World Physical Therapy Day 2015 Resources on why physical therapy matters
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 Further resources ...................................................................................................................... 20
Notes about this booklet The 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.
World Confederation for Physical Therapy | 1
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 111 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”.
2 | World Confederation for Physical Therapy
About physical therapy 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
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.
• 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 World Confederation for Physical Therapy | 3
Facts and figures about physical therapists Physical therapists work with people of all ages to bring about improvements in their health and independence.
countries around the world, they have proved their effectiveness at getting and keeping people healthy.
Physical therapists provide exercise prescriptions to help people keep fit and achieve/maintain a healthy weight.
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.
Around 600 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. According to the World Health Organization, adults aged 18–64 should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorousintensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity. They should also do muscle strengthening exercises on two or more days 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
4 | World Confederation for Physical Therapy
More detailed information about what physical therapists do can be found in WCPT’s Description of Physical Therapy at www.wcpt.org/policy/psdescriptionPT.
Article by WCPT President This article by WCPT’s President, Emma Stokes, can be published in newsletters, magazines and journals, or passed to other publications as background information.
enable our patients and clients to achieve their potential.
If you are making any changes they should be checked with the WCPT Secretariat info@wcpt.org.
How can we ensure they fulfil their potential through our expert interventions and advice on exercise and movement? Are our services
What does fulfilling potential mean and how can physical therapists, empower and evoke that potential in our clients and patients? Potential is individually defined by each person, so physical therapists must truly adopt a patient-centred approach. The people who seek and need the services of physical therapists range from small babies to older people, from people with profound disabilities to the highest performing athletes. Through our engagement with them and our focus on physical activity, exercise and movement we have the power to ensure that people reach their potential whatever that may be. Research indicates that 31% of the world’s population do not meet the recommended physical activity guidelines, 65% of our patients and clients don’t complete their home exercise programmes and 10% fail to complete their journey of care with us1,2. So one area I would urge all physical therapists to consider for World Physical Therapy Day is how we work with our patients and clients to ensure that the health behaviour changes that are important to sustainable healthy lives are “owned” by them. Research is showing that the addition of motivational strategies to physical therapy and exercise interventions can enhance attendance and adherence3. The overarching message of World Physical Therapy Day is “Movement for Health” and on this day when we mark the foundation of WCPT and communicate to thousands of people around the world the value of physical therapy, let’s also ask ourselves what more can we do to
recognised and employed in the best way within our health services? How can their potential be further developed and optimised? Increasingly, the evidence is there in support of the value of physical therapy. We provide examples in this booklet and a number of our member organisations have open resources that provide the support and evidence for the value of physical therapy4,5. Let’s use World Physical Therapy Day to communicate the impact that physical therapy can have on individual lives, and to reach out to politicians and other key decision makers to move our profession closer to fulfilling its full potential in changing the lives of the people we serve.
Emma Stokes, WCPT President 1. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U, et al. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet 2012;380:247–57. 2. Bassett SF. The assessment of patient adherence to physiotherapy rehabilitation. N Z J Physiother 2003;31:60–6. 3. McGrane N, Galvin R, Cusack T, Stokes EK (2014) Addition of motivational interventions to exercise and traditional physical therapy: a review and meta-analysis 101(1):1-12. 4. Canadian Physiotherapy Association (2015) The Value of Physiotherapy www.physiotherapy.ca/Advocacy/Legislation/TheValue-of-Physiotherapy accessed 21 June 2015. 5. The Chartered Society of Physiotherapy (2015) Physiotherapy works – the evidence. www.csp.org.uk/professional-union/practice/yourbusiness/evidence-base/physiotherapy-works accessed 21 June 2015. World Confederation for Physical Therapy | 5
About physical therapy, independence and participation The facts People with disabilities are more likely to be unemployed. An Organization for Economic Cooperation 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
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. Costeffectiveness 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, 6 | World Confederation for Physical Therapy
Verbeek J (2011), Interventions to enhance return-to-work for cancer patient, Cochrane Database of Systematic Reviews, Feb (2)CD007569 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007569. pub2/abstract
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.and.org.au/data/Conference/DAE_ Report_8May.pdf
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...”
individuals, families, and communities.” “Many countries – particularly low-income and middleincome 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
“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 World Confederation for Physical Therapy | 7
About physical activity and child obesity According to the World Health Organization, the number of overweight or obese children is likely to increase from 42 million in 2013 to 70 million in 2025.
Children’s choices, diet and physical activity habits are influenced by their surrounding environment.
Source: WHO www.who.int/end-childhood-obesity/facts/en/
Children who are obese have a high incidence of musculoskeletal impairments.
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 The vast majority of overweight or obese children live in developing countries, where the rate of increase has been 30% higher than in developed countries. Source: WHO www.who.int/end-childhood-obesity/facts/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/
Source: WHO www.who.int/features/factfiles/obesity/en/
Source: http://onlinelibrary.wiley.com/doi/10.1111/j.14401754.2011.02102.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
8 | World Confederation for Physical Therapy
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/pachildren-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.
World Confederation for Physical Therapy | 9
Acta Paediatr. 2010 Jun;99(6):900-5. www.ncbi.nlm.nih.gov/ pubmed/20175763 O’Malley et al., A Pilot study to profile the lower limb musculoskeletal health in obese children. Pediatric Physical Therapy. www.ncbi.nlm. nih.gov/pubmed/22735484. Full text www.hrbchdr.com/sites/default/ files/A_Pilot_Study_to_Profile_the_Lower_Limb.19.pdf
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.
10 | World Confederation for Physical Therapy
About physical activity and cardiovascular disease 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.
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;41:622628. 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
Cardiovascular general Cardiovascular disease is now the leading cause of deaths worldwide. Globally, 17.5 million people died from cardiovascular disease in 2012, 31% of all deaths. 7.4 million were due to coronary heart disease and 6.7 million due to stroke. Over three quarters of cardiovascular disease deaths occur in low- and middleincome countries.. 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
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
World Confederation for Physical Therapy | 11
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
Heart disease
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: 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
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/10865274 Lee 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
12 | World Confederation for Physical Therapy
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.
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; 143:659672. 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.
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 diabetesrelated 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 in 2014 9% of adults had diabetes, and that in 2012 diabetes was the direct cause of 1.5 million deaths. 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 has lost $558 billion in national income due to heart disease, stroke and diabetes alone. Source: World Health Organization factsheet www.who.int/chp/ chronic_disease_report/media/china.pdf?ua=1
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
World Confederation for Physical Therapy | 13
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 prediabetes. 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
14 | World Confederation for Physical Therapy
About physical activity and active ageing 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 150 minutes of moderate-intensity physical activity throughout the 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
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):237986. 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
World Confederation for Physical Therapy | 15
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
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.
Walking 10,000 steps is effective in lowering blood pressure and increasing exercise capacity in individuals with hypertension.
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
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
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.
Improving joint health
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
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/
16 | World Confederation for Physical Therapy
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
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 cognitive function in older adults. Older people with active lifestyles also exhibit higher levels of functional health, a lower risk of falling, and have reduced risk of moderate and severe functional limitations.
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 former President of WCPT.
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
World Confederation for Physical Therapy | 17
About physical activity and cancer 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 link between physical activity and cancer
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.
Source: American Cancer Society http://onlinelibrary.wiley.com/ doi/10.3322/caac.21142/full
Cancer facts
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
Cancers are among the leading causes of morbidity and mortality worldwide, with approximately 14 million new cases and 8.2 million cancer related deaths in 2012. Source: WHO www.who.int/mediacentre/factsheets/fs297/en/
The number of new cases of cancer is expected to rise by about 70% over the next two decades. 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/
18 | World Confederation for Physical Therapy
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.
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.
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
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 metaanalysis. 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
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/15914748 Meyerhardt 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
Studies have indicated a relationship between higher physical activity levels and lower mortality in cancer survivors. A recent meta-analysis reported that, postdiagnosis, 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 World Confederation for Physical Therapy | 19
Further resources Materials produced by WCPT’s member organisations also make the case for physical therapy and the difference it can make to individuals, societies and economies.
Australian Physiotherapy Association Chronic Disease and Physiotherapy www.physiotherapy. asn.au/APAWCM/Advocacy/Position_Statements/ APAWCM/Advocacy/Position_Statements. aspx?hkey=5eb019e2-29f9-40a0-bd4d-f98605d23da5 Health and wellbeing of children and young people www.physiotherapy.asn.au/DocumentsFolder/ APAWCM/Advocacy/2018_HealthWellbeing_ ChildrenandYoungPeople.pdf Mental health and physiotherapy www.physiotherapy. asn.au/DocumentsFolder/Advocacy_Position_Mental_ Health_2011.pdf Physiotherapy for people with disability www. physiotherapy.asn.au/DocumentsFolder/Advocacy_ Position_Disability_2010.pdf Transition of young people with a chronic health condition to adult health services www.physiotherapy. asn.au/DocumentsFolder/APAWCM/Advocacy/ PositionStatement_2014_TransitionCare2.pdf
American Physical Therapy Association Issue briefs www.apta.org/PolicyResources/IssueBriefs/ (APTA login required)
Canadian Physiotherapy Association The value of physiotherapy www.physiotherapy.ca/ Advocacy/Legislation/The-Value-of-Physiotherapy Physical activity for youth and children www. physiotherapy.ca/getmedia/5693d03d-cf27-4835-b87b49e564ab7274/Physical-Activity-for-Children-andYouth_en_2.pdf.aspx 20 | World Confederation for Physical Therapy
Physiotherapy New Zealand How physio can help http://physiotherapy.org.nz/yourhealth/how-physio-can-help/
Chartered Society of Physiotherapy Physiotherapy works - the evidence www.csp.org.uk/ professional-union/practice/your-business/evidencebase/physiotherapy-works
Irish Society of Chartered Physiotherapists Information leaflets www.iscp.ie/your-health/ information-leaflets.html
World Confederation for Physical Therapy | 21
Visit www.wcpt.org/wptday for more information about World Physical Therapy Day and the resources available
This booklet has been produced by: World Confederation for Physical Therapy Victoria Charity Centre 11 Belgrave Road London SW1V 1RB United Kingdom Š World Confederation for Physical Therapy 2015