates from the 2005 Canadian Community Health Survey. Cancer 2008 Jun;112(11):2475-82. www.ncbi.nlm.nih.gov/pubmed/18428195

This information was produced with the kind assistance of Julie Walsh-Broderick, HRB Research Fellow, Department of Physiotherapy, Trinity Centre for Health Science, St James’s Hospital, Dublin

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Here are some useful references for articles that show the benefit of physical therapy in:

• hypertension

• cardiovascular disease

• stroke

• diabetes

• obesity

• chronic obstructive pulmonary disease.

Hypertension

ACSM’s Guidelines for Exercise Testing and Prescription. 9th Ed. Baltimore MD: Lippincott Williams & Wilkins; 2013.

Blumenthal JA, Sherwood A, et al. Exercise and weight loss reduce blood pressure in men and women with mild hypertension: effects on cardiovascular, metabolic, and hemodynamic functioning. Arch Intern Med. 2000;160(13): 1947-58.

Miller ER, Erlinger TP, Young DR, et al. Results of the diet, exercise, and weight loss intervention trial. Hypertension. 2002;40(5):612-618.

Tanaka H, Bassett DR, Howley ET, Thompson DL, Ashraf M, Rawson FL. Swimming training lowers the resting blood pressure in individuals with hypertension. J Hypertens. 1997;15:651-7.

Cardiovascular disease

Ades P. Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease. N Eng J Med. 2001; 345, 12.

Balady G et al. Cardiac rehabilitation programs. A statement for healthcare professionals from the American Heart Association. Circ. 1994;90:1602-10.

Brown A, Taylor R, Noorani H, Stone J, Skidmore B. Exercise-based cardiac rehabilitation programs

Useful references about physical therapy

for coronary artery disease: a systematic clinical and economic review. Ottawa, Canada; Canadian Coordinating Office For Health Technology Assessment (CCOHTA), 2003.

Brubaker PH, Kaminsky LK, Whaley MH. Coronary Artery Disease: Essentials of Prevention and Rehabilitation Programs. Champaign IL Human Kinetics, 2002.

Brubabaker PH, Warner JG, Rejeski DG, et al. Comparison of standard and extended length participation in cardiac rehabilitation on body composition, functional capacity, and blood lipids. Am J Cardiol 1996;78:769-773.

Davies EJ, Moxham T, Rees K, Singh S, Coats AJS, Ebrahim S, Lough F, Taylor RS. Exercise based rehabilitation for heart failure. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD003331. DOI: 10.1002/14651858.CD003331.pub3.

Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy. Evidence to Practice. 5th Edition. St Louis. Mosby. 2012.

Heran BS, Chen JMH, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD001800. DOI: 10.1002/14651858.CD001800.pub2. www.ncbi.nlm.nih.gov/pubmed/21735386

National Institute for Health and Clinical Excellence. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. CG108. London, UK: National Institute for Health and Clinical Excellence; 2010.

National Institute for Health and Clinical Excellence. Prevention of cardiovascular disease at population level. London, UK: National Institute for Health and Clinical Excellence; 2010.

Pollock M et al. Resistance Exercise in Individuals With and Without Cardiovascular Disease: An Advisory

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From the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association. Circ. 2000; 101: 828.

Seki E et al. Effects of Phase III Cardiac Rehabilitation Programs on Health-related Quality of Life in Elderly Patients with Coronary Artery Disease. Circ J. 2003; 67: 73-77.

Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004 May 15;116(10):682-92.

Vincent K, Vincent H. Resistance Training for Individuals With Cardiovascular Disease. J Cardiopulm Rehab. 2006; 26: 207-16.

Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004 Sep 11-17;364(9438):937-52.

Stroke

Dean CM, Richards CL, Malouin F. Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Arch Phys Med Rehabil. 2000;81(4):409-17.

Endres M, Gertz K, et al. Mechanisms of stroke protection by physical activity. Ann Neurol. 2003;54(5):582-90.

English C, Hillier SL. Circuit class therapy for improving mobility after stroke. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD007513. DOI: 10.1002/14651858.CD007513.pub2.

Ouellette MM, LeBrasseur NK, et al. High-intensity resistance training improves muscle strength, self-reported function, and disability in long-term stroke survivors. Stroke. 2004;35(6):1404-9.

Outpatient Service Trialists. Therapy-based rehabilitation

services for stroke patients at home. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002925. DOI: 10.1002/14651858.CD002925.

Pollock A, Baer G, Pomeroy VM, Langhorne P. Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001920. DOI: 10.1002/14651858.CD001920.pub2.

Royal College of Physicians Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke. 3rd ed. London, UK: Royal College of Physicians 2008

Saka O, Serra V, Samyshkin Y, McGuire A, Wolfe CCDA. Cost-effectiveness of stroke unit care followed by early supported discharge. Stroke 2009; 40(1): 24-29.

Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews 2013, September. Art. No.: CD000197. DOI: 10.1002/14651858.CD000197.pub3.

Teixeira-Salmela LF, Olney SJ, et al. Muscle strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors. Arch Phys Med Rehabil. 1999;80(10):1211-8.

Diabetes

Castaneda C, Layne JE, Munoz-Orians L, et al. A randomized controlled trial of resistance exercise training to improve glycemic control in older adults with type 2 diabetes. Diabetes Care. 2002;25(12):2335-41.

Dunstan DW, Daly RM, Owen N, Jolley D, De Courten M, Shaw J, Zimmet P. High-intensity resistance training improves glycemic control in older patients with type 2 diabetes. Diabetes Care. 2002 Oct;25(10):1729-36.

Evans WJ. Effects of exercise on body composition and functional capacity of the elderly. J Gerontol A Biol Sci Med Sci. 1995;50 Spec No:147-50.

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Fenicchia LM, Kanaley JA, Azevedo JL Jr, et al. Influence of resistance exercise training on glucose control in women with type 2 diabetes. Metabolism. 2004;53:284–289.

Greaves CJ, Sheppard KE, Abraham C, Hardeman W, Roden M, Evans PH, Schwarz P, Image Study Group. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health 2011 Feb 18;11(119):Epub

Orozco LJ, Buchleitner AM, Gimenez-Perez G, Roqué i Figuls M, Richter B, Mauricio D. Exercise or exercise and diet for preventing type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD003054. DOI: 10.1002/14651858.CD003054.pub3.

Umpierre D, Ribeiro PAB, Kramer CK, Leitao CB, Zucatti ATN, Azevedo MJ, Gross JL, Ribeiro JP, Schaan BD. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis. JAMA 2011 May 4;305(17):1790-1799

Obesity

Dunstan DW, Daly RM, Owen N, Jolley D, De Courten M, Shaw J, Zimmet P. High-intensity resistance training improves glycemic control in older patients with type 2 diabetes. Diabetes Care. 2002 Oct;25(10):1729-36.

Hagberg JM, Graves JE, Limacher M, et al. Cardiovascular responses of 70- to 79-yr-old men and women to exercise training. J Appl Physiol. 1989;66(6):2589-94.

Shaw KA, Gennat HC, O’Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003817. DOI: 10.1002/14651858.CD003817.pub3.

Waters E, de Silva-Sanigorski A, Hall BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L, Summerbell CD. Interventions for preventing obesity in children.

Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD001871. DOI: 10.1002/14651858.CD001871.pub3.

Chronic Obstructive Pulmonary Disease

Ries AL, Bauldoff GS, Carlin BW, Casaburi R, Emery CF, Mahler DA, Make B, Rochester CL, Zuwallack R, Herrerias C. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest. 2007 May;131(5 Suppl):4S-42S.

American College of Sports Medicine. Guidelines for Exercise Testing and Prescription. 9th Ed. Baltimore MD: Lippincott Williams & Wilkins; 2013.

Casaburi R, Patessio A, Ioli F, et al. Reduction in exercise lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease. Am Rev Respir Dis. 1991;143:9-18.

Casaburi R, Porszasz J, Burns MR, Carithers ER, et al. Physiologic benefits of exercise training in rehabilitation of severe COPD patients. Am J Respir Crit Care Med. 1997;155:1541–1551.

Casaburi R. Mechanisms of the reduced ventilatory requirement as a result of exercise training. Eur Respir Rev. 1995;5:25, 42–46.

Clark CJ, Cochrane LM, et al. Skeletal muscle strength and endurance in patients with mild COPD and the effects of weight training. Eur Respir J. 2000;15(1):92-97.

Coppoolse R, Schols A, Baarends EM et al. Interval versus continuous training in patients with severe COPD: a randomized clinical trial. Eur Respir J. 1999;14:258-263.

Gosselink R, Langer D, Burtin C, Probst V, Hendriks HJM, van der Schans CP, Paterson WJ, Verhoef-de Wijk MCE, Straver RVM, Klaassen M, Troosters T, Decramer M, Ninane V, Delguste P, Muris J [Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF) [Royal Dutch Society for Physiotherapy]]. KNGF guidelines: Chronic

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obstructive pulmonary disease clinical practice guidelines [with systematic review]. Nederlands Tijdschrift voor Fysiotherapie [Dutch Journal of Physical Therapy] 2008;118(4 Suppl):1-60

Gosselink R, Troosters T, Decramer M. Effects of exercise training in COPD patients: interval versus endurance training. Eur Respir J. 1998;12:2S.

Gosselink R, Troosters T, Decramer M. Exercise training in COPD patients: the basic questions. Eur Respir J. 1997;10:2884–2891.

Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomized controlled trial. Lancet. 2000;355:362-368.

Hernandez MTE, Rubio TM, Ruiz FO, et al. Results of a home-based training program for patients with COPD. Chest. 2000;118:106-114.

Hirata K, Okamoto T, Shiraishi S. The efficacy and practice of exercise training in patients with chronic obstructive pulmonary disease (COPD). Nippon Rinsho. 1999;57(9):2041-5.

Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003793. DOI: 10.1002/14651858.CD003793.pub2. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003793.pub2/abstract

Maltais F, LeBlanc P, Jobin J, et al. Intensity of training and physiologic adaptation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1997;155:555–561.

National Institute for Health and Clinical Excellence. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. Update guideline. London: National Institute for Health and Clinical Excellence 2010. http://publications.nice.org.uk/chronic-obstructive-

pulmonary-disease-cg101

Ng LWC, Mackney J, Jenkins S, Hill K. Does exercise training change physical activity in people with COPD? A systematic review and meta-analysis. Chronic Respiratory Disease February 2012; 9(1):17-26

Normandin EA, McCusker C, Connors ML, et al. An evaluation of two approaches to exercise conditioning in pulmonary rehabilitation. Chest. 2002;121:1085-1091.

Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD005305. DOI: 10.1002/14651858.CD005305.pub3.

Ries AL, ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. Chest. 1997;112:1363-1396.

Seymour JM, Moore L, Jolley CJ, Ward K, Creasey J, Steier JS et al. Outpatient pulmonary rehabilitation following acute exacerbations of COPD. Thorax 2010; 65(5):423-428

Troosters TR, Casaburi R, Gosselilnk R, Decramer M. Pulmonary rehabilitation in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;172(3):19-38.

Vogiatzis I, Nanas S, Roussos C. Interval training as an alternative modality to continuous exercise in patients with COPD. Eur Respir J. 2002;20:12–19.

ZuWallack R. The nonpharmacologic treatment of chronic obstructive pulmonary disease: advances in our understanding of pulmonary rehabilitation. Proc Am Thorac Soc. 2007 Oct 1;4(7):549-53. Review.

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