PEPonline
Professionalization of Exercise Physiologyonline

An international electronic
journal for exercise physiologists
ISSN 1099-5862

Vol 9 No 12 December 2006

 

Exercise Physiology and Exercise as Medical Treatment
Tommy Boone, PhD, MPH, FASEP, EPC
Professor and Chair
Department of Exercise Physiology
The College of St. Scholastica
Duluth, MN 55811

 

If I told you that I had a formula that would help you live longer, avoid-and even cure-some diseases, relieve stress, and makes you stronger with virtually no bad side effects, you’d probably be willing to pay a lot of money for it…what if I told you it was free?...The truth is, I do have a formula like that…the formula is physical activity-simple exercise. – David C. Neiman, Dr PH

Introduction

A great deal of evidence indicates that exercise has the capacity to improve physiological and mental health.

– Royal College of Physicians, '91

Why exercise?  Why put a client at the mercy of regular exercise?  Is there a health benefit?  What about the role of exercise in longevity?  How does exercise boost the immune response that helps the body resist adverse effects of stressors?  What is the role of exercise in obesity and its associated negative effects on health?  Is the use of exercise medical treatment, or is it therapy and aren't both the same?  What is the medical role of exercise physiologists in the use of exercise as a medical treatment with patients who have a chronic disease and/or disability?

Interestingly, aside from the last two questions, the answer to the rest of the questions isn’t hard to figure out.  Clearly, exercise is recognized as having a very positive and potent therapeutic influence on the mind and body.  Today, physicians understand this point as well as physical therapists and nurses [1].  Of course this hasn’t always been the case.  Medicine’s view of exercise hasn’t always been positive.  For decades, there were concerns about the role of exercise in maintenance of health.

Exercise is an old prescription for good health.

Exercise as a medical treatment has only just recently gained acceptance.  But, there are still questions that should be answered.  For example, “Why are exercise physiologists so slow to recognize that the use of exercise is medical treatment?”  And, given the therapeutic benefits of exercise as a medicine, how do exercise physiologists view themselves when prescribing exercise?  It is possible to prescribe a medicine (such as exercise) and not consider the prescriptive process as a medical treatment?  If exercise is a prescriptive medicine, then, what is the difference between exercise physiologists and physical therapists (aside from the fact they have licensure)?

Medicine involves the diagnosis, understanding, and treatment of illness.  All three factors define the practice of medicine.  Since exercise physiologists do not diagnose illness, they do not practice medicine.  However, they can (and do) understand illness, and they can (and do) treat illness with exercise.  Perhaps, it is best to think of the exercise prescription as a complementary medicine, especially since complementary medicine is thought of as “treatments” used along with the conventional therapies doctors prescribe?

If this view is correct, exercise physiology is a complementary medicine.  Exercise physiologists are, therefore, complementary medicine practitioners!  Obviously, the distinction between exercise physiologists and many complementary and alternative therapies is that exercise physiology is founded on a sound scientific body of knowledge.  This may not be the case with certain complementary therapies.  For now, the question is whether it is in the best interest of exercise physiology to conclude that exercise is a complementary medicine, much like acupressure, chiropractic, cranial osteopathy, herbal medicine, hypnotherapy, music therapy, qi gong, sports massage, yoga, and other disciplines?

Parallels between Medicine and Exercise Physiology

Healthy lifestyle requirements include stress management, regular exercise, and a sound diet.

While not all medical doctors are trapped by the prescription pad, many are.  Others are trapped by their failure to think beyond traditional medical roots. The practice of medicine combines evidence-based scientific thinking and the art of applying medical knowledge to treat patients.  By comparison, the practice of exercise physiology combines scientific thinking that underlies physical activity, treatment services concerned with the analysis, improvement, and maintenance of health and fitness, rehabilitation of heart disease and other chronic diseases and/or disabilities, as well as the professional guidance and counsel of athletes and others interested in athletics, sports training, and human adaptability.  The goal of both professions is to treat the client, who may also be a patient. 

If exercise is medicine and if the use of exercise is a medical treatment, is exercise physiology an interdisciplinary sub-specialty of medicine (like aerospace medicine, diving medicine, forensic medicine, evolutionary medicine, travel medicine, and sports medicine to mention a few)?  In other words, that part of “exercise physiology” that deals with treatment services could just as easily be called “exercise medicine.”  This is an especially important point, given that exercise physiologists and other healthcare professionals are exploring the prescriptive benefits of exercise as a medical treatment. 

Impediments to Exercise as Medicine

Ironically, the exercise physiology view of exercise per se has not progressed much in the past several decades.  Exercise is primarily viewed as an activity that fitness professionals use for athletes.  Even the use of exercise in cardiac rehabilitation isn’t viewed much differently from the earlier use of exercise in adult fitness programs.  In fact, it is common knowledge that exercise physiologists who work with cardiac rehabilitation patients are often seen as exercise technicians or ECG techs rather than healthcare professionals.  In short, exercise physiologists appear ill-prepared to think of the use of exercise as medicine.  And, in a word, the undergraduate curriculum isn’t focused on exercise as medicine.  Another problem is the fact that there is so much emphasis on research at the doctorate level.  Still another part is that academic exercise physiologists, in particular, have not taken the responsibility for the professional development of exercise physiology as a healthcare profession. 

  

The risk of cardiovascular death is lower as physical activity levels are increased.
Exercise for sports training is not the same as exercise for rehabilitation.  Often, both receive significant instruction time and/or an internship requirement, but neither is a strong emphasis on exercise as medicine.  Neither view argues for the prevention of cardiac (exercise) rehab programs.  This is most unfortunate, given the healthcare costs in the United States.  Naturally, it is best to prevent a health problem before it happens.  This is why taking responsibility for one’s health is essential to the prevention of heart disease or stroke.  Exercise is unquestionably the way to prevent, where possible, if not, postpone the well-known major causes of death [2].  

Increasingly, it has become apparent that exercise is as much a medical pill as a beta-blocker is to a heart patient.  To which, again, the question is worth asking: “Why are exercise physiologists so slow to recognize that “exercise is a prescriptive medicine?”  For certain, this is not a new idea.  Hippocrates wrote, “…all parts of the body which were made for active use, if moderately used and exercised at the labor to which they are habituated, become healthy, increase in bulk, and bear their age well, but when not used, and when left without exercise, they become diseased, their growth is arrested, and they soon become old..." [3].  So, why is it that exercise physiologists don’t come together as a collective body of professionals in support of their own professional society to prescribe exercise?

Exercise Physiologists Write Exercise Prescriptions

Exercise prescription is useful in almost all chronic diseases.

Exercise as medicine is a powerful concept with its own reality.  Shouldn’t exercise physiologists think of exercise as medicine? The first-half of their title is “Exercise,” in much the same way that the word “Doctor” is taken to mean medicine.  Exercise physiology students should also be educated to think of exercise as medicine.  They need to know, according to Dorland’s Medical Dictionary, that medicine is “any drug or remedy” to bring about an improvement or prevention of a disease or dysfunction.  Maybe exercise isn’t just medicine, but better than medicine!  It is clear that exercise physiologists must become leaders in the rationale for medically directed exercise prescriptions.  It is akin to practicing medicine, although thoroughly not the same.  Exercise physiologists are not medical doctors, and medical doctors are not exercise physiologists. Even when medical doctors express an interest in the prescription of exercise, the true role of its application should exist with exercise physiologists, as is true for medication prescriptions with physicians. 

Now is the time for the ASEP leaders to take a leadership role in the recommendation and use of exercise prescriptions to promote and/or prevent disease and/or disability.  Exercise physiologists therefore must think of exercise as a medicine, not just as a research opportunity or even in the execution of an athletic event or performance.  The facts in favor of exercise as medicine are unquestionable as are the predictable results of regular exercise.  Scientific papers over many decades clearly show what happens with regular exercise, both in terms of acute and chronic responses in regards to cardiovascular, muscular, and biochemical changes.  There are many books that speak to the specificity of these responses, both anaerobic and aerobic.
  • Exercise is very likely the most important prescription clients can take each day.

Now is the time to get to the role of exercise as medicine and the application of the exercise prescription in the prevention and/or treatment of lifestyle diseases.  Exercise physiologists have more than adequate information to guide clients in the development of the cardiovascular and muscular systems.  They know that regular exercise of low to moderate heart rate intensity helps to protect clients against coronary artery disease [4-6], osteoporosis, certain cancers, high blood pressure [7,8], and adult onset diabetes mellitus [9].  They also know that exercise is associated with the release of endorphins that help to create positive feelings and improved self-esteem.  And, when properly prescribed, exercise decreases the risk of overuse injuries.

The ASEP Influence on Exercise Prescription

What is important now is that exercise physiologists should commit to fostering high ethical standards for the implementation of the exercise prescription.  This distinction is a professional one, driven by necessity and the purpose of exercise physiology to benefit society and to do so safely.  One of the many purposes of the American Society of Exercise Physiologists [10] is to expand the members’ knowledge of exercise as medicine.  The ASEP leaders believe that the education of students is at the center of change.  The Board of Accreditation, under the direction of The Center for Exercise Physiology-online [11], is the driving force in the development of new ideas to sustain the commitment to exercise as medicine.   

Aside from exercise improving insulin sensitivity and glycemic control in clients with type 2 diabetes, increasing high-density lipoprotein levels, decreasing low-density lipoprotein and triglyceride levels as well as symptoms of anxiety and depression [12], members of the Board of Accreditation understand the role of exercise in improving psychological well-being, especially in the improvement of body image and fat to lean body mass ratio.  Consequently, the Board [13] is involved in setting standards of competency, ethical behavior, and practice to ensure professional safety and efficacy of treatment for clients.  Members understand that exercise physiologists have a choice, if not a challenge, to take control of exercise as a therapeutic medical intervention.     

The medical community generally recognizes that exercise improves physiological and psychological function [14], including the amelioration of symptoms that make up the disorder comprising chronic debilitating fatigue (i.e., chronic fatigue syndrome) [15].  Exercise has also been associated with improvement in fatigue that accompanies chronic illness, such as cancer [16], multiple sclerosis [17], and fibromyalgia [18].  In 1982, British epidemiologist Jeremy Morris wrote: “Exercise is today’s best buy in public health [19].

Since the early 1980s, the work by Morris [20] set the stage for evidence-based findings that pointed to exercise as a viable treatment for decreasing some forms of cancer, mental problems, falls and fractures, and osteoporosis [21].  Of all the healthcare professionals, exercise physiologists should be recognized as the authority in exercise principles and prescription components (e.g., intensity, volume, frequency, progression, and precautions).  They should be first in line to speak about and to apply exercise to alleviate the deteriorations of aging, particularly in regards to osteoarthritis pain [22] and loss of musculoskeletal integrity.

Exercise is any activity that is planned and regular.

Exercise physiologists must consider this point of view if they are to fully and appropriately address the unquestionable facts that support exercise as medicine. They should take the necessary time required to think about exercise as the foundation of psychophysiology medicine. The more they do so, the more they will come to understand their particular role in the medical use of exercise.  And, similarly, the more they will teach their colleagues and students that their leadership role in the use of exercise as medicine is mandated by the nature of their profession. 

Everyone thinks of changing the world, but no one thinks of changing himself.  – Leo Tolstoy

This is why the last sentence of the Foreword of the Surgeon General Report on Physical Activity and Health [4] is so important: “The stakes are high, and the potential rewards are momentous: preventing premature death, unnecessary illness, and disability; controlling health care costs; and maintaining a high quality of life into old age.”  Exercise physiologists must get serious about affirming their role and commitment to exercise physiology and healthcare.  The time for this emphasis is both opportune and pressing. There is a scientific consensus and, now, a scientific rationale that supports regular, low to moderate intensity exercise as medicine and, therefore, improvement in health.  The more obvious physiological changes resulting from exercise and, in general, a more active lifestyle associate with:

  • A lower overall mortality rate
  • A decreased risk of coronary heart disease
  • Prevention or delayed development of hypertension
  • A decrease in risk of colon cancer
  • A lower risk of developing non-insulin-dependent diabetes mellitus
  • A favorable body composition
  • A decrease in depression and anxiety


The Professionalism of Exercise Physiology

Remember, the purpose of this article is to cause the reader to reflect on why exercise physiologists are often the last to discuss and/or apply “exercise’ to healthcare concerns. While there are a dozen plus ways to write about this point, the following steps should prove useful in improving the exercise physiologist’s communication with others and, in so doing, the steps should also help shed light on the profession of exercise physiology.

Exercise physiologists should align their thoughts, feelings, actions, and words with the ASEP perspective to create the maximum influence on others that they are experts in the use of exercise as medical treatment.  The good news is that the public is very receptive to this kind of thinking.  In some sense, they seem to expect the exercise physiologist to communicate “exercise information” for public health purposes.

Exercise physiologists should look to the ASEP vision and mission statements [23] to guide their thinking and loyalty to the profession of exercise physiology and their professional society.  Hence, instead of thinking it is not possible to “step up to the plate” – ASEP leaders need to help members figure out practical, win-win ideas to build the spirit of professional development and application.They also can help with the “how to” communicate the importance of their professional title and how it compliments their collective role in applying exercise as medicine.  After all, those who have professional titles are decades ahead of those who do not.

A great deal of interest resides with other healthcare professionals, especially in identifying candidates who will benefit from regular exercise.  As the idea of exercise as medical treatment becomes increasingly popular, exercise physiology and medicine (particularly, general practitioners) should work together.  With medical referral and follow up with various cardiovascular and musculoskeletal evaluations by exercise physiologists, the following health conditions could easily be anticipated to benefit from individual-driven exercise prescriptions based on low to moderate intensity exercise:

  • Overweight
  • Obesity
  • Poor physical fitness (strength, endurance, and flexibility)
  • Stress
  • Depression
  • Arthritis
  • Hypertension
  • Low back problems
  • Respiratory problems (asthma, short of breath, and economy)
  • Poor lipid profile
  • Diabetes
General Practitioners vs. Exercise Physiologists

Hammond and colleagues [24] published a very interesting paper describing “exercise on prescription,” in which general practitioners prescribe exercise as an alternative to orthodox, biomedical approaches to the management of adult lifestyle, exercise, and health problems. Apparently, it is increasingly popular within the United Kingdom.  The authors discussed “…various aspects associated with exercise on prescription including patient selection, targeting of general practices and leisure venues, ethical considerations, adherence issues, and the most appropriate specific exercise options…” [24, p. 33]. While this type of intervention has merit, the problem with it is the reliance on the medical community per se. This should not be the approach taken by exercise physiologists of the United States. 

Exercise prescription pertains to all at-risk patient groups and clients.

 

Part of the purpose of this paper is to argue for the professionalism of exercise physiology as the background from which exercise physiologists are encouraged to become more active in healthcare through a more rigorous “prescription” of exercise.  Rather than waiting for collaboration with the medical community, although an important aspect of the agenda to place more emphasis on exercise as medicine, the exercise physiology profession should declare exercise as a powerful primary and secondary care intervention.  This can (and should) be done by marketing exercise and structured testing procedures.  Also, exercise programs addressing lifestyle changes should be viewed as life-long leading to sustained physical and mental benefits.

Thirty minutes or more of physical activity or three 10-minute bouts of aerobic exercise per day can yield excellent health benefits.
Encouragement of clients is critical, given the pattern of drop-out.  Those who are evaluated and placed on an individualized exercise program along with lifestyle and other common-sense instructions for better health will drop out if not attended to on a regular basis.  Of course not all individuals will enjoy exercise or be as ready to start and/or continue.  There remains a lot to learn about motivational strategies, setting of goals, and “how to” improve behavior.  In addition to all at-risk patients and clients, emphasis should be placed on attention to the fitness and health needs of the children and young people [25].  The latter point is particularly important since exercise boosts the body’s metabolic rate and caloric expenditure of exercisers of all ages, thus helping to prevent and control type 2 or non-insulin dependent diabetes and the associated complications.   

This concern, regarding exercise prescription, is pertinent to equity in recognition of exercise physiologists as healthcare practitioners.  Perhaps, therefore, in so far as it is important to the professional development of exercise physiology, and given the capacity and hope that exercise gives to providing an answer to the economics of healthcare and the complications associated with disease and/or disability, the reasonableness of the arguments highlighted in this paper will be considered and acted upon by exercise physiologists throughout the United States.  For certain, it is being acted upon in the United Kingdom, given that the 2004 Department of Health announced that it was approving the application for medical specialty status for Sport and Exercise Medicine [26].  The future SEM specialist is expected to have the academic knowledge and hands-on competencies to address exercise related conditions, give advice on the use of exercise as medicine, and provide other medical support. 
 
If all of the benefits of exercise could be packaged in a single pill, it would be the most widely prescribed medication in the world.
                                     -- DrNick.com
At the end of the day, it is obvious that medical doctors and others will be prescribing exercise as therapeutic medicine.  Thus, my question is this: Why aren't exercise physiologists considered an important part of the multidisciplinary approach to healthcare?  Is it not logical that the profession of exercise physiology can stand up to a rigorous comparison to other conventional specialties?  Exercise physiologists have already conducted and published the research, and they have developed an evidence based application of exercise that is integral to dealing with the problems of unhealthy living, obestity, and lack of physical activity.
 
Admittedly, success is not a secret.  It is hard work and commitment to the right vision. Interestingly, in 1985, sports and exercise medicine was accepted as a full university based medical speciality in Finland [27].  Exercise medicine is therefore recognized a medical specialty like surgery, internal medicine, and pediatrics. Shouldn't exercise physiologists view exercise a natural medicine as well?  And, if they do, why aren't they participating in the ASEP effort to identify exercise as not only medicine, but a natural therapy that should be prescribed by exercise physiologists.

The need for physical activity is real throughout the world.  Not everyone is qualified to implement exercise programs.  Safety, effectiveness, and adherence are major concerns, thus making the prescription quite a challenge [28].  "Like a medicine or drug, exercise results in very specific hormonal, biochemical, and structural changes in the human body....There is a dose-response curve which means that there are optimal amounts depending on the desired effect.  Too little gives no results -- to much, like a medicine overdose, can cause problems. For example, the correct dose of exercise strengthens bone and boosts immunity.  Too much can weaken bones and deplete the immune system." [29]

Final Thoughts

From the exercise physiologist's point of view, the key to the exercise as medicine is the exercise prescription.  But, the distinction is certainly worth the review.  While the prescription can be as simple as 20 minutes per day, a few days every week, it is certainly less than the prescriptive perspective necessary to mitigate much of the reasons why exercise is important in the first place.  The exercise physiologist's perception of the exercise prescription is much more  engaging and multifaceted.  It invovles low to moderate levels of regular exercises, along with lifestyle activities, expectations, pressures, responsibilities, and a common sense means of dealing with overall mental and physical stressors.   Perhaps, least understood, it involves a complex analysis of the cardiovascular system, musculoskeletal system, and emotional and mental states of mind.  The interconnectedness of the mind and body is critical in the practice of exercise physiology.

For now, it may be enough to conclude two things:  First, just as complementary and alternative medicine (CAM) is on the rise in the United States, there is a general trend of growing public acceptance and increased usage of exercise as medicine.  Exercise physiologists should be at the forefront in the use of exercise to augment traditional medical services.  And, similarly, in regards to CAM, Lundgren and Ugalde [30] reported that the "Extrapolated expenditures for 1990 amounted to $13.7 billion, of which $10.3 billion were out-of-pocket dollars."  Americans have the money to pay for services and time on alternative medicine, and exercise physiologists are in a great position to provide the services.  Second, just look at the return in the client's investment.  This is what the exercise physiologist has to offer to society:

  • Increased maximal oxygen uptake
  • Increased cardiac output
  • Decreased resting heart rate
  • Decreased systolic blood pressure
  • Decreased body fat
  • Increased metabolism
  • Increased lean muscle mass
  • Increased capillary density of muscle
  • Increased mitochondrial density of muscle
  • Increased HDL cholesterol
  • Increased muscle strength and endurance
  • Increased endorphins
  • Improved cardiovascular endurance
  • Counteracts osteoporosis
  • Counteracts obesity
  • Improves myocardial efficiency
  • Improves blood supply to muscles
  • Decreases risk of heart disease, stroke, and certain cancers
  • Improves blood sugar control
  • Improves structure and function of ligaments, tendons, and joints
  • Improves mood, self-esteem
  • Decreases stress and anxiety

 

References

1.    Boone, T. (2006). Exercise – Exercise: Sounds Familiar. [Online]. http://boonethink.com/?p=60

2.    Shephard, R.J. and Balady, G.J. (1999). Exercise as Cardiovascular Therapy. Circulation. 99:963-972.

3.    Hippocrates. On the Articulations. The Genuine Works of Hippocrates. Translated from the Greek with a Preliminary Discourse and Annotations. London: Sydenham Society. 1849. circa 400 BC: part 58.

4.    U.S. Department of Health and Human Services: Physical Activity and Health: A Report of the Surgeon General. (1996). Atlanta, GA: US Department of Health and Human Services, Center for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.

5.    Paffenbarger, R.S., Hyde, R.T. Wing, A., and Hsieh, C. (1986). Physical Activity, All-Cause Mortality, and Longevity of College Alumni. New England Journal of Medicine. 314:605-613.

6.    Manson, J.E., Stampfer, M.J., Willett, W.C., Colditz, G.A., Speizer, F.E., and Hennekens, C.H. (1995). Physical Activity and Incidence of Coronary Heart Disease and Stroke in Women. Circulation. 9:927. Abstract

7.    Hagberg, J.M., Montain, S.J., and Martin, W.H. (1989). Effect of Exercise Training in 60-69-year-old Persons with Essential Hypertension. American Journal of Cardiology. 64:348-353.

8.    Blair, S.N., Goodyear, N.N., Gibbons, L.W., and Cooper, K.H. (1984). Physical Fitness and Incidence of Hypertension in Healthy Normotensive Men and Women. Journal of American Medical Association. 252:487-490.

9.   Wasserman, D.H. and Zinman, B. (1995). Fuel Homeostasis. In Ruderman, N. and Devlin, J.T. (Editors). The Health Professional’s Guide to Diabetes and Exercise. Alexandria, VA: American Diabetes Association.

10. American Society of Exercise Physiology. (2006). ASEP Home Page. [Online]. http://www.asep.org/

11.  The Center for Exercise Physiology-online. (2006). CEP Home Page. [Online]. http://www.exercisephysiologists.com/

12. Frontera, W.R., Meredith, C.N., O’Reilly, K.P., et al. (1988). Strength Conditioning in Older Men: Skeletal Muscle Hypertrophy and Improved Function. Journal of Applied Physiology. 64:1038-1044.

13. Board of Accreditation. (2006). CEP Home Page: Board of Accreditation for Exercise Physiologists. [Online].  http://www.exercisephysiologists.com/boardofaccreditation/index.html

14.  Powell, R., Bentall, R., Nye, F.J. and Edwards, R.H. (2001). Randomized Controlled Trial of Patient Education to Encourage Graded Exercise in Chronic Fatigue Syndrome. British Medical Journal. 322:387-390.

15. Wallman, K.E., Morton, A.R., Goodman, C., and Grove, R. (2005). Exercise Prescription for Individuals with Chronic Fatigue Syndrome. eMJA: The Medical Journal of Australia. 183:142-143.

16. Courneya, K.S. (2003). Exercise in Cancer Survivors: An Overview of Research. Medicine and Science in Sports. 35:1846-1852.

17.  Petajan, J.H., Gappmaier, E., White, A.T., et al. (1996). Impact of Aerobic Training on Fitness and Quality of Life in Multiple Sclerosis. Annuals of Neurology. 39:432-441.

18. Richards, S.C.M. and Scott, D.L. (2002). Prescribed Exercise in People with Fibromyalgia: Parallel Group Randomized Controlled Trials. British Medical Journal. 325:185-188.

19. Morris, J.N. (1992). Exercise versus Heart Attack: History of a Hypothesis. In Marmot, M., Elliot, P. (Editors). Coronary Heart Disease Epidemiology: From Aetiology to Public Health. Oxford: Oxford Medical Publications. P. 252.

20.  Morris, J.N., Heady, J.A., Raffle, P.A.B., et al. (1953). Coronary Heart Disease and the Physical Activity of Work. Lancet. 2:1053-1057, 1111-1120.

21. Physical Activity and Health: A Report of the U.S. Surgeon General. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.

22. American Geriatrics Society Panel on Exercise and Osteoarthritis. (2001). Exercise Prescription for Older Adults with Osteoarthritis Pain: Consensus Practice Recommendations. Journal of American Geriatrics Society.

23. Boone, T. (2005). Understanding Vision and Mission Statements. Professionalization of Exercise Physiologyonline. 8:5 [Online]. http://www.asep.org/asep/asep/ManagingTheOrganization.html

24.  Hammond, J.M., Brodie, D.A., and Bundred, P.E. (1997). Exercise on Prescription: Guidelines for Health Professionals. Health Promotion International. 12:33-41.

25. Thurston, M. and Green, K. (2004). Adherence to Exercise in Later Life: How Can Exercise on Prescription Programmes be Made More Effective? Health Promotion International. 19:379-387.

       26. Cullen, M. and Batt, M. (2005). Sport and Exercise Medicine in the United Kingdom                   Comes of Age. British Journal of Sports Medicine. 39:250-251.

27. Kannus, P. and Parkkari, J. (2000). Sports and Exercise Medicine in Finland. British Journal of Sports Medicine. 34:239-240.

28. Teh, K.C. (2004). Exercise as Medicine. Singapore Medical Journal. 45:52-54.

29. FitQuips. (2006). FitQuips ArchiveDrNick.com [Online].    http://www.drnick.com/fitquips/archive/fq_exmedicine.html              

       30. Lundgren, J. and Ugalde, V. (2004). The Demographics and Economics of                              Complementary Alternative Medicine. Physical Medicine and Rehabilittion Clinics of               North America. 15:955-961.

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