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Rehab to Recovery

Medical fitness centers are well-established as rehab providers, but commercial fitness centers can also play a role in bridging the gap between later stages of rehabilitation and full recovery.

Traditionally, there is a disconnect between latter stages of rehabilitation from injury or illness and complete recovery, as marked by the resumption of normal exercise patterns. Medical fitness facilities have addressed this gap, and have benefited the lucrative market created by a growing older population burdened by ailments such as obesity, cardiovascular disease and arthritis.

By 2006, some 875 medical fitness centers had sprung up in the United States, helping to drive a compound annual growth rate in members of slightly more than 15 percent. These centers typically offer memberships to the general public, outpatient clinical services and educational/wellness programs. In contrast to an average age of 39.2 for the fitness industry as a whole, the average age reported by medical fitness centers is 47.1.

"The role of the fitness center for rehab is to supplement the medical profession," says Peter S. Allen, fitness manager for the University of Southern Maine Lifeline Center for Wellness and Health Promotion, Portland, Maine. "So, the Lifeline Center works closely with physical therapists to continue a person's recovery from injury by designing an exercise prescription not only to rehabilitate the injury, but [to] condition the entire body."

Medical practitioners are supportive of the role exercise can play in rehabilitation. "More and more, exercise is being recognized as medicine, crucial for prevention and treatment of a broad spectrum of chronic health conditions," says Brad A. Roy, chair-elect and administrator of the Summit Medical Fitness Center, Kalispell, Mont. These include conditions such as diabetes and other metabolic disorders, obesity, heart failure, musculoskeletal conditions (post-injury, arthritis, fibromyalgia, Parkinson's, multiple sclerosis, etc.), pain management, depression and chronic fatigue. Fitness centers have something to contribute.

Commercial appeal

Some commercial fitness centers have spotted that the medical fitness market can create new revenue opportunities for them. "They see the dollar signs," says Roy, "especially in the [older] population, where 77 percent of today's wealth belongs to those who are over the age of 50." In addition, the older market is seen as having long-term exercise needs, says Hank Boerner, chair of the Medical Fitness Association, Richmond, Va. And, many of those older members readily acknowledge their need to commit to a sustained exercise-enriched lifestyle. Because of this, they are better prospects for retained business.

But, can commercial fitness centers really aspire to address the specialist needs of the medical fitness market? Boerner points out key differences between commercial fitness centers and medical fitness centers: staffing and programs. "Most commercial facilities that I have been associated with do not have the staff to assist the rehab population," he says. "Not to say that they could not hire them, but they are not usually prepared to pay the salaries that are required to hire physical therapists, exercise physiologists, dieticians, nurses, physicians and other degreed professionals needed to support this population."

However, a handful of commercial fitness centers are overcoming these obstacles. For instance, Gainesville Health and Fitness, Gainesville, Fla., offers rehab services, as does Dedham Health and Athletic Complex, Dedham, Mass. Gainesville has a Core Spinal Fitness program, an Arthritis and Aquatic Center, and an outpatient rehabilitation center with 15 physical therapists who specialize in musculoskeletal rehab, sports medicine, spine rehab, lymphadema, weight loss for adolescents, arthritis, incontinence, massage therapy, and headache and neck pain. Dedham has an alliance with Beth Israel Deaconess Hospital-Needham, Mass., to meet a wide array of rehabilitation needs. Another example is Island Health and Fitness Center, Ithaca, N.Y., developed by Community Corners and the Cayuga Medical Center, also located in Ithaca.

Washington Athletic Club (WAC), Seattle, Wash., has also made inroads into medical fitness, partnering with well-qualified rehabilitation companies. "[T]he symbiotic relationship of the physical therapy clinic and the facility will allow both businesses to grow and refer to each other," says Stuart Eivers, a physical therapist at WAC. With its onsite physical therapy clinic, WAC can offer regular physical therapy services. "If clients are having some sort of musculoskeletal issue that is limiting them in training, or has them considering dropping membership or participation at the facility, physical therapy can bring them back, or at least reassure them to stick with it," says Eivers. WAC does this through a 15-minute injury screening and trainer consultation. "It normally keeps the client within the loop of training," he says.

Equipment considerations

Most fitness facilities already have equipment that could satisfy later-stage rehabilitation work. Boerner says that, for post-rehabilitation work, fitness centers do not need any special equipment. The equipment needed depends on the stage of rehabilitation, and the population being served.

Allen agrees that equipment needs depend on what kind of rehabilitation is being offered. "We don't need any special equipment to service [physical therapy and cardiac or pulmonary rehab]," he says. "However, we hope to open up a disability center in the future, working with spinal-cord-injured participants, and would need adapted equipment [for that]."

Dealing with higher-risk populations also requires appropriate emergency equipment and procedures. The Medical Fitness Association notes that almost all medical fitness centers have AED equipment, first aid kits and written emergency procedures. Of those with AEDs, 61 percent have one unit, and 39 percent reported two or more units, for an average of 1.5 units per center.

According to the Medical Fitness Association, in 2006, the breakdown was as follows:

  • 98 percent of medical fitness centers had AED equipment
  • 98 percent had first aid kits
  • 97 percent had written emergency procedures
  • 73 percent had emergency call buttons
  • 56 percent had closed-circuit TV

Physician referrals

To keep a steady flow of rehab business, fitness centers need to secure referrals from physicians and therapists who are engaged in earlier phase rehabilitation work. But, are physicians amenable to fitness centers having a role in rehabilitation? "Absolutely," says John Caliri, director of FirstHealth Centers for Health and Fitness, Pembroke, N.C. "We are receiving an increasing amount of referrals from physicians for massage therapy, personal training, membership and nutritional counseling."

Physicians seem to be warming to fitness centers. "We are seeing an increase in direct physician referral into health and fitness," says Caliri. "Doctors realize the role an active lifestyle plays in one's health, and they are looking toward medical fitness centers for the expertise to help their patients."

Boerner says that physicians will refer, so long as the fitness center has the proper staff. He adds that constant contact with the physicians will also support referrals. Kim Blair, fitness center supervisor at the Valley Fitness Center, Renton, Wash., says that Valley Fitness gets many physician referrals, which is helped by having physicians who are members. "We also strive to communicate well with the physicians, and ensure we have a medical clearance before we do any sort of exercise with a member needing a medical clearance," she says.

As for the commercial sector, Eivers says WAC receives some direct referrals from physicians, but most referrals come from the trainers and massage therapists who work at WAC: "Many clients refer themselves to the clinic." However, he adds that WAC has developed a good reputation among the physicians who know of the program, and know that their patients are WAC members.

Rehabilitation Drivers

The three ailments below create billion-dollar demand for rehab fitness services:

Obesity The majority of the U.S. population does not meet recommended levels of physical activity - 27.6 percent of the adult population is completely inactive and 46.2 percent is insufficiently active. According to a study reported by the Centers for Disease Control and Prevention (CDC), Atlanta, Ga., physical inactivity, overweight and obesity were associated with 23 percent of health plan healthcare charges, and 27 percent of national healthcare charges. Estimates of the healthcare costs in 2004 related to overweight and obesity range from $98 billion to $129 billion. Almost 80 percent of obese adults have diabetes, high blood pressure, coronary heart disease, high blood cholesterol levels or osteoarthritis.

Cardiovascular disease and stroke According to the CDC, more than 70 million Americans (more than one-fourth of the population) live with a cardiovascular disease. The cost of cardiovascular diseases and stroke in the U.S. for 2006 was estimated at $403 billion, including direct and indirect costs.

Arthritis According to the Arthritis Foundation, Atlanta, Ga., arthritis is the most common cause of disability in the U.S. In 2002, 66 million people in the U.S. reported arthritis or chronic joint symptoms. Physician-diagnosed arthritis affects nearly one in four Americans. Arthritis costs the U.S. economy $86.2 billion annually. Arthritis and its related disability will increase to affect 71 million Americans by 2030.

Benchmarks for Success 2006. Medical Fitness Association: Richmond, Va., 2006.


Engaging in rehabilitation work exposes fitness centers to the high-risk exercise population, and medical clearance is essential. At Oakwood Healthcare Systems located throughout Michigan, each client fills out a questionnaire, evaluating whether they are at risk to exercise. "They fill out consent forms, and we have the physicians sign a medical release form stating their patients are able to exercise. Finally, we get a prescription from the doctor," says Karen Mitchell, physical therapy supervisor. Blair at Valley Fitness says, "We do not do any instruction without a doctor's medical clearance and, usually, a referral from a physical therapist. This way, we know the member's boundaries, and the therapists are great about giving us recommendations."

At FirstHealth, all members who meet certain requirements must receive physician approval before beginning an exercise program. "When any member/client of the fitness center is working with their physician and would like for us to communicate with that doctor, they sign a release form so that we can legally share protected health information with that specific provider," says Caliri. FirstHealth can then supply the physician with a variety of information, including progress notes, usage records of the member and testing results. "Each physician is different, and requests a different amount of interaction," Caliri says. "We provide them with what they ask, along with anything else that we encounter that we deem pertinent to the treatment of the client."

Allen says that the Lifeline Center strictly follows American College of Sports Medicine (ACSM) guidelines. "It is important to have as much information as possible on the client to establish a safe, effective exercise prescription," he says. "We require physician clearance on any client who is stratified in the moderate- or high-risk category based on ACSM guidelines, or has had an acute illness or injury. Physician clearance notifies physicians that their patient is joining the Lifeline Center, and gives them an opportunity to add to the exercise prescription."

As these examples indicate, it requires more than a beefed up disclaimer for commercial fitness centers to access the medical fitness market. "It goes way beyond disclaimers," says Boerner. "The bottom line is staffing and programs offered." The operational mindset for medical fitness is quite different than the commercial fitness mindset. "This market requires a lot more personal attention and time," Boerner says.

Roy says that fitness centers need to address code preparation and practice, outcome measures and community service. He adds that commercial facilities frequently come up short in other respects, too - a lack of well-thought-out and practiced emergency plans, and no medical director or medical advisory board. According to the Medical Fitness Association, one-third of medical fitness centers report having a paid medical director. Of these, approximately one-fifth has full-time status. Additionally, around one-fourth of centers have a medical advisory board.

Medical oversight is "incredibly important," Caliri says. "The role of medical oversight is to ensure the appropriateness of activity within the center, to serve as a resource to the staff concerning medical questions, and to serve as a liaison between the center and the local physicians." In exchange for a free membership, Valley Fitness has a group of physicians who form the medical board and who attend staff meetings at least on a quarterly basis, teach about a topic and are available for questions.

Personnel issues

Having the right rehabilitation expertise is the crux issue in whether a fitness facility can address this market. Finding and paying for qualified personnel is the stumbling block for most commercial fitness centers. "Clinical integration has a distinct chain of command and will stay that way for the near future," says Boerner. "The patients need treatment from rehab professionals immediately post-surgery or illness. After that is when the fitness portion of maintenance comes in. With proper staffing, it can be done in a commercial facility or a hospital-based wellness center."

Boerner says that personnel involved in providing physical therapy or rehabilitation should have the appropriate degree and license to provide such services. FirstHealth personal training staff all have a minimum of a B.S. degree in exercise science or a related field, in addition to a national level certification from an agency accredited through the National Commission for Certifying Agencies. FirstHealth also has trainers that have specialty certifications, master's degrees and, in some circumstances, are athletic trainers.

"Personnel should be licensed in physical therapy if practicing physical therapy," says Allen. "At USM Lifeline, we do not practice physical therapy. We develop and carry out exercise prescriptions with guidance/approval from the medical community based on ACSM guidelines. Our staff have degrees in the field of health and fitness, as well as national certifications."

WAC therapists are employed by Manual Therapy International, Seattle, Wash., and have some post-graduate training in manual therapy. But, personal trainers also have a role to play when a patient is being transitioned into training. "The therapist contacts the trainer to consult with them regarding limitations and progression," says Eivers.

A good partnership

Commercial fitness centers' prospects in the rehab market will be restricted unless they can match the staffing of wellness centers, or, as in the case of WAC, create partnerships that provide the necessary specialist expertise. "This trend of pairing physical therapy with fitness facilities is a good one for all involved," says Eivers. "It does take some analysis and experience. But, with good information and consultation with other people in the industry, it can be done successfully and sustainably."
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