Breakthrough Thinking in Exercise Physiology
Tommy Boone, PhD, MPH, MA, FASEP, EPC
Professor and Chair
Department of Exercise Physiology
The College of St. Scholastica
Duluth, MN 55811
“There is nothing so wasteful as doing the wrong thing that
totally distracts from the right thing.”
EXERCISE PHYSIOLOGY is not that different from most other emerging
professions. Time allows for gradual solutions using different kinds
of thinking and processes. Proponents of other professions understand
this point all too well. Many refer to major changes in their professional
work as “breakthrough thinking”. Increasingly, more exercise physiologists
understand the need for change. They understand the purpose of a
professional organization like the American Society of Exercise Physiologists
(ASEP). They understand its mission, and they see it as a breakthrough
in thinking about exercise physiology as an emerging profession.
The ASEP Board of Directors has set in motion change that will modernize
the traditional thinking about exercise physiology? Finally, students
and members of the emerging profession are questioning the differences
between exercise science and exercise physiology. Similarly, it is
no longer popular to argue that only the person with a PhD degree can be
referred to as an exercise physiologist. And, it is no longer okay
for professors to not concern themselves with the career problems faced
by their students. The ASEP organization has helped to set in motion
a new way to think about the field, what is exercise physiology, what are
the appropriate credentials, and a host of other professional issues.
Hence, there can no longer be any doubt that ASEP is the breakthrough
organization for the emerging profession. The formation of ASEP in
1997 and its recent involvement in the accreditation of three undergraduate
programs that meet the ASEP content and philosophy demonstrates its integral
part in the professional development of exercise physiology [1].
This accomplishment is a powerful example of the hard work of many members
of the organization. The fact that ASEP is the accrediting body for
exercise physiology programs is consistent with the belief that the discipline
is becoming a profession. Does it have a long way to go? You
bet it does, but why not? Does anyone think that architecture, dentistry,
education, engineering, journalism, law, library science, medicine, nursing,
pharmacy, social work, and physical therapy among others became professions
overnight? Of course not. There were many influences from society
and the professional community. The right environment for professional
preparation takes time to develop and, even then, it is always changing
to meet the key issues that arise from new and different thinking.
The emergence of the Society is the most significant breakthrough in
thinking about exercise physiology that has occurred in decades.
It is organized to help all exercise physiologists achieve what they are
capable of and, most importantly, to understand that exercise physiology
begins and ends with the exercise physiologist. We are the rightful
owners of our emerging profession, and we are responsible for doing the
right thing. As an example, our students now have the opportunity
to sit for a Board Certification exam [2]. This
credential is based on the ASEP perspective that specific academic content
and hands-on skills are important in demonstrating professionalism.
There can't be any doubt that the EPC exam serves the greater good of society.
In time, it will also be a requirement within the public sector for employment
available to exercise physiologists. The requirement will be directly
related to needs of society as reflected in the health, wellness, and fitness
concerns and services.
The Society is a first-rate organization with a strong sense of professional
responsibility. Well-focused and self-confident members of three
different Boards are responsible for ensuring that the ASEP vision [3]
becomes a 21st century reality defined by hope and opportunity. The
ability of these members to communicate the worth of ASEP is fundamental
to all exercise physiologists finding their way out of the job dilemma.
They also understand the importance of new professional relationships,
building of self-confidence, and the power of genuinely positive communication.
Fostering positive feelings is part of coming together and spreading the
hope of a better future for students and those already working in the field.
Part of this process is the faculty throughout the colleges and universities
who will be challenged to provide an education that is "culturally sensitive"
to the huge healthcare concerns of the consumer. Another part includes
the increased discussion and writing about professionalism at all levels
of academic degrees. Students must, therefore, be prepared as practitioners
to meet the needs of individuals and families by understanding the role
that ethics play in professional behavior and the significance of a professional
education.
The Society is also very much like any business that understands the
attention that must be given to its members. Service is a life-or-death
issue in every organization. Yet, with surprisingly few facilities
and/or resources, the ASEP web site represents no shortage of practical
information and service to its members; all of which has taken an intense
concentration and thoughtful response to the pressure to increase opportunities
and respect for all exercise physiologists. It began just prior to
1997 when a small group of concerned professionals stopped in their tracks
and listened to a dozen or so confused colleagues whose enthusiasm for
their work turned to fear. After some discussion and several hours
of listening, it was clear that the problem was multifaceted. What
was obvious then and is still true today is the total separation that exists
between the PhD faculty, particularly the authors of several popular texts,
and their students. In short, essentially no college teacher was
communicating with students beyond mentoring those who needed helped with
research. Why they continue to fail in appreciating the reality of
the traditional marketplace for exercise physiologists is an interesting
question? College teachers share a responsibility to prepare graduates
who can and who will integrate professional issues with standard practice
opportunities [4].
The Lone Ranger Style is Out
College teachers can no longer act like the “Lone Ranger” doing their
own thing at the expense of the students’ well-being. The education
that the students are suppose to get (and many expect to get) is complicated
in itself, but it must get done. Students have the right to expect
their teachers to teach, to organize class lectures, and to demonstrate
the application of the exercise physiology body of knowledge to the public
sector [4]. They also have the right to expect
their teachers to take an interest in whether there are good paying jobs
after college is completed. Students understand that teachers must
do research and prepare for tenure and promotion, but neither should be
substituted for the students’ education!
Many students feel left out of the big picture and, frankly, some feel
as though they have been forgotten. They see themselves as part of
the building process the teachers use to define their academic position
as a faculty member. It all seems so obvious a mistake to do so when
teachers need students to ensure that they have a college job. That’s
why it is so important to know the difference between exercise physiologists
who understand this problem and have membership with the Society and those
who do not. The breakthrough thinking of ASEP is a rather simple:
Be
respectful of your students. Treat them like you would your own
children. It is a matter of an intuitive feeling for what is right.
Teachers must be sensitive to career opportunities and what can be done
to improve the career outlook. They must also be concerned about
the public image of the exercise physiology. It is important that
exercise physiologists understand how society views the emerging profession.
Public image is important to the practice of exercise physiology.
It has a direct influence on how exercise physiologists expand beyond the
gym and personal fitness jobs and even cardiac rehab into community-based
areas of health, wellness, and fitness that may be less obvious.
Off the Wall Thinking
Breakthrough thinking, even if it is considered “off the wall thinking”
is imperative if we are to correct our existing problem of poor employment
[5]. It is not helpful for our graduates if society
still thinks of us as physical educators and/or coaches. Here, ASEP,
must do a better job in helping the public understand the role of the exercise
physiologist in the healthcare system and the variety of other unique and
important, and even complex services (athletic performance, exercise prescriptions,
stress tesing protocols, and rehabilitation to mention a few) that exercise
physiologists provide. ASEP leadership should also think about developing
a Guide to Exercise Physiology Practice that is similar but not
the same as the Standards of Professional Practice. A publication
of this type may help the public sector to better understand the emerging
profession. Similarly, it is important that we within the field are
in agreement that the image of the exercise physiologist is characterized
by the Board Certification exam (the EPC credential) and not by academic
rank. In other words, the emphasis on image should be on the "profession
of exercise physiology". Members of the profession may have (as will
always be the case) different academic degrees for different reasons.
The point is that we are an emerging profession with members who are certified,
competent, trustworthy, and autonomous in their professional application
of the exercise physiology body of knowledge.
Part of what it means to think differently is to put yourself in the
students’ place. Imagine the challenges and concerns faced by the
students. Another part of critical thinking (and breakthrough thinking)
is to show respect and dignity to the students and the educational process.
Understanding their needs and facing up to our responsibilities as teachers
are critical to the attitude that we (meaning students and faculty) are
in this together. In my mind, there is no such thing as the college
teacher in pursuit of his/her dreams (whether it is research, promotion,
or an administrative position) without first being committed to his/her
students (and, therefore, committed to teaching). Self-actualization
and self-fulfillment are meaningless if the pledge to teach and boost the
self-esteem of students is less than first-rate. Perhaps, it is a
good first step to admit the truth and, therefore, to recognize the problem.
The second step is to work at changing personal behavior by committing
to a different way of thinking. Perhaps, it is as easy as saying,
“I have decided to start working on behalf of my students. The result
of my new way of thinking is that I’m now setting goals and making decisions
that have a direct influence on the success of my students in the public
sector.” Thinking this way allows the teacher the opportunity to
see reality from the students’ eyes and to understand their concerns, hopes,
and dreams.
The Emerging Profession
Crafting images of what is possible in the future is also an ASEP breakthrough
in thinking that gives meaning to what we do. These images (i.e.,
professional organization, credentials, and security) are right and appealing.
They help with giving up the old ways of doing things for bringing in new
ideas. It is a way of thinking that allows for a significant grip
on the future of what exercise physiology is to become. The "15"
ASEP goals and objectives are realistic, and they are attainable [6].
Many different steps have been taken to take charge of the emerging profession,
including but not limited to ethical conduct [7], standards
of professional practice, accreditation, certification, and licensure.
The point is this: Exercise physiologists have joined ASEP
to do what is necessary to make the difference in marketing their students
and the emerging profession of exercise physiology.
Interestingly, for the ASEP member, what was bizarre yesterday (such as
the founding of ASEP) is normal today. Although it is indeed unfortunate
that some exercise physiologists still fail to get the big picture, the
thrust of the Society is that “one person” can make a difference!
There is not only logic to this belief, but there is also a reality to
it. It seems odd that it has taken so long to get this point across.
But, it bears repeating because it is true. Just look at the work
of Matt Wattles in Idaho [
8], Aliisa Seppela in Nebraska
[
9], Jason Young in Wisconsin [
10],
Pat Ayres in Minnesota [
11], and the others who have
created state associations to support ASEP. Begin with yourself.
Is your view of exercise physiology defined by the sports medicine myth
[
12]? Are you inclined to trust the thoughts of
ASEP exercise physiologists? Take, as an example, the work of Dr.
Robert Robergs [
13], and his excellent “Exercise Physiology”
texts [
14,15]. How exercise physiologists manage
their thinking determines the rate and quality of the future views of exercise
physiology in the public sector, which reminds me:
“He who cannot change the very fabric of his thought will never
be able to change reality.” – Anwar El-Sadat
Dr. Robergs and the ASEP Board of Directors [
16] are
breakthrough thinkers in the exercise physiology. They understand
that “half a belief is no belief at all” [
17].
What is the point of doing something half way in today’s competitive market?
The short answer is: There isn’t a point to it. It is a complete
waste of time and energy. It is as sad as the continued persistence
by exercise physiologists, some of whom do not even work in the field,
to teach and/or argue the out-dated idea that exercise science is somehow
the appropriate title for our undergraduate programs. Regardless
of their traditional thinking and the support of the old establishment,
there are no jobs in the public sector for the exercise scientist.
It is self-defeating and irresponsible to continue the compromise of our
students. The name of the academic degree defines the person, both
academically and professionally. The notion of an umbrella degree
having importance is as meaningless as half a baby.
My point is this: Half an academic degree, by failure
to upgrade the curriculum and/or call it by its rightful name is no degree
at all. The truth of these words lies in my experiences as a college
professor for more than three decades. The product that we offer
to the public has a significant price to it. Not only does it cost
in tuition terms, but also in pride and self-esteem and in disappointment
and pain. The academic setting, where we lead our students toward
hope and possibilities, is no place for keeping things as they have been.
Communication and Passion
In all of this, it should be obvious that communication is not automatic.
It is work, and it is constant. The commitment to communicate passion
requires strong emotions, “off the wall” ideas, and shared values and beliefs
[18]. It also requires something inside that is
greater than everything else. We have made progress, and it has caused
many colleagues to ask the question, “Do you know why we failed to start
our own professional organization before now?” The answer to the
question is directly related to our confusion that has kept us from changing
the “…very fabric of ‘our’ thoughts…” not to mention discouraged,
when returning from yet another generic national meeting feeling that something
is not right. When everyone at a meeting belongs to his/her own
professional organization and, yet attends an umbrella organization to
present research, something is not right. When a young person
speaks of the National Association of Athletic Trainers [19]
as his/her professional organization, and the exercise physiologist continues
to think that the umbrella organization is his/her professional organization,
something
is not right. When a dozen other individuals speak of their professional
organizations (whether it is biomechanics, nutrition, medical, physical
therapy, or nursing) and, still, the exercise physiologist does not get
the message, something is seriously wrong.
In addition to academic exercise physiologists who have been slow in
turning the corner on this subject, it is also logical that another part
of this problem bears directly on not having an academic course in professionalism
[20]. Professors spend a lot of time teaching
about research findings and doing research because both are important.
Professors understand the value and importance placed on research and,
yes, we (and I'm including myself in this process) have spent considerable
amount of time in publishing our work. Unfortunately, we have failed to
understand the obvious: That is, if we do not have a determined path
to take, then any path is as good as the next [21].
The point being, neither research is a path by itself that leads to professionalism
nor is the teaching of research findings. As teachers, our job is
to help students understand the emerging field of exercise physiology.
We cannot do this with our heads buried in past thinking. Our students
look to us as being responsible in initiating change, even when it may
create an imbalance in how we think.
Ironically, the problem is that the college teachers do not have a vision
beyond their work towards promotion and/or tenure. No one is actually
thinking about a vision or the need to have one. Too many are defending
the status quo, and too few are making decisions to serve the students
and create opportunities and relevant degree programs. They reason
that it is enough to work within the definition of an occupation or a discipline
under the heading of exercise science. And, there are other reasons
too. The lack of an emphasis on academic preparation and marketing
has not helped. And, no one has identified a market niche for the
exercise physiologist. Had there been a vision, and had we followed
the lead of other healthcare practitioners, we would have studied, researched,
and taught about professional issues. Had we done so, we would have
set objectives and developed new and creative ways to think about exercise
physiology. We would have also figured out that we have come up short
in doing whatever is necessary to ensure that we “make things happen for
our students”. And, in particular, we would have worked to ensure
that the outcome, that is, the academic degree and/or professional certification
would lead to an increase in job opportunities, financial stability, and
professional respect.
Emphasis on Professionalism
ASEP exercise physiologists have ironed out the circumstances of who
they are and why they exist. They understand that the first step
towards this new thinking is the importance of seeing exercise physiology
differently. The definition of exercise physiology, in particular,
has been bought into the 21st century [22]. The
second step included the publication of the same as well as its integration
throughout the ASEP publications. Repeatedly, this has been the ASEP
message on behalf of all exercise physiologists. The only other message
has been and will always be the absolute respect and care for all the members
of the ASEP organization. The key characteristic of this 21st century
thinking is the ability to see the world with realistic possibilities,
especially as we continue to work in customizing “who we are” and “what
we do” as ASEP members. Many have asked four questions:
1. Is it right and will ASEP fill a vital need for non-PhD
exercise physiologists?
2. Are members expected to benefit from their efforts to professionalize
exercise physiology?
3. Will the Society emerge as the professional organization that stands
out and makes things happen?
4. Can it receive the stamp of excellence while in pursuit of the entrepreneurial
spirit?
The answer to each question is ‘yes’. The biggest problem we face
is our own lack of confidence. Too many of us dwell on the past.
We have not learned from it, and so we continue to fail to think in ways
to improve future performance. ASEP is our reality. The Society
is working. As members, we must develop a mental toughness that is
necessary to balance the tensions of those who disagree with us.
Our reality needs to be positive. Think positive. Believe in
your power to break free from past thinking. The impossible is possible
when we dwell on what has already been done. All we have to do is
continue to acknowledge that we are responsible for our future. ASEP
is right, and it is filling a vital need for all exercise physiologists.
As I write this brief article, I am reminded of the work ahead of us.
But I am also confident in the membership’s ability and understanding of
our collective vision. In fact, just recently this was demonstrated
with the work of the following members of the Board of Accreditation:
1. Dr. LaGary Carter
2. Dr. Don Diboll
3. Dr. Mike Greenwood
4. Dr. Melissa Knight-Maloney
5. Dr. Robert Robergs
6. Dr. Don Rodd
7. Mr. Jesse Pittsley
8. Dr. Dale Wagner
9. Dr. Darryn Willoughby
Each of these individuals has been a leader in the accreditation evaluation
of the three academic institutions [
1]. They have
served ASEP well, and we should recognize their commitment that has moved
exercise physiology into the 21st century. With emphasis placed on
professionalism, the Board of Accreditation met its obligation and promise
to the members. The members have given their approval of “accreditation”
to three undergraduate programs in exercise physiology. One of the
great strengths of the Society has been the willingness of its members
to work on behalf of the professionalization of exercise physiology.
1.
Slippery
Rock University 
Exercise
Science Program
2. Wright
State University Exercise
Science Program
3. University
of New Mexico - Abuquerque Exercise
Science Program
Note: Within
"5" years, these programs are to be re-named to Exercise Physiology.
Breakthrough Thinkers
These programs are historically significant. They are the
first-ever
academic programs endorsed by an exercise physiology organization.
The faculty members who oversee these programs are to be commended for
their work. They are our “breakthrough thinkers” in the field.
You might find it helpful in your thinking about accreditation and why
it is important if you were to contact these program directors. You may
want to ask them, “Why did you undergo the accreditation process with ASEP?”
None before these three programs ventured to do what each has done.
Put yourself in their place and measure your program against their program,
and your readiness for the future against their readiness. You, too,
may decide to track the benefit of your program with accreditation versus
without it.
Breakthrough thinking in exercise physiology is new. Most of the
time, it is entirely a new experience resulting from a personal and/or
collective readiness to put something aside and/or move to complete a single-minded
goal. Some even believe it is next to impossible, but of course it
isn’t. Others believe it is the simplest idea to date. As an
example, an organization of exercise physiologists is right and timely.
It should have happened decades ago. Exercise physiology is too advanced
in a great many ways to remain a discipline of study under the umbrella
term exercise science. Exercise physiology is not about graduating
exercise scientists. For certain, it is a very unlikely event to
see a job title in which the employer is looking for an “exercise scientist”.
Since many PhD exercise physiologists understand my point, why are they
still held captive by past thinking? Their students cannot win at
the cemetery of dead end jobs. If you are a student reading this
article, learn to be jealous with your time in college, be involved in
your education, and don’t tolerate professors who surrender your opportunities
for their rewards.
Ten Statements to Guide Your Thinking
Fortunately, when you look at ASEP and where it is headed, there is
hope of a better future. Ask yourself these questions: “Who’s
in charge? Who’s in control? To whom have exercise physiologists
surrendered leadership?” ASEP is focusing on any idea that will benefit
members of the emerging profession. Members are looking at every
idea to see if it has possibilities. If it does, the idea is acted
upon. The point is this: Never underestimate the value of hard-working,
committed individuals with the willingness to work hard to ensure success.
In this regard, if you will “think” about the following Ten Statements
to Guide Your Thinking, you will be amazed at the outcome:
1. Think, don’t react when the possibility surfaces that allows
for, if not, mandates a better future for all exercise physiologists.
2. Think, don’t stop short on a great idea just because it didn’t come
from within your own circle of colleagues.
3. Think, don’t give in to not finding out the possibilities of a new
organization because you may get some heat if others knew your real feelings.
4. Think, don’t reject the notion of yet another organization because
you don’t want to spend more money and time investing in it.
5. Think, don’t do something or fail to do something because it may
upset a colleague or create a disagreement in how things have always been
done.
6. Think, don’t reject the idea of a professional organization for
exercise physiologists because it has never been done that way.
7. Think, don’t reject a better idea because your association with
a particular person or group may reflect on you in a negative way.
8. Think, don’t reject the notion that your ideas are somehow less
important than the ideas of your colleagues.
9. Think, don’t give in to the feelings of inferiority because no one
has encouraged you to achieve great things or to believe in your ability
to think independently.
10. Think, don’t believe it is right to pull back and not get involved
because others are afraid to make a commitment.
Final Remarks
I've read that "In times of turmoil, those who succeed are usually
those who are willing to experiment, take risks, and adapt."[
23]
It is absolutely imperative that the faculty in our academic institutions
stand up to the challenges before the emerging profession and the students
who have embraced it. The mission statement of every institution
that offers an exercise physiology program of study is critical to the
professionalization of exercise physiology and to the successful transition
of the students from these institutions into the public sector. I
strongly urge that the institutional mission should be written in accordance
with the ASEP vision, goals and objectives. It is our collective
responsibility to recognize that we are part of the problem so we all may
have a significant in correcting it. The most basic and rational
approach to take is to provide a professional course and education that
is consistent with the professional needs of the students.
References
1. American Society of Exercise Physiologists. (2002).
Exercise Physiology "Accredited" Academic Programs in the United States.
[Online]. Accessed June 25, 2002. http://www.asep.org/asep/asep/accreditedINSTITUTIONS.html
2. American Society of Exercise Physiologists. (2002).
Information for the EPC Candidate: A Guide. [Online]. Accessed June 25,
2002. http://www.asep.org/asep/asep/EPCManual.html
3. American Society of Exercise Physiologists. (2002).
Vision. [Online]. Accessed June 25, 2002. http://www.asep.org/asep/asep/vision.htm
4. Boone, T. (2002). Professional Behavior in the
Academic Ranks in Exercise Physiology. Professionalization of Exercise
Physiology-online. Vol 5 No 7 July. [Online]. Accessed June 25, 2002. http://www.asep.org/asep/asep/ProfessionalBehavior.html
5. Nadler, G. and Hibino, S. (1994). Breakthrough
Thinking. Rocklin, CA: Prima Publishing.
6. American Society of Exercise Physiologists. (2002).
Goals and Objectives. [Online] Accessed June 25, 2002. http://www.asep.org/asep/asep/goals.htm
7. American Society of Exercise Physiologists. (2002).
Code of Ethics. [Online]. Accessed June 25, 2002. http://www.asep.org/asep/asep/ethics.htm
8. Wattles, M. (2002). President, Idaho Association
of Exercise Physiologists. [Online]. Accessed June 25, 2002. http://www.idaep.org/
9. Seppela, A. (2002). President, Nebraska Association
of Exercise Physiologists. [Online]. Accessed June 25, 2002. http://www.naep.8m.com/index.html
10. Young, J. (2002). President, Wisconsin Association
of Exercise Physiologists. [Online]. Accessed June 25, 2002, http://waep.8m.com/index.html
11. Ayres, P. (2002). President, Minnesota Association
of Exercise Physiologists. [Online] Accessed June 25, 2002. http://www.asep.org/asep/asep/conlaws.html
12. Boone, T. (2001). The Sports Medicine Myth. Professionalization
of Exercise Physiology-online. Vol 4 No 7 [Online]. Accessed June 25, 2002.
http://www.asep.org/asep/asep/SportsMedicineMyth.html
13. Robergs, R. (2002). Welcome to My Web Site. [Online].
Accessed June 25, 2002. http://www.unm.edu/~rrobergs/index.htm
14. Robergs, R.A. and Roberts, S.O. (1997). Exercise
Physiology: Exercise, Performance and Clinical Applications. Mosby, St.
Louis, 1997 (now published by McGraw-Hill, Dubuque, Iowa). [Online]. Accessed
June 25, 2002. http://www.unm.edu/~rrobergs/books.htm
15. Robergs, R.A and Roberts, S.O. (2002). Fundamental
Principles of Exercise Physiology: For Fitness, Performance and Health.
McGraw-Hill, Dubuque. [Online]. Accessed June 25, 2002. http://www.unm.edu/~rrobergs/books.htm
16. American Society of Exercise Physiologists. (2002).
Board of Directors. [Online]. Accessed June 25, 2002. http://www.asep.org/asep/asep/execbod.htm
17. Levine, S.R. and Crom, M.A. (1993). The Leader
in You. New York, NY: Simon & Schuster.
18. Boone, T. (2002). The Power and the Influence
of Beliefs. Professionalization of Exercise Physiology-online. Vol 5 No
7 July. [Online]. Accessed June 25, 2002. http://www.asep.org/asep/asep/ExercisePhysiologyBeliefs.html
19. National Athletic Trainers' Association. (2002).
Home Web Page. [Online]. Accessed June 25, 2002. http://www.nata.org/
20. Pittsley, J. (2002). Are We Teaching Professionalism.
Professionalization of Exercise Physiology-online. Vol 5 No 6 June. [Online].
Accessed June 25, 2002. http://www.asep.org/asep/asep/AreWeTeachingProfessionalism.html
21. Hassel, P.L. and Palmer, D.R. (1992). Marketing
Allied Health Educational Programs. Santa Clara, CA: Eagle Publishing &
Communications.
22. American Society of Exercise Physiologists. (2002).
ASEP Board of Certification Standards of Professional Practice. [Online].
Accessed June 25, 2002. http://www.css.edu/ASEP/StandardsofProfessionalPractice.html
23. Threlkeld, A.J., Jensen, G.M., and Royeen, C.B.(1999).
The Clinical Doctorate: A Framework for Analysis in Physical Therapist
Education. Physical Therapy Vol 79 No 6 June. [Online]. Accessed June 25,
2002.
http://www.ptjournal.org/PTJournal/June1999/v79n6p567.cfm