Physiotherapy Theory and Practice, 25(5–6):354–368, 2009

Copyright r Informa Healthcare

ISSN: 0959-3985 print/1532-5040 online
DOI: 10.1080/09593980902813416

Physical therapy in the 21st century (Part II):

Evidence-based practice within the context
of evidence-informed practice
Elizabeth Dean, PhD, PT
Professor, Department of Physical Therapy, Faculty of Medicine, University of British Columbia,
Vancouver BC, Canada

Part II of this two-part introduction to this Special Issue on physical therapy practice in the 21st
century outlines a health-focused strategy for physical therapists to lead in the assault on lifestyle
conditions, global health care priorities, described in Part I. Consistent with contemporary definitions of
physical therapy, its practice, professional education, and research, physical therapy needs to reflect 21st-
century health priorities and be aligned with global and regional public health strategies. A proposed focus
on health emphasizes clinical competencies, including assessments of health, lifestyle health behaviors, and
lifestyle risk factors; and the prescription of interventions to promote health and well-being in every client
or patient. Such an approach is aimed to increase the threshold for chronic conditions over the life cycle
and reduce their rate of progression, thereby preventing, delaying, or minimizing the severity of illness and
disability. The 21st-century physical therapist needs to be able to practice such competencies within the
context of a culturally diverse society to effect positive health behavior change. The physical therapist is
uniquely positioned to lead in health promotion and prevention of the lifestyle conditions, address many of
their causes, as well as manage these conditions. Physical therapists need to impact health globally
through public and social health policy as well as one-on-one care. This role is consistent with con-
temporary definitions of physical therapy as the quintessential noninvasive health care practitioner, and
the established efficacy and often superiority of lifestyle and lifestyle change on health outcomes com-
pared with invasive interventions, namely, drugs and surgery. A concerted commitment by physical
therapists to health and well-being and reduced health risk is consistent with minimizing the substantial
social and economic burdens of lifestyle conditions globally.

Introduction related to physical therapy to assess health and

This article is the second of a two-part
introduction related to the practice of physical
therapy in the 21st century. A case was made in
Part I for physical therapy in the 21st century
to be informed by epidemiology and the global
crisis of lifestyle conditions. This part outlines
evidence-based assessment and interventions
address the risk factors and manifestations of
lifestyle conditions. This strategy in which
practice is aligned with health care priorities is
consistent with contemporary definitions of
physical therapy, the definition of health by the
World Health Organization (WHO) (2008), and
the International Classification of Function
(ICF) (2002) that have been adopted by the

Accepted for publication 10 November 2008.

Address correspondence to Elizabeth Dean, PhD, PT, Department of Physical Therapy, Faculty of Medicine, University of British
Columbia, Rm 212, Friedman Building, 2177 Wesbrook Mall, Vancouver, BC, Canada V6T 1Z3. E-mail: elizabeth.dean@ubc.ca

354
355 Dean /Physiotherapy Theory and Practice 25 (2009) 354–368
World Confederation of Physical Therapy and
its member countries.
A health-focused strategy proposes that the
noninvasive interventions of physical therapy, in
particular, health education and exercise, need
to be maximally exploited in every individual
through awareness and knowledge of the leading
health care priorities and risk factors and of
health behavior change. Health-focused practice
is proposed that legitimizes health as a physical
therapy priority in which the individual’s overall
health and health risk factors are foci of prac-
tice. Health behavior reflects one’s lifestyle and
mediating influences. Lifestyle modification is
the single most powerful strategy a clinician
can use to maximize health. Lifestyle practices
including smoking, suboptimal nutrition, inacti-
vity, stress, and poor sleep are largely behavioral
and are best modified with an understanding of
health behavior change psychology and environ-
mental factors, including physical and psycho-
social facilitators and barriers. As a basis for
implementing health behavior change, leading
theories and models of health behavior and
health behavior change are reviewed. Self-
management with underpinnings in the self-efficacy
literature appears to be a powerful strategy for
effecting positive behavior change and health
outcomes. Health behavior change and the pro-
motion of self-management are discussed in the
context of culture, which largely defines one’s
lifestyle and risk factors (Anand et al, 2000).
Finally, the implications of a health-focused
model of practice are presented with reference to
clinical practice, professional education, and
research. The exploitation of physical therapy
practices including education and exercise to
address our leading health priorities is justified
on the basis of their established long-term
effectiveness, low risk, and low cost.
Health-focused practice: Rationale
Leading health reports, such as the Romanow
Report (2002) and the Report of the Kirby
Commission (2002) in Canada, call for greater
responsiveness of health care delivery to societal
need. In the 20th century, the profession of
physical therapy demonstrated its responsive-
ness to health priorities (e.g., the casualties of
the world wars and polio epidemics). This trend
was evidenced by the amount of journal and
conference space and time dedicated to these
topics at those times. Over the latter part of the
20th century and into the 21st century, there is
an apparent lag in the degree to which the
physical therapy profession is prioritizing 21st-
century health issues that it is preeminently well
suited to address. Among the highest priorities
are smoking cessation and reducing obesity,
given the cascade of secondary pathologies
associated with these (Mokdad, Marks, Stroup,
and Gerberding, 2004; Zalesin et al, 2008) and
their substantial social and economic burdens.
Furthermore, physical therapists through
exploitation of health education and exercise
can reverse hypertension and diabetes or sub-
stantially mitigate them and their dire con-
sequences; see review (Dean, 2006).
Health-focused practice: Components
Table 1 outlines a proposed structure for
health-focused practice that is consistent with
contemporary definitions of physical therapy and
can serve as a primary pillar of practice and
competency standards for the 21st century. The
foci of care include multiple health behavior
change (i.e., smoking cessation, nutrition, weight
control, physical activity, exercise, stress manage-
ment, and optimization of sleep). A plethora
of literature exists to support the inclusion of
these topics and the benefits of their being
addressed. Traditionally, health care profes-
sionals, including physical therapists, have
focused on impairment, ill health, injury, and
disability. As outlined in Table 1, inclusion of
health and determinants of health and the
requisite knowledge, skills, and attitudes into
entry-level curricula that are needed to effect
optimal health in our clients and patients is
timely. In this way, health and well-being are
legitimized as the first priority of the physical
therapist in advancing world health, the health
of the community in the context of the general
public, the workplace, schools, as well as at the
level of the individual client or patient. This
would focus the physical therapist’s attention to
health in the generally well population and on
managing an individual’s presenting problem in
the context of the individual’s overall health risks
and chronic conditions.
 Dean /Physiotherapy Theory and Practice 25 (2009) 354–368 356

Table 1. Health-focused physical therapy practice (noncommunicable lifestyle conditions).

Focus A: Smoking reduction and cessation

Focus B: Nutrition optimization
Focus C: Weight control (weight reduction or gain, and normalizing)
Focus D: Physical activity (progressive increase in regular daily activity)
Focus E: Exercise (structured exercise programs)
Focus F: Stress reduction and management
Focus G: Sleep hygiene and optimization
Focus H: Substance abuse cessation (e.g., alcohol and drugs)
Essential knowledge:
K Determinants and definition of health

K Determinants of health of the village, community, country and individual and their
interrelationships
K Assessment and measurement outcome of health and wellbeing

K Assessment and measurement outcome of risk factors for the lifestyle conditions

K Knowledge of the epidemiology and etiology of these risk factors and their manifestations

across the life cycle (i.e., from childhood to old age)

K Valid, reliable, and sensitive outcome measures, i.e., health status questionnaires, and risk factor

assessment tools for the lifestyle conditions, namely, ischemic heart disease, chronic obstructive
lung disease, cancer, hypertension and stroke, diabetes, osteoporosis, and psychosocial well-being
K Multiple health behavior change and simultaneous interventions and strategies

K Theories and models of health and health behavior change including sustained positive health

lifestyle practices (e.g., social cognition theory, theory of reasoned action and perceived
control, self-determination theory, transtheoretical model, model of health motivation,
cognitive behavior therapy, and health belief model)
K Evidence-based update on sustained smoking reduction and cessation programs; and detailed

knowledge for the translation and prescription of this information to meet the needs of
different people and patients
K Evidence-based update on sustained optimal nutrition for across the life span and for clients with

different needs (e.g., healing, injury, critical care, burns; and detailed knowledge for the translation
and prescription of this information to meet the needs of different people and patients)
K Evidence-based update on sustained weight reduction programs, and the physiology and

psychology of normal weight and its maintenance; and detailed knowledge for the translation
and prescription of this information to meet the needs of different people and patients
K Evidence-based update on the dose of physical activity needed for sustained health, fitness, and

athletic requirements; and detailed knowledge for the translation and prescription of this
information to meet the needs of different people and patients
K Evidence-based update on the dose of structured exercise needed for sustained aerobic and

anaerobic power, and for muscle strength and endurance; and detailed knowledge for the
translation and prescription of this information to meet the needs of different people and patients
K Differential health and fitness benefits of aerobic exercise, strengthening exercise, and flexibility

exercise including dose-response relationships.

K Evidence-based update on the physiology and psychology of stress reactions, and their

sustained management; comparative understanding of diverse methods for stress management,

and detailed knowledge for the translation and prescription of this information to meet the
needs of different people and patients
(Continued)
357 Dean /Physiotherapy Theory and Practice 25 (2009) 354–368

Table 1. Health-focused physical therapy practice (noncommunicable lifestyle conditions) (Continued).

K Evidence-based update on the physiology of normal sleep and pathology of disordered sleep;
assessment and evaluation of sleep and strategies for addressing sleep disorders or referring to
another professional
K Evidence-based update on the physiology and psychology of substance abuse including alcohol
and illicit substance, and detailed knowledge for the translation and prescription of this
information to meet the needs of different people and patients (sustained cessation or
minimally harm reduction)
K Current health behavior change theories and models and their application
K Assessment of factors that affect lifestyle change for a given individual, that is, facilitators and barriers
K Understanding of the determinants of health including gender, age, level of education,
psychosocial status, race, ethnicity, and other cultural considerations
K Data base of resource people and materials available to support these interventions including
knowledge of the role of all health care team members including traditional healers and
spiritual leaders and guides, and existing health education literature and resources through
community groups committed to serving various groups (e.g., heart association, lung
association, diabetes association, and cancer association)
K Understanding of iatrogenic medicine and the number of deaths and adverse effects of drugs
and surgery and associated costs
K Understanding of iatrogenic medicine (i.e., adverse effects of biomedical care, drugs and surgery)
into physical therapy practice as a basis for avoiding drug prescription, minimizing the dosage,
minimizing the duration of administration, or postponing the need for medication, as a means of
reducing the untoward consequences of these agents and their societal and economic costs
K Understanding of iatrogenic medicine (i.e., adverse effects of biomedical care, drugs and surgery)
into physical therapy practice as a basis for avoiding the need for surgery, minimizing the severity
of the surgery, improving surgical outcomes, or postponing the need for surgery as a means of
reducing the untoward consequences of surgery and their societal and economic costs
K Social and economic burdens of disability and morbidity

Health-focused practice: Health Health-focused practice: Risk factor

assessment and evaluation
The assessment of health and well-being is
distinct in that it consists of assessing the com-
ponents of the ICF model (2002) in relation to
their adequacy and the individual’s abilities and
health-related quality of life. Multisystem status
may reflect the individual’s lifestyle choices over
time and environmental exposure. The goal of
health promotion is to reinforce positive health
behaviors and reduce negative heath behaviors.
Decision analysis can be a useful tool to effect
health behavior change by having the individual
compare the benefits and costs of changing and
of not changing a given health behavior or
multiple health behaviors.
assessment and evaluation
Risk factor assessment refers to the systematic
assessment of an individual’s nonmodifiable and
modifiable risk factors for the lifestyle conditions.
There are many risk factor assessment tools
available for use; however, standardized tools
constructed from credible sources are essential to
maximize their clinical utility with respect to
assessing an individual’s type and degree of risk.
Risk factor assessment and classification are
based on the results of valid and reliable tools.
These are usually questionnaire format and based
on longitudinal epidemiological and population
health studies of large numbers of people. By
tracking the nonmodifiable and modifiable risk
 Dean /Physiotherapy Theory and Practice 25 (2009) 354–368
factors for the lifestyle conditions, clinicians can
predict the conditions for which a given individual
may be at risk, and they also can be used as
outcomes by tracking change over time and in
response to intervention.
The global health assessment was published
for use by health care professionals (Grundy
et al, 1999). This risk factor assessment consists
of six questions including lipid levels. Degree of
risk is distinct for men and women and color
coded for teaching purposes such that an indivi-
dual can readily observe current level of risk and
a shift in risk on reevaluation.
The Harvard School of Public Health is another
credible source for risk factor assessment tools. It
has constructed online questionnaires on ‘‘Your
Disease Risk’’ based on the extensive epidemio-
logical data and regression analyses (Harvard
School of Public Health, 2008). An individual’s
risk of IHD, cancer (12 classifications), stroke,
and osteoporosis can be assessed with condition-
specific risk assessment tools based on a relatively
few specific questions and risk rated over several
grades of severity from low to high risk. These risk
classifications can serve as indexes or outcome
measures to assess the effects of health behavior
change. An individual may score above average
risk for lung cancer, as an example, but if this score
was the highest possible risk 6 months ago, this
constitutes change in a positive direction.
Risk factor assessment needs to be based on
credible tools. The two scales above predict the
risk of developing specific conditions which is
of considerable clinical relevance, whereas others
are designed to predict mortality (e.g., the
SCORE project developed in Europe) (Conroy
et al, 2003).
Anthropometric measures are also important
risk indicators. These constitute the new ‘‘vital
signs’’ of the 21st century that warrant being
assessment priorities if the tide of obesity is to be
turned (Campbell, 2003). Body mass index
below 18.5 and over 24.9 is associated with
health risk—the latter with ischemic heart dis-
ease and other systemic conditions. Waist girth
is comparable to BMI as an indicator of risk,
and waist-to-hip ratio is superior to either of
these (Yusuf et al, 2005). Body weight, height,
and waist and hip measures are fundamental
to the physical therapy assessment in the 21st
century and warrant being recorded based on
standardized valid procedures.
358
Health-focused practice: Interventions
The physical therapist can use the results of
the risk factor assessments for each lifestyle
condition as the basis for intervention. Lifestyle
conditions, however, often share common health
behavior risk factors, hence, the current interest
in multiple health behavior change (Noar,
Chabot, and Zimmerman, 2008; Prochaska,
2008; Prochaska, Spring, and Nigg, 2008). For
most people, at least those seen by the physical
therapist for the first time, a comprehensive
risk factor assessment of lifestyle conditions is
warranted. The aim of risk factor reduction
interventions is to shift the individual to the
lowest risk severity category as possible. These
categories are based on population statistics, so
in relation to other cultures, these could still be
considered high. The risk categories reflect the
culture in which the original data underlining
the ranges of risk were collected.
Lifestyle modification interventions based on
education, including advice and recommenda-
tions for smoking cessation, basic optimal nutri-
tion, weight control, regular physical activity
and exercise, stress management, and sleep
hygiene may be common to a number of condi-
tions for which the patient is at risk. The effect
size of the change required for general health
benefit or risk factor reduction, however, varies
for different conditions. The lower the risk
category achieved, the better.
Most clients or patients are likely to benefit
from a general health program; the specific
parameters being based on the assessments of
health, health behaviors, risk factors, and any
manifestations of lifestyle conditions. The physi-
cal therapist has expertise in viewing the indivi-
dual’s health holistically in addition to addressing
individual impairments. Based on sound clinical
reasoning, the physical therapist can prioritize the
individual’s concerns to help reduce the most
serious of the risks in a sequential or concurrent
manner, depending on the person’s individual
presentation and needs, or reverse or mitigate
manifestations of lifestyle conditions. In addition,
the client or patient may have come to the phy-
sical therapist with a problem not directly related
to one of the primary lifestyle conditions (e.g.,
low back pain). Thus, risk factor modification
and reduction needs to be instituted concurrently
with management for the presenting problem,
359 Dean /Physiotherapy Theory and Practice 25 (2009) 354–368
in this case an orthopedic complaint. Risk of
lifestyle conditions related to obesity, for example,
necessitates a nutritional plan coupled with
increased regular physical activity and structured
exercise program. Although the physical therapist
may prescribe treatment directed at symptomatic
relief of the low back pain, this problem may be
influenced or eliminated by weight reduction
(Bener, Alwash, Gaber, and Lovasz, 2003; Deyo,
1991; Liuke et al, 2005).
Furthermore, the problem may be remediated
long term if the causes or contributing factors
(e.g., obesity and sedentary lifestyle) are
addressed before irreversible injury, refractory
to management, ensues or surgery is indicated.
Similarly, two thirds of patients requiring knee
and joint replacements are overweight. Reducing
obesity may avert the need for joint replacement,
reduce complications, improve postsurgical
outcome, and reduce need of repeat surgery.
The patient or client is actively involved with
reviewing the results of the health assessment
with the physical therapist and establishing a
health plan for the short and long term that the
person actively supports and to which he or she is
committed. Health behavior change is a complex
activity involving multiple factors including psy-
chosocial and economic ones. These factors need
to be identified and addressed to maximize the
outcome of a health behavior change program. In
cases in which multiple risk factors are present
and multiple health behavior change indicated,
decisions need to be made about what inter-
ventions are needed and whether these are
staged, concurrent, or sequential. Health beha-
vior change theory and strategies are described in
detail with special reference to sustained physical
activity and exercise in the article by Rhodes and
Fiala in this issue.
Smoking cessation counseling
Smoking cessation reduces or reverses many
of the lethal effects of long-term smoking and
associated morbidity (Table 2). Knowledge of
these immediate and long-term benefits of
smoking cessation to an individual and his or
her family are components of the clinician’s
arsenal by establishing goals and incentives for
the smoker. Although long-term smoking can
lead to irreversible lung damage, reduction in
Table 2. Health benefits of quitting smoking.
Immediate benefits
Healthier Quitting smoking removes
family harmful environmental tobacco
smoke
That pollutes non smokers’
breathing space.
Healthier Your body starts to heal itself. The
‘you’ level of carbon monoxide and
the nicotine in your system will
decline rapidly.
Benefits after 1 Year
Increased risk of ischemic heart disease
decreased 50%
Benefits after 3 Years
Risk of heart disease is declining to levels
similar to lifelong nonsmokers
Benefits after 5 Years
Risk of cancers of the oral cavity and
esophagus reduced 50%
Risk of bladder cancer reduced about 50%
Risk of stroke can return to similar levels as
nonsmokers
Risk of cervical cancer significantly reduced
Benefits after 10 Years
Risk of lung cancer decreased 50–70%
Benefits after 15 Years
Risk of ischemic heart disease is similar to
lifelong nonsmoker
Risk of death similar to lifelong nonsmoker
Sources: U.S. Surgeon General’s Report, 2000; Manson et al,
1992; American Lung Association, 2006.
risk of heart disease, stroke, and cancer is largely
commensurate with length of quit duration. For
smokers who have difficulty quitting, advocat-
ing competing health strategies has been pro-
posed (Naslund, Fredrikson, Hellenius, and de
Faire, 1996). Improved nutrition and physical
activity and exercise, however, do not necessa-
rily counter the negative effects of smoking
(Luedemann et al, 2002).
Physical therapists need to be informed about
advances in the prevention of smoking in young
people and smoking cessation programs that may
include either nonprescription or prescription medi-
cation. In 1996 the APTA adopted the guidelines of
the Agency for Health Care Policy and Research
(AHCPR, 1997), and these have been revised since
 Dean /Physiotherapy Theory and Practice 25 (2009) 354–368
(AHCPR, 2000). These guidelines were adopted
by the APTA to acknowledge publicly and pro-
fessionally its commitment to health. These guide-
lines provide clear, direct, and personal statements
related to smoking cessation that are designed to be
used by practitioners with their patients.
A decision will need to be made in consultation
with the patient’s or client’s physician about
whether pharmacological support is indicated
(e.g., nicotine replacement therapy), and if so,
what the prescription parameters should be in
terms of coordination with noninvasive strategies.
Smoking reduction warrants being monitored by
both the physical therapist and physician to
ensure pharmacological support is progressively
withdrawn as indicated.
Basic nutrition counseling
Optimal nutrition is essential for healing and
repair, immunity, maintaining an optimal body
weight as well as providing energy for metabo-
lism. Physical therapists who exploit exercise
as a primary therapeutic intervention to prevent,
remediate, or mitigate the effects of disease and
disability perturb metabolic demands in their
clients and patients. Physical therapists need an
understanding of metabolism and the factors that
influence it, and of healthy nutrition, nutritional
assessment, and nutritional regimens to maximize
human performance in patient populations. This
is often common knowledge for physical thera-
pists who work with athletes, but it is a less
common aspect of knowledge and intervention in
Health condition
(disorder or disease)
Body functions
and structures
Environmental
factors
Figure 1. International classification of function (WHO, 2002).
360
clients who are not athletes but perform at a
maximal capacity on a daily basis. Without this
knowledge, assessment and exercise prescription
are suboptimal, and in turn, therapeutic outcomes
suboptimal. Familiarity with established nutri-
tional guidelines is essential for basic advice. Some
individuals will require consultation with nutri-
tionists or dieticians for regimens for specific
conditions including significant weight loss and
related monitoring and follow-up.
Comprehensive care of the individual who is
overweight with abnormal blood sugars includes
normalization of blood sugar (with recommen-
dation for low glycemic foods and small frequent
nutritious snacks rather than infrequent large
meals), weight reduction, saturated fat and trans-
fat restriction, strict blood pressure and lipid
control, regular physical activity and exercise,
and avoidance of tobacco (Wilson and Kannel,
2002). The effectiveness of these interventions
needs to be monitored like any other component
of physical therapy management.
Regular physical activity and
exercise prescription
Typically, mobilization and exercise are direc-
ted at correcting impairments and enhancing the
patient’s capacity for activity and participation.
Outcomes related to improving abilities and parti-
cipation include self-care, home management,
return to work, and resumption of avocational
activities (Figure 1). Return to work is often
Activity Participation
Personal factors
361 Dean /Physiotherapy Theory and Practice 25 (2009) 354–368
related to oxygen transport capacity in terms
of cardiovascular/respiratory endurance and peri-
pheral muscle strength. Exercise is advocated
preventively to avoid the deleterious effects of
restricted mobility and to provide optimal syste-
mic health.
Within a health model, physical activity and
exercise are prescribed to optimize health and to
reduce health risks. Knowledge is emerging that
provides a basis for the prescription parameters
for physical activity and exercise to optimize
vascular and endocrine health as well as other
health benefits, and the requisite change that is
needed to predict a given health risk change. See
review (Dean, 2006).
Mental health, stress management,
and sleep hygiene recommendations
Mental health has long been known to impact
physical well-being and functional capacity, and
some argue that contemporary life in high-income
countries can negatively affect mental health and
well-being (e.g., undue or prolonged unhappiness,
anxiety and depression, and associated life skills
dysfunction). Optimism is associated with better
health outcomes and pessimism with poorer ones.
Anxiety and depression impact physical well-
being, and conversely illness and chronic condi-
tions adversely impact mental health. Stress is
considered a normal part of life, yet chronic
unabated stress leads to chronic physical com-
plaints. Physical as well as mental ill health can
impact sleep health, and in turn impaired sleep
can affect physical and mental health. Thus, these
aspects of mental health can confound a client or
patient’s clinical presentation physically, and their
improvement or remediation alone may improve
functional capacity and well-being. Thus, early
identification and ongoing evaluation of mental
health and sleep issues are important. The physi-
cal therapist needs to recognize when an indivi-
dual may need to be referred to a mental health
professional or to work together with such a
professional to maximize a client’s functional
capacity and participation in life. Good health
recommendations including physical activity may
address certain transient mental health problems,
such as stress, anxiety, and some forms of
depression either directly or indirectly.
Effecting positive health and health
behavior change
Behavior change is a complex process that is
mediated by multiple factors. Information on
health benefit and risk reduction alone is inade-
quate to effect behavior change. Because psy-
chosocial factors impact lifestyle conditions and
people’s responses to these (Hudson and Pope,
2006), both directly and indirectly, psychosocial
approaches to management are supported
(Nater, Gaab, Rief, and Ehlert, 2006). Because
of the complexity of behavior change, various
health professionals are involved with this pro-
cess and complement each other’s efforts. Phy-
sical therapists can be sole agents of change for a
given individual or work with other team
members to support the individual in achieving
health goals.
The prominent theories and models related to
health behavior change are summarized in Table 3.
These include Social Cognitive Theory in which
self-efficacy is a central component (Bandura,
1977, 1986, 1997; Baranowski, Perry, and Parcel,
2001; Whitehead, 2001); the Theory of Reasoned
Action or Planned Behavior (perceived behavioral
control construct) (Ajzen, 1991; Armitage and
Connor, 2001; Glanz, Lewis, and Rimer, 1991);
Self-determination Theory (Deci and Ryan, 1985;
Ryan and Deci, 2000; Sheldon, Williams, and
Joiner, 2003); the Transtheoretical Model of
Change (Prochaska and DiClemente, 1982;
Prochaska and Velicer, 1997); behavior modifica-
tion (Skinner, 1988; Wierenga and Oldham, 2002);
and the Health Belief Model (Becker, 1974;
Rosenstock, Strecher, and Becker, 1994; Strecher
and Rosenstock, 1997). The fundamental features
of these leading theories of health behavior change
are shown in Table 3.
Knowledge of these theories and models
enable physical therapists to understand the
factors contributing to the development of both
positive and negative health behaviors and why
those behaviors are being sustained in a given
individual, and in the case of negative health
behaviors, the challenge of effecting a positive
health behavior change that is sustained in the
long term. Each theory and model has a unique
construct and basis for assessment and inter-
vention of each health behavior. Examples are
shown in Table 3 of the health behaviors that
Table 3. Predominant behavior change theories and models with reference to health behavior change.
Theory or model
Social Cognitive Theory
Bandura, 1977; Bandura, 1986;
Bandura, 1997;
Baranowski, 2001; Strecher et al,
1986; Whitehead, 2001
Theory of Reasoned Action or
Planned Behavior
(Perceived behavioral control
construct)
Ajzen, 1991; Armitage and
Conner, 2001; Glanz, 2001
Self-determination Theory
Deci and Ryan, 1985; Ryan and
Deci, 2000; Sheldon, 2003
Transtheoretical Model of Change
Prochaska, 1982; Prochaska, 1997
Premise or construct Examples of health application
J Addresses social cognitive component of health Schwarzer & Fuchs,1995; Allen,
behavior change including knowledge, belief, 2004
motivation, drive, attitude, and self-efficacy J Smoking cessation
J Triadic: behavior, personal, and environmental J Exercise promotion
determinants J Nutrition and weight control
J Dependent upon ‘cognitive processes in the
acquisition of and retention of new behavioral
patterns’
J Predominant construct self-efficacy
J Cognitive behavioral therapy integrates beha-
vioral modification principles
J An individual’s decision to engage in a health Armitage and Conner, 2001;
behavior such as exercise is based on his or her Courneya, 2001;
intention Norman, 1999
J Intention is a function of the person’s attitudes, J Exercise promotion
perceived control and self-efficacy, and social J Smoking cessation
factors
J Motivation to change, participate in and main- AHRQ, 2000; Williams et al, 2002
Dean /Physiotherapy Theory and Practice 25 (2009) 354–368
tain a specific behavior J
J
Smoking cessation
Role of intrinsic motivation and social influence J Weight loss
J Directly associated with health behavior change Prochaska et al, 2005; Snow et al,
vs. predictors of behavior 1994; Henry et al, 2006; Kim
2006; Jones et al, 2003
J Nutrition and dietary change
J Exercise promotion
J Smoking cessation
J Alcohol consumption control
362
Behavior Modification
Skinner, 1988; Wierenga and
Oldham, 2002
Health Belief Model
Strecher and Rosenstock, 1997;
Becker, 1974;
Rosenstock et al, 1994
Extension to the Health
Belief Model
Dishman, 1986
J Extrinsically conditioned motivation Srinath et al, 1995; Granath et al,
J Feedback 2006; van der Ven et al, 2005; 363
J Stimulus control and antecedent events to the Herning et al, 2005
behavior J
J Reinforcement of the behavior—positive and
Smoking cessation
J Nutritional counseling and
negative and reinforcement schedules, i.e., con- glycemic control
tinuous or intermittent J Weight control
J Consequent events
J Exercise
J Shaping with the reinforcement of small pro-
J Stress management
gressive steps toward a larger goal
J Principles can be incorporated into a model of
lifestyle modification that incorporates other
factors such as culture (e.g., Guise, 2000;
Wierenga and Oldham, 2002)
Readiness to take health action depends on: Applications incorporated into the
J
literature on the application of the
Perceived susceptibility to the disease transtheoretical model and
J Perceived severity or seriousness of the disease
J Perceived benefits of the health action
decisional analysis
J Perceived barriers to performing the action
J General health motivation
J Demographic variables
J Psychosocial variables
J Structural variables (e.g., knowledge of the
disease and contact with the disease)
J ‘Cues to action’, i.e., related to stimuli in the
one’s environment to participate
Main perceived barriers: Proposed that these reported
Dean /Physiotherapy Theory and Practice 25 (2009) 354–368
J
barriers are more justification for
Effort lack of participation rather than
J Time
J
explanations for it; do not emerge
Health limitations
J
as important factors predictive of
Obstacles exercise participation
 Dean /Physiotherapy Theory and Practice 25 (2009) 354–368
have been successfully addressed by using
interventions based on each theory or model.
Education that is tailored to the individual or
tailored to a group is perhaps the most important
component of the expertise of the contemporary
physical therapist to effect health behavior change
along with the individual’s motivation to effect
such change. Preventive health messages from a
health care provider can be powerful and a strong
predictor of health behavior change (Nisbeth,
Klausen, and Andersen, 2000; Thomas et al, 2002;
Tresch and Aronow, 1996; Winslow, Bohannon,
Brunton, and Mayhew, 1996). Currently, pre-
ventive health messages, however, tend to be
delivered to a relatively small number of patients,
unsystematically, from their health care providers,
if at all. Thus, lifestyle recommendations warrant
being delivered as a holistic management priority
to every patient, in a structured, conscious
manner comparable to the precision of a pres-
cribed treatment program. The cumulative time
each physical therapist spends with each patient
over each day, each week, and each year translates
into hundreds of teachable moments. The poten-
tial for societal impact and global assault on the
lifestyle conditions is substantial.
The Transtheoretical Model (Prochaska and
DiClemente, 1982) of readiness to change (Table 4)
has received considerable attention in practice.
Specific questions are asked to determine a
patient’s stage of readiness with the intent of tar-
geting strategies to shift a patient from one stage to
the next (i.e., to move toward ‘‘preparation’’ and
‘‘action’’ and then ‘‘maintenance’’ of the desirable
behavior. Self-efficacy, a concept first proffered
by Bandura (1977), is considered an important
determinant of readiness to change and one’s
capacity to effect and maintain a behavioral
change (Meland, Maeland, and Laerum, 1999).
When stage of readiness to change is considered in
promoting healthy lifestyles, health coaching can
be successful even when brief (Steptoe, Kerry,
Rink, and Hilton, 2001). Although this model has
been critiqued on the basis of the argument that
health behavior change is more likely a continuous
rather than discrete variable and that its validity
has been queried, the model remains compelling
from a practical and clinical perspective.
Patients receiving care, particularly those who
are hospitalized, can be a receptive and captive
audience for positive health messages and
advice. They present a prime opportunity for
364
Table 4. The stages of readiness to change (Prochaska and
DeClementi, 1982).
Precontemplation
J Not currently engaged in the target behavior
J Not seriously thinking of change in the
next 6 months
J Unaware of the need to change or deny the
need to change
Contemplation
J Not currently engaged in the behavior
J Seriously considering making a change
within the next 6 months
J Acknowledges that the behavior is unhealthy
J Seeking out information regarding the pros
and cons of changing
Preparation
J Planning to change within the next 30 days
J Have attempted to change in the previous
year
J On the verge of taking action to change
behavior
J Beginning to reevaluate themselves in light
of the new behavior
Action
J Engaged in the desired behavior
J The change has only occurred in the past
6 months
J Trying the behavior but is at high risk of
relapse
Maintenance
J Has maintained the behavior for 6 months
Note: An individual can be at different stages for different
health behaviors.
a teachable moment. Older individuals may
be especially motivated to better understand
their risk factors and to change their lifestyles
(Gariballa et al, 1996).
The impact of the physical therapist as an agent
of change may reflect her or his capacity to serve
as a role model. Health care providers (e.g., physi-
cians) who exercise are more likely to recommend
that patients exercise as well as advocate other
health behaviors (Abramson et al, 2000; Wells,
Lewis, Leake, and Ware, 1984). Thus, practicing
what one preaches may have a powerful effect on
increasing adherence of patients to health and
lifestyle change recommendations.
365 Dean /Physiotherapy Theory and Practice 25 (2009) 354–368
When patients are in the preparation and action
stages of the Prochaska and colleagues’ model,
the physical therapist can teach a range of self-
monitoring skills and strategies along with know-
ledge about circulatory and heart disease, risk
factors, and disease prevention. Blood pressure
self-monitoring can be taught provided the equip-
ment is calibrated and checked, standardized pro-
cedures are used, and the patient’s measurement
proficiency is evaluated (Mengden et al, 2000).
Health education for people in the precontem-
plative stage of readiness to change warrants being
targeted differently than those in other stages of
readiness. The Canadian Cancer Society (1999a,b),
for example, has two publications regarding smok-
ing cessation: one for those who are not yet
ready to quit (precontemplative stage) and one for
those who are (contemplative stage). The former
publication focuses on what can be expected when
the individual feels at a contemplative or higher
stage of readiness and what resources would be
available. This publication can serve as a proto-
type for education related to other health behaviors
for individuals at the precontemplative stage of
readiness to change.
The theories and models of health behavior
and health behavior change counseling support a
role for a range of approaches. One or more
approaches, however, may be indicated, depen-
dent on the individual, the context, the condi-
tions, and their stages and severity, motivational
factors, and readiness. These theories and models
do not suggest that any one approach will elicit
a given outcome. In some instances, for learner
engagement, brief counseling can be effective,
whereas others require a systematic targeted
approach with a consideration of enabling and
disenabling factors, and in others greater depen-
dence on the expertise of other team members
(e.g., nutritionist or psychologist).
Follow-up
The challenge of health promotion and risk
factor reduction is targeting those in need and
then implementing healthy lifestyle practices that
are sustained. Follow-up is essential to ensure
that health behavior change is occurring and to
determine when the program needs to be pro-
gressed or maintained. An analysis of the indivi-
dual’s facilitators and barriers to health behavior
change will enable the physical therapist to build
sustainability into the program. The degree of
health benefit from a given behavior change or
the clinical effect size needs to be considered to
establish a time frame. For example, to what
extent does an observed clinical change (e.g.,
3 mmHg reduction in systolic blood pressure or
10-pound weight reduction) for a given individual
translate into health benefit and reduced risk for
a given lifestyle condition?
Health-focused practice: Implications
Health-focused practice in physical therapy
practice has several implications for professional
education and research as well as clinical practice.
First, health-focused practice legitimizes health as
a focus of physical therapy rather than a primary
focus on illness and disability. Epidemiology and
the elements of health, health risk, and chronic
conditions that need to be included in entry-level
curricula are outlined in Table 1. Even when ill-
ness or disability is the reason for a patient seeing
a physical therapist, health-focused practice will
ensure that the patient’s health priorities are
being addressed in the context of the presenting
concern and priority. This will provide an opti-
mal level of care for the patient overall and may
augment the management of the primary pro-
blem (e.g., a weight reduction program for a
patient with low back pain, or smoking cessation
in a patient with cardiovascular disease being
seen for a groin strain).
Lifestyle factors impact the health and well-
being of individuals multisystemically. Address-
ing lifestyle factors may eliminate the cause of an
individual’s impairments as opposed to a primary
focus on the impairment and enhance quality of
life. Even if the cause is not eliminated, the
symptoms may be reduced such they are more
responsive to impairment-focused interventions.
Health-focused physical therapy practice
would enable those involved with developing
practice standards and clinical competencies and
professional education curricula to integrate
content related to health and epidemiological
trends and priorities. In turn, such health profi-
ciencies articulated by the profession would help
have this essential area of health care recognized
by third-party payers of health care, which is
an important initiative given the powerful force
 Dean /Physiotherapy Theory and Practice 25 (2009) 354–368
that this has been directing physical therapy
practice in some countries (e.g., the United
States) (APTA, 2001).
With the profession adopting health-focused
practice in the 21st century, researchers can cite
health as a primary value of care within the
profession, hence, a legitimate area of research
investigation by physical therapists. Physical
therapy research is needed to help develop and
refine health and wellness assessment and out-
come measures, and the sensitivity of risk factor
indices as outcomes. A healthy control group
would be an advance in the biomedical research
model (e.g., randomized control clinical trials as
well as other research designs) so that the power
of health can be fully understood.
Conclusion
The inclusion of a health focus into physical
therapy practice this century is both timely
and evidence informed. This focus legitimizes
health and well-being as physical therapy priori-
ties, irrespective of a practitioner’s specialty or
practice setting. In turn, health-focused practice
alerts other health care professionals and the
public to the profession’s commitment to this
fundamental value and formally establishes
common ground with other professionals com-
mitted to the health and well-being of the people
in our communities. Such assessment and inter-
vention need to be viewed as clinical compe-
tencies as well as the skills to effect health
behavior change through outcome evaluation.
Early detection and intervention, the leading
health priorities in the 21st century, may avert the
potentially life-threatening lifestyle conditions.
Acknowledgment
The author gratefully acknowledges Mike
Bodner for granting permission to adapt a table
of his work (Table 3) for this publication.
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