MedFit Professional Winter 2020

Page 1








Lisa Dougherty |, publisher

Josh Vogt |

05 08 OPENING A CLOSED DOOR How to gain access to the medical suite Mary Hoagland-Scher


Are you a medical fitness professional? Lisa Dougherty

national sales director

Josh Vogt | editor

Erin Eagan | audience development manager

Rachel Spahr | graphic designer

Kelli Cooke | contributing writers

Mary Hoagland-Sher, Devon Palermo featured columnists

David Rachel III, Dr. Evan Osar, Lisa Dougherty



Become the trusted referral for rehabilitation therapists Devon Palermo








’ve been asked quite a few times what a Medical Fitness Professional is and how it is defined. Some of you may envision working with sick people, in hospitals, wheelchairs, and the like. Many of you may not even realize that you are already working in this space… Are you working with clients over 50; who have chronic disease (high blood pressure, cholesterol, metabolic disorders); have given birth; going through menopause; have thyroid issues; have had a joint replaced, arthritis, or osteoporosis; battling depression or stress and are on antidepressants; are obese (men over 25% body fat women over 30% body fat); have musculoskeletal disorders; have overcome cancer; have had an injury or surgery and just finished physical therapy and looking to you for fitness? If yes to any, then yes, you are working in the “medical fitness space.” It is imperative that you stay up-to-date on the many factors of medical fitness, otherwise, you may potentially cause more harm than good. These are our clients today. We called them “special populations” years ago. With over 65% of our population diagnosed with

at least one chronic disease (and many undiagnosed), you can’t train this “unwell” population with your standard workouts. We are entering a new era with medical fitness in terms of understanding how exercise can help individuals with chronic illness and stress. This is a very exciting time for the fitness industry as baby boomers are becoming our target population. They are seeking fitness professionals who understand where they are in life and their complex health issues when their doctor tells them to start an exercise program. Most of the general public do not know how to create or follow a progressive fitness program. People with chronic medical conditions have an even greater challenge. They need to find a fitness professional that has specialty training to understand their specific needs and limitations. Anyone with basic knowledge of the fitness industry can advertise themselves as a fitness trainer. This does an injustice to the many experienced and credentialed health and fitness professionals. This also puts the consumer at risk and places an unfair burden on them to screen and research the

credentials of a potential health and fitness professional. I started the MedFit Network as a national online registry for consumers and membership organization for professionals who want to grow in this space. The MedFit Education was then founded to help facilitate more education and continued education. This magazine is another extension of this mission. Join us and be one of the pioneers who not only prevent, but reverse chronic disease, restore functionality, vitality and hope in people. You have the ability to step into a heightened position as a Medical Fitness Professional to influence and coach those in need with your talents, and in exchange, have the opportunity to be rewarded beyond measure.


Dr. Evan Osar



his article is meant to be a wake-up call to the fitness industry. The health of our population and country are at stake. While advancements have extended our country’s overall lifespan, it has occurred primarily through the use of medications and life-saving procedures rather than through lifestyle changes. The stark reality is that the overall health of Americans is declining as evidenced by the $3.5 trillion spent every year on health care expenditures. Another alarming statistic is that between 1997 and 2016, there were approximately 4.5 billion prescriptions written per year. 70% of Americans take at least one and 20% take five or more prescription medications (Preidt 2017). The majority of these medications were taken to address lifestyle-related diseases and the subsequent impacts of poor nutrition choices and lack of physical activity. Additionally, many prescription and over-the-counter medications are used to treat osteoarthritis, the most common cause of physical disability in the world. While genetics, weight, and age have been considered as underlying factors, the decrease in quantity, as well as quality, of physical activity have been shown to be much greater factors to the onset and prevalence of osteoarthritis in modern society (Wallace 2017, Osar 2018). While often attributed to causes outside



one’s control (i.e. genetics), the fact is that the diseases contributing to the greatest number of deaths (heart disease, cancer, and Type 2 diabetes) and disability (osteoarthritis) are directly related to controllable factors. While each has a genetic component, lifestyle has a much greater impact on the incidence and prevalence of these diseases. One of the most important and underappreciated components in the overall decline in one’s physical, physiological, and cognitive health, is the lack of physical activity. Less than 20% of the population meet the daily physical activity guidelines and less than 5% of the adult population participates in 30 minutes of physical activity. Even more disturbing is that more than 78 million U.S. adults and 12 million children are obese. Dr. Caldwell Esselstyn has been attributed with the quote, “Genetics loads the gun, lifestyle pulls the trigger.” This suggests that lifestyle is as important as genetics in the expression of many chronic diseases. This sentiment is reiterated in a recent study from Bodai et. al (2018). “Epidemiological, ecologic, and interventional studies have repeatedly indicated that most chronic illness, including cardiovascular disease, cancer, and type 2 diabetes, are the results of lifestyles fueled by poor nutrition and physical inactivity.” The health of our population and country is at stake. This is a call for fitness professionals to step up and recognize that you are

the first line of defense against the deleterious impacts of lifestyle diseases. It is your responsibility to educate your communities that lifestyle changes, incorporating proper nutrition as well as increased physical and cognitive exercise, should be the first step in addressing chronic lifestyle diseases. You can continue to change the health of our nation by implementing evidence-based nutrition, exercise, and cognitive training programs. Be the solution your clients, your community, and our country needs by investing in advanced education in nutrition, exercise, movement, and cognitive training. Create relationships with allied health professionals so that we can collectively educate, collaborate, and coordinate the changing of our nation’s health care system. Dr. Evan Osar is an internationally recognized speaker, author, and expert on assessment, corrective exercise, and functional movement. He was a MedFit Professional of the Year finalist in 2020. Dr. Osar is committed to educating and empowering fitness professionals while helping them develop relationships with allied health professionals. He is author of the Corrective Exercise Solutions to Common Hip and Shoulder Dysfunction and has developed the industry’s most complete training certification, the Integrative Movement Specialist™. With his wife Jenice Mattek, he created the online educational resource

David Rachal III



s we seek to develop a clear role within the pathway protocol for the prevention, treatment and management of chronic disease, it’s time we define what is a ‘medical fitness provider.’ In doing so, we create a foundation for creating a job description, performance measures, quality assurance and career path for the profession. As a first step we must collectively recognize medical fitness as a service and articulate what it represents. For this service to be classified as medical, it must be relating to the science of medicine or to the treatment of illness and injuries. Next, it’s important to note that the definition of fitness is the condition of being physically fit and healthy. Therefore, we can apply deductive reasoning to define medical fitness as the application of a medicinal science to produce a condition of health. Now, of course in order to provide medical fitness we must identify who is qualified to provide this service in a meaningful context to provide a positive outcome for the patient and value within the healthcare continuum. These individuals should have a formal education in health, exercise and or nutrition science and be trained to work with individuals with chronic diseases. While this describes a variety of degrees, it creates a baseline for credibility for this new career. In addition, it’s important that while there is not a license for this specific career path, there is an accredited credential

that can be obtained to secure the necessary specialization for using exercise and nutrition science to treat and or manage chronic disease. In 2007, the American College of Sports Medicine (ACSM) and the American Medical Association teamed up to create the Exercise is Medicine® Credential. This credential was designed to serve as a beacon to healthcare that these individuals have been verified as credible healthcare providers ready to work with physicians and patients to collaboratively produce positive health outcomes for those battling chronic disease. ACSM’s Exercise is Medicine Initiative with AMA has made this profession a viable career path and credible healthcare ancillary that can be identified under the Center of Medicaid and Medicare Services Health Care Provider Taxonomy Codes. These codes define a healthcare service provider type, classification, and area of specialization and if you look closely at Respiratory, Developmental, Rehabilitative and Restorative Service Providers you will find taxonomy code 224Y00000X. This code states that these individuals are classified as Clinical Exercise Physiologists. A classification that is clearly suitable for the knowledge, skills and capabilities of the medical fitness professional and appropriate for the profession. At this point the argument could be made that we should simply identify as Exercise Physiologist, however it has been proven that exercise alone is not enough. Nutrition

science must be an essential component of any viable medical fitness service to produce optimal health outcomes. A science that is inclusive of most, if not all, exercise science/ physiology curriculum leading to a degree at an accredited university/college. Can a physician be a medical fitness provider...yes! A nurse practitioner...yes! A physical therapist...yes! It’s important to note that a medical fitness provider is not exclusive of those with an exercise science degree. A medical fitness provider is a practitioner of medical fitness. Today we define the medical fitness provider as a credentialed healthcare professional who is formerly trained to work with patients with chronic disease where the application of evidence-based exercise and nutrition science has been shown to be of therapeutic value, including but not limited to cardiovascular, pulmonary, and metabolic disorders. David Rachal III’s lifetime commitment to engage, educate, and empower individuals to achieve optimal health has led to the success of hundreds of private clients benefiting from his use of exercise as medicine. His vast subject matter expertise in healthcare and fitness has allowed him to serve as a soughtout fitness presenter/speaker to developing programs that are used to educate and train military personnel at Quantico and the U.S. Air Force Academy. David is the MedFit Professional of the Year winner for 2020.



OPENING A CLOSED DOOR How to gain access to the medical suite


our passion is to help people maintain or regain optimal health and fitness. Under current law and standards, you are only permitted to work with clients who are already fit and healthy or have been released for independent exercise and have passed your health screening questionnaire. But those are not the people you yearn to work with. The clients you seek must have authorization or approval from a medical provider before you can proceed. How often have you met with a potential new client, asked them to get clearance from their doctor and then never seen them again? Or, a client develops a new pain or problem and you refer them for consultation and that ends the relationship. Another frequent sce-

Understand the current reimbursement rules In most cases providers cannot bill for services unless the patient is in the room with them. Therefore, time spent talking on the telephone, responding to emails, or filling-out forms is usually unreimbursed time. This means that your client will probably need to actually make an appointment to be assessed and cleared for exercising with you. To streamline the process, send a letter with your client introducing yourself and what you do. Include a form stating your concerns and your proposed training plan. Design the form to be easy to read, with a simple agree or disagree that can be checked or circled and space for the provider’s signature. You might also want to leave room for comments and questions. If you have received a response from a provider, you should consider sending intermittent progress reports updating the provider about your mutual client/patient.

nario: Your client has followed through with your request only to be referred by their primary care provider for a cardiac treadmill test, but your concern about their low back pain or shoulder dysfunction was not addressed. Success as a medical fitness professional is dependent upon working relationships with medical professionals. In order to establish those relationships, the aspiring medical fitness trainer needs better understanding of the medical system. What follows are a few insights into the medical system that medical fitness professionals need to understand. Recognize how busy the medical practitioner might be “Estimates suggest that a primary care physician would spend 21.7 hours per day to

provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients.”1¡. Today, the average primary care provider is responsible for roughly 2,300 patients, so not quite 21.7 hours of work/day, but more than any individual can possibly provide. In order to cope with the workload, doctors must rely on their support staff to help whenever possible. Do not be alarmed or offended if your inquiries are met by a nurse or medical assistant. Most providers simply do not have the time to meet with you for introduction or discussion. On the flip side, most doctors would love to have effective, safe and reliable resources for their patients who need to lose weight, get fit, manage diabetes, recover from surgery or cancer treatment etc. They need you.

Be familiar with HIPAA The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to protect an individual’s medical confidentiality particularly when changing jobs which at that time meant changing health insurance providers. Unfortunately, the law is complicated and places multiple restrictions on who members of a medical team can talk to about a patient’s medical condition. As an unlicensed party, the fitness professional is not privy to “protected health information” (PHI) without direct written consent from the patient (your client). Due to these restrictions, the medical providers cannot fill-out or respond to your request for information or clearance without your client’s “written” consent. If the client takes the form and returns it to you, this action implies they have agreed to share the information. If you send the form directly to the provider, that permission has not been granted unless the client has signed a HIPAA release form allowing the doctor to share personal health information with you personally. The aforementioned are a few reasons why you may have perceived a wall or barrier


between you and medical providers. One solution is to ask your client if you might accompany him or her to the appointment to obtain medical clearance or guidance. That way the medical provider would have a specified time and be

Generally speaking, the average MD knows very little about exercise science. Most do not know about the effects of eccentric versus concentric loading, how to train for endurance versus strength, what to do to improve

The aspiring medical fitness professional must have a thorough understanding of the pathophysiology of the conditions they will be working with in order to communicate effectively with medical providers. reimbursed for addressing your concerns. You would be communicating directly with the medical provider and not support staff, and it would be easiest for the client/patient. It is also a way to introduce yourself to the medical provider and initiate a working relationship. Although you will probably not be compensated, it may be well worth your time in the long run. Once you have made it into the office with your client, now what? Know your details Because there are so many different avenues to becoming certified as a personal trainer, there can be large differences in the knowledge base and competence of one trainer compared to another. The aspiring medical fitness professional must have a thorough understanding of the pathophysiology of the conditions they will be working with in order to communicate effectively with medical providers. In addition, you need skill and experience in the programs you design and utilize with your clients. Be able to back up your training plans with published research. Recognize that a medical fitness professional has a fund of knowledge that the medical provider does not have Exercise science is not covered in medical school curricula. Medical school is about illness and disease not health and fitness.



stability, balance and core strength. Fitness professionals are not inferior to medical professionals; you have a different knowledge base. Recognize and believe that you have something to offer. You may not know all of the anatomy and biochemistry that the doctor does, but you have a basic understanding of your client’s condition and you know the potential benefits of your interventions. Share this information with the medical providers. Stay within your scope of practice Because personal trainers and medical fitness professionals are not licensed by any governmental or legal agency, and because laws vary from state to state, there is no clear definition of the skills and competencies of a medical fitness professional. Working

outside of your scope of practice can lead to civil and even criminal penalties¡¡. Therefore, for the time being, if you want to work with clients struggling to manage chronic illnesses, recover fully from injuries or surgeries, etc., you need to work under the wing of medical professionals who have prescriptive authority — those professionals in the medical field licensed to diagnose problems and prescribe treatment. Dr Robert Butler MD, founder of the National Institute on Aging once said: “If exercise could be packaged in a pill, it would be the single most widely prescribed and beneficial medicine in the nation.” There are pockets here and there in the US where medical providers and fitness professionals work together. In many cases there is a visionary medical provider at the helm of an interdisciplinary team. In other cases, fitness professionals have worked hard to become part of a medical delivery model.¡¡¡ The more medical fitness professionals that can take the leap and align themselves with medical providers, the more people will be helped. ¡

Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation Justin Altschuler, MD, David Margolius, MD, Thomas Bodenheimer, MD and Kevin Grumbach, MD Ann Fam Med September/ October 2012 vol. 10 no. 5 39

¡¡ For an excellent discussion of this issue, see: Abbott, Anthony Ed.D, FACSM, FNSCA. Scope of Practice, ASCM Health and Fitness Journal ,Sept/Oct 2018, Vol 22 Issue 5 pp 51-55

¡¡¡ Watch Medfit TV webinar by David Rachal III, “ Exercise Prescription: Integrating Services with Medical Professionals and Insurance Providers”

Dr. Mary Hoagland-Scher, MD is a board-certified family physician who practiced medicine for 30 years. When she entered Harvard Medical School with a BA in psychology from Yale College, her goal was to help people stay healthy. As the focus of western medicine shifted away from health to disease management with a strong emphasis on pharmaceutical and or surgical intervention, she became uneasy with her role and decided to discard her prescription pad and learn new tools. Having completed NASM CPT, CES, SFS, and many other courses in the fitness world, she’s taught anatomy, physiology and pathology to aspiring massage therapists and personal trainers. She has joined the MedFit Network and MedFit Education Foundation Medical Advisory Board in hopes of helping to shrink the chasm between fitness and medicine.


Become the trusted referral for rehabilitation therapists


here are special and unique bonds that are made between clinician and patient in a rehabilitation setting. Many times, rehab patients are at a very difficult time in their lives and through months of daily expert guidance, hard work, education, and often even fun, alongside their rehab team, they make considerable gains back towards independence.



Because of this daily interaction, the rehab team develops a vested interest in the continued progress of their patient. Over the course of many months of the blood, sweat and tears of intensive therapy sessions, a friendship has been formed and considerable progress made together. It’s no wonder that rehab professionals are very selective with the fitness referrals they make once their patients are ready for the post-rehab world.

They are selective because they want the absolute best for their patient; they want someone with an understanding of their patient’s diagnosis; someone who understands medical precautions and contraindications; and someone who can safely continue to progress their patient without putting them at risk for a secondary issue. Though they may be selective with referrals, a trusted source for continuing their patients’ goals is needed.

Devon Palermo

start-up as many rehab clinics will have an orientation process and procedures to allow you to be present in a clinic, but it is definitely worth the time investment. Just being in this environment you can learn a lot about how therapists progress their rehab patients, guard their rehab patients during activity, interact with and educate their patients as they progress them to discharge (the point where you would continue their work). You may also get some valuable opportunities to learn from and build relationships with many therapists in one setting. Lead warm-ups for local 5K races There are 3.2-mile run-walk-and-wheels events that take place all over the country. Donating your time to your community Spina Bifida Walk ‘n Roll or Parkinson’s walk is a great way to become visible in your community and demonstrate what you have to offer for all abilities.

Here are some ways to bridge the gap and gain the trust of your local rehabilitation professionals: Require a medical or physical therapy release Having medical releases before beginning ongoing sessions is an excellent way to open dialog with your client’s doctor or physical therapist and further, ensures that you are programming their fitness plan accordingly. Send your assessment with your client to share in their next appointment along with a simple inquiry form about restrictions or suggestions to use in your program design. This will go a long way in establishing a great level of trust and building a rapport with the clinic. Volunteer at a rehab clinic One of the best ways to build a rapport with local rehab professionals and patients is to spend time shadowing/observing or volunteering in a rehab inpatient and/or outpatient clinic. This can be a time-consuming

Speak at local support groups Same as with the 5Ks, there are support groups that take place monthly or quarterly for stroke survivors, caregivers, individuals living with Multiple Sclerosis and more. Contacting the organizer of these groups and offering to donate time to speak about the benefits of continued exercise or even providing a no-cost group class during the scheduled talk time is a really good way to connect with both the organizers and their peers and those in attendance who would benefit from a continued exercise program. Educate yourself on adaptive/medical exercise equipment Understanding the different options there are for accessories and actual exercise equipment, for stroke survivors or those living

with spinal cord injury, is another great way to demonstrate an understanding of working with a rehab population and continuing to bridge the gap between rehab and fitness. Not all equipment is accessible nor safe, so while thinking outside the box is great, ensuring safety is optimal. Take the time to learn about all the great adaptive equipment that can benefit the population you work with. Host an open house at your gym Host regular open house events at your facility and invite any and all rehab professionals, patients, and people from your community. Offer instructional sessions during the open house to demonstrate your adaptive programming/equipment. This is a great way give a sneak peek into what you’re doing to provide a safe environment for patients to continue their progress. Offer to provide a lunch in-service to rehab staff Meeting with a clinic full of therapists is an excellent way to educate those therapists that you have done your research, understand your population, and really want to bridge the gap between rehab and fitness. A presentation focused on the population you’re most comfortable working with (Parkinson’s, stroke survivors, etc.), the programs you offer, and pictures or videos of some of the work done in your gym. Bringing food is always a great incentive! Bridging the gap between rehab and fitness is a process that is long overdue and much needed. By focusing on the points above you will be working towards and moving one step closer to improving the therapist-trainer model, adding a valuable resource to your community and providing a safe environment and safe programming to continue progressing your post-rehab clients.

Devon Palermo is a leading authority on Adaptive Fitness for those living with or recovering from a disability. He is the Founder and Principal director of DPI Adaptive Fitness, A company focused on safe and effective adaptive fitness for individuals living with disabilities. With over 15 years of experience in both fitness and rehab, he is the go-to resource for clients, therapists, and doctors in the DC, Maryland and Virginia area looking to maximize the benefits of adaptive exercise to improve strength, balance, function and abilities. Devon was a MedFit Professional of the Year finalist for 2020.



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