Part I of this two-part introduction to this Special Issue on the practice of physical therapy in the 21st century outlines the epidemiological basis and rationale for evidence-informed physical therapy practice for addressing contemporary health priorities. This evidence emanates from the definition of health by the World Health Organization (WHO) and the International Classification of Functioning (ICF), and WHO and other international databases on the prevalence of lifestyle conditions. Lifestyle conditions include ischemic heart disease, smoking-related conditions, hypertension and stroke, obesity, diabetes, and cancer. Epidemiological data combined with evidence supporting the effectiveness of noninvasive interventions related to physical therapy to address these priorities (e.g., health education and exercise) are highly consistent with the promotion of health and wellness and the ICF. Given their commitment to exploiting effective noninvasive interventions, physical therapists are in a preeminent position to focus on prevention of these disabling and lethal conditions in every client or patient, their cure in some cases, as well as their management. Thus, a compelling argument can be made that clinical competencies in 21st century physical therapy need to include assessment of smoking and smoking cessation (or at least its initiation), basic nutritional assessment and counseling, recommendations for physical activity and exercise, stress assessment and basic stress reduction recommendations, and sleep assessment and basic sleep hygiene recommendations. The physical therapist can then make an informed clinical judgment regarding whether a client or patient needs to be referred to another professional related to one or more of these specialty areas. The prominence of physical therapy as an established health care profession and its unique pattern of practice (prolonged visits over prolonged periods of time) attest further to the fact that physical therapists are uniquely qualified to lead in the assault on lifestyle conditions. Evidence-based physical therapy practiced within the context of epidemiological indicators (i.e., evidence-informed practice) maximally empowers clinicians to promote lifelong health in every person and in turn, the health of communities. This vision of physical therapy's leading role in health promotion and health care in the 21st century holds the promise of reducing the need for invasive health interventions (drugs and surgery). Part II of this introduction describes evidence-based physical therapy practice within this context of evidence-informed practice.

Other than activity and exercise, lifestyle practices such as not smoking and healthy nutrition, well established for preventing and managing lifestyle-related non-communicable diseases (i.e., heart disease, cancer, hypertension, stroke, obstructive lung disease, diabetes, and obesity), are less emphasized in the physical therapy guidelines for addressing chronic pain, e.g., back pain. This state-of-the-art review examines the relationships between lifestyle behaviours and musculoskeletal health, with special reference to chronic pain, and their clinical and research implications. A state-of-the-art review was conducted to synthesize evidence related to lifestyle factors (not smoking, healthy diet, healthy weight, optimal sleep and manageable stress, as well as physical activity) and musculoskeletal health, with special reference to chronic pain. The findings support that health behaviour change competencies (examination/assessment and intervention/treatment) may warrant being included in first-line management of chronic pain, either independently or in conjunction with conventional physical therapy interventions. To address knowledge gaps in the literature however three lines of clinical trial research are indicated: 1) to establish the degree to which traditional physical therapy interventions prescribed for chronic pain augment the benefits of lifestyle behaviour change; 2) to establish the degree to which adopting healthier lifestyle practices, avoids or reduces the need for conventional physical therapy; and 3) to establish whether patients/clients with healthier lifestyles and who have chronic pain, respond more favourably to conventional physical therapy interventions than those who have less healthy lifestyles. Lifestyle behaviour change is well accepted in addressing lifestyle-related non-communicable diseases. Compelling evidence exists however supporting the need for elucidation of the role of negative lifestyle behaviours on the incidence of chronic pain, and the role of positive lifestyle behaviours on its incidence and effective management. Addressing lifestyle behaviour change in patients/clients with chronic pain, e.g., back pain, as a first-line intervention might not only constitute a novel approach, but also reduce the socioeconomic burden related to chronic pain as well as non-communicable diseases.

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 contemporary 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 compared 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.

The First Physical Therapy Summit on Global Health was convened at the 2007 World Confederation for Physical Therapy (WCPT) Congress to vision practice in the 21st century and, in turn, entry-level education and research, as informed by epidemiological indicators, and consistent with evidence-based noninvasive interventions, the hallmark of physical therapy. The Summit and its findings were informed by WHO data and validated through national databases of the countries of the five WCPT regions. The health priorities based on mortality were examined in relation to proportions of physical therapists practicing in the areas of regional priorities and of the curricula in entry-level programs. As a validation check and to contextualize the findings, input from members of the 800 Summit participants was integrated and international consultants refined the recommendations. Lifestyle-related conditions (ischemic heart disease, smoking-related conditions, hypertension, stroke, cancer, and diabetes) were leading causes of premature death across regions. Contemporary definitions of physical therapy support that the profession has a leading role in preventing, reversing, as well as managing lifestyle-related conditions. The proportions of practitioners practicing primarily in these priority areas and of the entry-level curricula based on these priorities were low. The proportions of practitioners in priority areas and entry-level curricula devoted to lifestyle-related conditions warrant being better aligned with the prevalence of these conditions across regions in the 21st century. A focus on clinical competencies associated with effective health education and health behavior change formulates the basis for The Second Physical Therapy Summit on Global Health.

Given their enormous socioeconomic burdens, lifestyle-related noncommunicable diseases (heart disease, cancer, chronic lung disease, hypertension, stroke, type 2 diabetes mellitus, and obesity) have become priorities for the World Health Organization and health service delivery systems. Health care systems have been criticized for relative inattention to the gap between knowledge and practice, as it relates to preventing and managing noncommunicable diseases. Physical therapy is a profession that can contribute effectively to patients'/clients' lifestyle behavior changes at the upstream end of prevention and management. Efforts by entry-to-practice physical therapist education programs to align curricula with epidemiological trends toward best health care practices are varied. One explanation may be the lack of a frame of reference for reducing the knowledge translation gap. The purpose of this article is to provide a current perspective on epidemiological indicators and societal priorities to inform physical therapy curriculum content. Such content needs to include health examination/evaluation tools and health behavior change interventions that are consistent with contemporary values, directions, and practices of physical therapy. These considerations provide a frame of reference for curriculum change. Based on 5 years of experience and dialogue among curriculum stakeholders, an example of how epidemiologically informed and evidence-based best health care practices may be systematically integrated into physical therapy curricula to maximize patient/client health and conventional physical therapy outcomes is provided. This novel approach can serve as an example to other entry-to-practice physical therapist education programs of how to align their curricula with societal health priorities, specifically, noncommunicable diseases. The intentions are to stimulate dialogue about effectively integrating health-based competencies into entry-level education and advancing best practice, as opposed to simply evidence-based practice, across professions and health services and to establish accreditable, health promotion practice standards for physical therapy.

Low-grade inflammation and oxidative stress underlie chronic osteoarthritis. Although best-practice guidelines for osteoarthritis emphasize self-management including weight control and exercise, the role of lifestyle behavior change to address chronic low-grade inflammation has not been a focus of first-line management. This paper synthesizes the literature that supports the idea in which the Western diet and inactivity are proinflammatory, whereas a plant-based diet and activity are anti-inflammatory, and that low-grade inflammation and oxidative stress underlying osteoarthritis often coexist with lifestyle-related risk factors and conditions. We provide evidence-informed recommendations on how lifestyle behavior change can be integrated into “first-line” osteoarthritis management through teamwork and targeted evidence-based interventions. Healthy living can be exploited to reduce inflammation, oxidative stress, and related pain and disability and improve patients’ overall health. This approach aligns with evidence-based best practice and holds the promise of eliminating or reducing chronic low-grade inflammation, attenuating disease progression, reducing weight, maximizing health by minimizing a patient’s risk or manifestations of other lifestyle-related conditions hallmarked by chronic low-grade inflammation, and reducing the need for medications and surgery. This approach provides an informed cost effective basis for prevention, potential reversal, and management of signs and symptoms of chronic osteoarthritis and has implications for research paradigms in osteoarthritis.