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Every educator (the authors included) is cautious about prescribing any intervention in a cookbook fashion. But there comes a time in a clinician's life when researching evidencebased exercise protocols for each client or even groups of clients becomes impossible. This is especially true when new information and ideas on the topic are being published with increasing frequency.

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Additionally, everyone needs a starting point. The goal of this book is to provide you, the physical therapist, with that starting point for exercise for clients, based on their primary medical (not physical therapy) diagnosis and various comorbidities present. This text offers a review and compilation of the literature to date and provides a consensus on approaches to exercise for each disease entity discussed.

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Physicians may use what looks like a "cookbook-like" approach with medical or surgical procedures. Physicians call these "protocols" and, as often as possible, these treatment protocols are developed as a result of research compiling evidence focused on outcomes. Establishing accepted protocols is an important way to provide evidence-based practice and develop guidelines that can be modified as further evidence regarding outcomes is published.

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Educators want students to understand the reasoning behind (for example) the causes and management of anemia so that students can create their own exercise prescriptions. This is certainly not an evidence-based approach, although it is a reasonable way to practice when the literature does not offer any alternative information.

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Exercise is being recognized more and more as an important modality to use in gaining good health and in recovering from illness and disease. Research supports the notion that exercise is an effective intervention for many diseases, illnesses, and conditions. But what kind of exercise is best? How much? How often? At what intensity? The physical therapist is uniquely qualified to prescribe exercise as an intervention for medical disease, given the understanding of pathology, physiology, biomechanics, and exercise. In order to prescribe the most appropriate and most effective exercise for each condition, evidence-based knowledge of these parameters is important.

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This text is an attempt to give you, the physical therapist, the most up-to-date information from which to start in prescribing exercise specifically to treat medical conditions. General concepts of disease and exercise should be used to modify these "prescriptions." The exercise types—their intensity, duration, and frequency—presented here are merely guidelines to get you started. Granted, the volume, breadth, and depth of evidence is fairly lacking at this time. You will see that reflected in the lack of specific parameters for many conditions reported in this text. We feel certain that, in time, the research will expand, broaden, and reflect the change in focus from treatment to prevention of medical conditions. We intend to keep abreast of those changes and keep you apprised of those changes with subsequent editions of this text.

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Some may wonder how this text is different from the American College of Sports Medicine's (ACSM) Exercise Management for Persons with Chronic Diseases and Disabilities. There are two main differences. First, this text is more of a quick reference, reflective of results of studies reported in the current literature. Second, we deal more with systemic diseases, whereas the ACSM's text covers more of the traditional orthopedic, neurologic, cardiopulmonary, and neuromuscular disorders.

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Physical therapists are practicing under direct access in a majority of the states, with the eventual goal of all 50 states becoming direct access states. This policy has influenced the profession in its move to develop entry-level doctorate programs. A doctor of physical therapy (DPT) is, indeed, the best health-care professional to assess human movement impairments and the physical needs of each client/patient to develop a plan of care, including an exercise prescription.

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Along with a DPT level of education, the American Physical Therapy Association (APTA) is positioning physical therapists to become primary care therapists. This means we are the first (and sometimes only) health-care professional to evaluate and treat the client. In this expanded role, advanced competencies such as described in this text will be quite appropriate.

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The APTA has also directed physical therapists to include primary, secondary, and tertiary prevention as part of our intervention whenever appropriate and possible. As more and more research shows the importance of exercise in fostering wellness and in preventing and treating various diseases, conditions, and illnesses, the focus will shift from a rehabilitation approach to a wellness/prevention approach. The need for information of this kind is already present and will only increase in the coming years.

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This text does not provide exercise prescriptions or protocols for neuromuscular or musculoskeletal conditions. It is designed to discuss exercise in the prevention and treatment of medical diseases, conditions, and illnesses such as cancer, heart disease, thyroid conditions, liver impairment, anemia, lupus, and so on.

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At the present time our profession focuses on treating neurologic and orthopedic clients who also have comorbidities. The future of physical therapy will need to include clients seeking physical therapy as the primary intervention for all medical conditions when appropriate.

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Regarding the need to include a pediatric focus, it seems that children always get left out. Most research in this topic area at this time is geared toward adults. Many diseases present in adults are not present in the pediatric population. The possible exceptions are cystic fibrosis and cancer. Research in pediatric groups is problematic for ethical reasons. Children tend to recover faster and with less intervention; activity is emphasized, but specific exercise protocols are not the focus of research efforts. We included information that was relevant in populations groups under age 18 whenever it was available.

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Progression of exercise programs will be necessary, but right now the research is based on foundational programs and has not begun to investigate the effects of progression or even how to progress. We hope topics like prescriptive exercise for medical disease and progression of exercise will become the focus of research by physical therapists in the very near future.

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Catherine C. Goodman
Kevin M. Helgeson

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