The New Image of Sports Medicine:
Should Exercise Physiologists be Concerned?
Tommy Boone, PhD, MPH, MA, FASEP,
Professor and Chair
Director, Exercise Physiology Laboratories
The College of St. Scholastica
Duluth, MN 55811
"Ideas won't keep: something
must be done about them." -- A.N. Whitehead
As an exercise physiologist, I understand
the power and importance of exercise. I’ve spent many years teaching
the value of exercise. Of course, it may be easier today than a few
decades ago. As a physical educator in the 1960s, exercise was just
beginning to be accepted as important to one’s health or fitness.
Physical fitness however was not considered a subject of “brain power”
or, at least, that was the general feeling. Anyone could teach fitness
classes. Of course that was not true then, and is not true today.
With the increase in personal trainers
without an academic degree in exercise physiology, the science of exercise
or training is not as important as the look. The public either doesn’t
know the difference or cares to know. So, what is the big deal?
It seems to me that exercise physiologists have continued to grow professionally
despite the lack of a vision. They are experts in the scientific
study of fitness and training. They have developed a highly specialized
body of knowledge that embraces preventive medicine, the role of exercise
in the treatment of disease, and the underlying science of function and
performance. They deserve professional recognition for the decades
of work on behalf of exercise physiology and the public’s health and the
science of exercise.
After earning the PhD degree from
Florida State University in the mid-70s, I continued to think as a physical
educator. It was a few years later that it occurred to me that I
was not a physical educator. As an exercise physiologist, I taught
kinesiology, functional anatomy (with cadavers), cardiac rehabilitation,
and a variety of different kinds of health and physical education courses.
My activity in those days was gymnastics. In fact, that is just about
all I did for nearly 15 years. Doing handstand, swinging on the parallel
bars, and doing flips were fun to do and physically and mentally beneficial.
Only later did I learn to jog and teach the scientific literature on aerobic
activities. Now, having come almost full circle and several universities
later, it appears to me that either type of activity (i.e., anaerobic or
aerobic) is good for the body and mind connection. And, I suppose
that I finally got past the notion that exercise per se is the answer to
society’s problems. Prevention is a good thing, but prevention is
not an exact science by any means. I no longer believe that regular
exercise will prevent me from having cancer or dying from some particular
disease. Of course, it is logical (and, for the most part, scientifically
demonstrated) that regular exercise can help decrease a person’s statistical
risk of succumbing to a particular disease and/or dysfunction. This
is not the reason I value regular exercise, however. Regular exercise
is probably the most logical method to lose weight, keep the mind relaxed,
have fun, and keep the body (both structure and function) from falling
apart with age.
There are numerous other reasons
for engaging in regular exercise. Many of the reasons have been researched
and published by exercise physiologists for at least five decades.
The research has resulted in a specialized body of knowledge about exercise,
health benefits, and the science of human performance. What is interesting
is the credible image of exercise physiologists in the medical community.
As a representative of the National Office of the American Society of
Exercise Physiologists, I can contest to the increase in referrals
from the medial community. Almost every other week, several individuals
will call the ASEP office to locate an exercise physiologist in their part
of the country to supervise an exercise program for them. This is
a hard won image for exercise physiology. For the medical community
to appreciate the value of exercise is a different perspective. Medical
doctors have not always valued exercise. In addition to physical
educators and a number of other professions with a side-interest in fitness,
exercise physiologists have no doubt the record for most scientific research
and knowledge on the subject. Hence, although the trend in the recent
10 years or so is still too new to thoroughly understand, it should not
go unnoticed that there may be more to gain from investing in fitness and
human development than previously considered by different professions.
Interestingly, in May of 2003, Wilmore
 published an article in The Physician and Sportsmedicine (PSM)
journal. The article is informative for physicians. The content
is consistent with what is taught in a typical undergraduate exercise physiology
course. However, from an exercise physiologist’s point of view, the
article raises the question, “What is gained from medical doctors prescribing
exercise?” It seems to me that physicians should refer their clients
to exercise physiologists who are academically prepared to deal with the
prescription of exercise. What appears to be happening, however,
is that physicians are being encouraged to practice exercise physiology.
Wilmore  wrote the following: “Clinicians who understand how the body
responds to exercise, how aerobic training improves cardiovascular fitness,
and the benefits and principles of prescribing aerobic exercise can effectively
encourage patients to become active and optimize programs for those already
active.” While it appears that the point of the article is to educate
physicians to the benefits of exercise for their patients, isn’t it better
to refer patients to exercise physiology? This is exactly what medical
doctors do when it comes to physical therapists and other healthcare professionals.
If physicians become credible leaders
in prescribing exercise, where does this leave exercise physiologists?
Some would say that it is not good. Others would say that we need
more credible professionals encouraging the public to exercise. Still
further might say, “Don’t we already have credible professionals?”
The answer to the latter question is “Yes, we do”. They are called
exercise physiologists! With the emergence of exercise physiology
as an evolving profession, exercise itself has taken on a new image.
It seems to me that most of that image comes from the countless number
of articles published by exercise physiologists about the health benefits
of aerobic training . There are also numerous consensus statements
written at least in part by exercise physiologists [3, 4]. A major
part of this expansion in the physiology of exercise is the increased understanding
of exercise as medicine. Exercise physiologists have known
for decades that exercise helps with controlling and/or modifying risk
factors for different diseases, including but not limited to heart disease,
diabetes, and osteoporosis. Apparently, the board members of PSM
have come to the same conclusions . I believe that there is a
downside to this thinking, especially since it may have a direct impact
on the practice of exercise physiology.
It should be clear among healthcare
professionals that exercise physiologists advanced the concept of exercise
prescription. Pollock’s work in the late 1960s and early 1970s (and
even years thereafter) demonstrated the role of exercise physiologists
in prescribing exercise based on heart rate intensity, duration, and frequency
[6, 7]. His research helped to advance the concept of exercise
prescription to realize significant physiological benefits. In the
1970s several of my students and I published papers about the physiological
changes that associate with rehabilitation and the exercise prescription
of cardiac rehabilitation patients [8-10] We also researched the
importance of an accurate heart rate from carotid palpation .
If the technique is not accurate, then the prescription will not be correct
either. Naturally this would be a problem of considerable magnitude.
This is why exercise physiologists have carried out volumes of research
in this area. This kind of thinking has somehow been missed or overlooked
by other professionals. This tells me that something is wrong.
Also, why has the PSM definition of sports medicine changed four times
“I think of sports medicine as having
four major aspects, only one of which is the medical supervision and care
of recreational and competitive athletes. The second aspect is the
use of exercise and sports for people who are physically or mentally handicapped.
The third aspect is helping people to develop and maintain physical fitness.
The fourth aspect is the use of exercise to treat and rehabilitate people
who have been ill or injured.” – Allan J. Ryan, MD, first editor-in-chief,
“Sports medicine is practiced in
a number of venues by clinicians with overlapping but distinct areas of
expertise. What ties the field together is its focus on a health model
of medicine. As such, in addition to the care of athletes – their
injuries, safety, and general health – sports medicine embraces preventive
medicine, the role of exercise in the treatment of disease, and the underlying
science of function and performance.” -- Gordon O. Matheson, MD,
PhD, 1999 
The addition of “…the underlying
science of function and performance” to the 1992 and 1998 definitions is
a distinct difference to the most recent 1999 PSM definition of sports
medicine. Why is this important? Perhaps, part of the reason
lies in the following statement: “Being a sports medicine physician
means having diverse practice skills, and we at PSM want to help you expand
your professional skills by helping boost your financial as well as your
clinical acumen” .
This is a very surprising statement,
particularly with its emphasis on “financial”. Also, referring to
sports medicine achievements in arthroscopic surgery in the same breath
with advances in the effects of ergogenic aids and strength building and
exercise prescription programs without acknowledging exercise physiology
is misleading. Instead of asking what do the upcoming years hold
for sports medicine, the question should be: “What do the upcoming years
hold for exercise physiology?” With its origin in physical education
, exercise physiologists have known for decades the importance of defining
the exercise physiology scope of practice. However, by not making
the scope of practice known among researchers and healthcare practitioners,
practitioners from other fields of study seem to believe they are responsible
for the development of the exercise physiology body of knowledge.
The use of exercise as exercise physiology
healthcare professionals is an evolving field. It is not medicine,
and it is not sports medicine. The goal is to zero in on academically
accredited university exercise physiology programs that link directly to
the ASEP Board Certification and the professional title, Exercise Physiologist.
The use of exercise in the healthcare setting ought to be recognized from
the standpoint of the exercise physiology, not sports medicine. This,
I believe, is critical to the professional development of exercise physiology.
Hence, the take home message is that exercise physiologists ought to be
consulted when discussing and/or promoting cardiovascular or aerobic fitness
programs. Similarly, when prescribing exercise, when using exercise
in health enhancement, maintenance, and rehabilitation, and when describing
exercise programs for athletics, exercise physiologists should be consulted.
I am dumb-founded to realize that this is not the case with many practitioners.
In other words, the defining, measuring,
and quantification of exercise (with various ergometers and exercise machines)
should employ the academic training of exercise physiologists. Further,
when describing the different sources of energy for different kinds of
exercise, exercise physiologists should be consulted. Still further,
when requesting an understanding of how exercise is prescribed (particularly,
strength vs. aerobic exercise), the qualified professional ought to be
the exercise physiologist. And, yet not once did Knuttgen  identify
or associate an exercise physiologist with the previous content information.
The online article, What Is Exercise? A Primer for Practitioners
fails to identify the “practitioners”. Worst yet, the author does
not use the “Exercise Physiologist” title at all in the 11-page article.
Since the author is the Exercise Physiology Series Editor of PSM, one can
only conclude that the article is written for sports medicine professionals.
By not connecting the exercise physiology content with the exercise physiology
title, there is no reason for anyone to look to the exercise physiologist
as the healthcare professional with specific academic training in those
areas. This is a problem that needs correction.
Some people might say that I am making
too much of this point. Many different professionals have the capacity
to express their unique academic skills and hands-on talent in their own
unique way. Those individuals who experience the greatest joy in
sports are likely to recognize the seed that it nurtures in creating a
distinctive lifestyle. At least this is how I would like to think.
Each of us however understands the unfolding of the healthcare dimension
to shaping a financial base. To reach out to serve the public is
an extraordinary gift to help. The reality is that healthcare costs
are rising. It does not take a scientist to figure out that different
forms of medicine, even if un-researched, may be allowed and encouraged
without proven benefits. The challenge is to make sure that the healthcare
professionals have credible, critical thinking skills based on proven scientific
method and academic course work.
Steve “Mississippi” Brock, the Ph.D.
exercise physiologist who is a successful entrepreneur, put it this way:
“There are many kinds of healthcare professionals. There are physical
therapists, occupational therapists, nurses, dietitians, physician assistants,
and others. The recognized healthcare professionals are those who
understand the importance of their own professional organization.
They understand risk taking with the American Society of Exercise Physiologists.
To be a member is to risk being defined as an ASEP exercise physiologist.
To speak positive about ASEP is to risk a startling difference from the
sports medicine sentiment. To reach out for others to join the ASEP
organization is to risk not being asked to join sports medicine. To place
the ASEP ideas and dreams before other exercise physiologists is to risk
losing friends. To share the ASEP vision is to risk not being embraced
by sports medicine colleagues. To hope for something better is to
risk losing everything. But risk is exactly what we must do if we
are to realize the unlimited creative career opportunities in exercise
Without exception, if we really believe
in the ASEP reality, it will guide us to a better future than we might
have otherwise experienced. Put another way, the possibilities we
imagine as experts in the workings of exercise and the ever-emerging reality
that exercise is medicine are endless. We must therefore see the
practical necessity of the connectedness between exercise prescription,
human performance, and exercise physiology. This brings me
back to the theme of this article. That is, exercise physiologists
have developed concrete scientific evidence of the connection between exercise
and lifestyles. This connection should be our reason for thinking
we are experts in the powerful reality of our profession as exercise medicine.
Any person who wants to immerse him- or herself in the exercise-medicine
connection should abandon the 20th century notion of exercise physiology
and sports medicine and start reconstructing the foundations of a personal
and professional organizational commitment of exercise physiology as healthcare
professionals under the responsibility of the American Society of Exercise
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