Historical perspective: Research supporting Exercise is Medicine in Canada
July 5, 2017
A look back: Exercise Physiology and CSEP's first 50 years
The Canadian Society for Exercise Physiology will be celebrating its 50th anniversary in 2017.
A signature initiative is a celebration of the contributions of Canadian researchers to exercise physiology over the past 50 years. The objective is to highlight significant Canadian contributors and their contributions to exercise physiology, health and fitness, nutrition and gold standard publications globally as well as provide insights on future research directions in these areas. These achievements have been organized into a series of short historical communiqués on prominent Canadian contributors and will be published on a monthly basis.
Historical perspective: Research supporting Exercise is Medicine in Canada
Brian R MacIntosh, Faculty of Kinesiology, University of Calgary, Calgary, Alberta
Sue Boreskie, CEO, Reh-Fit Centre, Winnipeg, Manitoba
Robert J Petrella MD, PhD, FACP, FACSM Family Medicine and Kinesiology Schulich School of Medicine and Dentistry and the Faculty of Health Sciences, Western University, and Medical Director, Canadian Centre for Activity and Aging, London, Canada.
Kaberi Dasgupta, Dept of Medicine, McGill University, Montreal, Quebec
Jonathon Fowles, Dept Kinesiology, Acadia University, Wolfville, Nova Scotia
“Exercise is Medicine” (EIM) is an initiative of the American College of Sports Medicine, started in 2007 in partnership with the American Medical Association. The basic goal of this initiative is to get more people physically active to improve health outcomes. The primary method of facilitating this important lifestyle change in individuals is to promote engagement of health care professionals in assessing current physical activity levels and prescribing physical activity for their patients or providing referrals to qualified exercise professionals for further support and programming. An integral part of this initiative is to engage exercise professionals in the mission to have physical activity and exercise an essential component of health care.
The Canadian Society for Exercise Physiology (CSEP) made the decision to bring EIM to Canada in 2011 and hosted the first Task Force meeting in May, 2012 (Table 1). However, Canadians were contributing to the research that forms the basis of this initiative long before this and continue to do so now (See Table 2). Here, we present some key Canadians who contributed substantially to our knowledge of the importance of physical activity to health. We also present some current Canadian research contributions that support increased physical activity as a medical and preventative treatment and successful means of accomplishing this daunting task. This is not meant to be an all-inclusive review, but a sampling of the kind of contributions Canadians are making to the effort to make a healthy world population.
Canadian Researchers Contributed to the Foundation of EIM
The historical development of “Exercise is Medicine” relies on strong research demonstrating the health value of doing regular exercise as well as demonstration of successful interventions that will engage a substantial portion of the population. In the first instance, the research is incontrovertible and Canadians have contributed substantially to this. In the second instance, there is a long history of exercise for cardiac rehabilitation and Canadians have also contributed substantially to this body of knowledge. Table 2 presents a list of CSEP Presidents who have made substantial contributions to this research effort. Highlights of these contributions are described here.
Roy Shephard is probably the most prolific exercise physiologist in Canada with no less than 790 publications yielded on a Medline search. His research on the importance of physical activity for health represents pioneering work that included the estimation that prevention of chronic disease by increased physical activity could slow the increase in health care costs. He designed fitness tests and training for the military and provided translation of that work to the general population as well as for special populations including: First Nations, physically challenged individuals, children and the aged. A list of accomplishments and corresponding references would not fit within the length of this paper, so a few examples are presented in Table 3.
Shephard was not the only Canadian exercise physiologist who paved the way for Exercise is Medicine. Don Bailey pioneered work on exercise in the treatment of osteoporosis, long before this became a popular topic. David Cunningham contributed extensively in research on exercise for cardiac rehabilitation patients. With Peter Rechnitzer, Cunningham founded the Canadian Centre for Activity and Aging at Western University. Epidemiologist Claude Bouchard published convincing evidence for the health benefits of exercise and investigated the genetic influence on the response to exercise training. Peter Katzmarzyk has also made a substantial contribution with epidemiological assessment of risk for chronic disease associated with inactivity. Don Paterson extended the work of Cunningham studying physical activity for the elderly and contributed to the 2007 update of the Physical Activity Guidelines. Marc Tremblay has studied pediatric exercise physiology, and spearheaded the development of the expanded Canadian Physical Activity Guidelines for the Canadian Society for Exercise Physiology. With this historical background, it is not surprising that research supporting Exercise is Medicine continues to this day in Canada.
Current Research Supporting EIM
The following is a sample of specific recent research conducted in Canadian institutions. Drs. Robert Petrella, and Kaberi Dasgupta were already conducting this work when CSEP brought Exercise is Medicine to Canada. Their work will help support the work of EIMC.
More people are living longer with chronic diseases, such as type 2 diabetes and cardiovascular disease. This is coupled with rising health expenditures to treat chronic diseases – costing the Canadian economy $190 billion annually (Elmslie, 2012). Chronic diseases are driven by modifiable lifestyle risk factors (including physical inactivity), which if reduced, could prevent or eliminate most chronic diseases and their complications (Organization, 2005). A Conference Board of Canada report (2014) estimates that getting as little as 10% of Canadians who currently have suboptimal levels of physical activity to exercise more will reduce health care spending for chronic diseases by $2.6 billion by 2040. Despite unequivocal evidence that decreasing these risk factors, including physical inactivity, can reduce chronic diseases, effective methods for implementation of risk-reduction strategies requires further exploration (Compernolle et al., 2014).
As a family physician and exercise science researcher, Dr. Petrella was intrigued that while family physicians believe lifestyle is core to chronic disease risk reduction, few physicians actually prescribe exercise or refer their patients to other qualified providers (Petrella et al., 2007). Dr. Petrella developed the first primary care physical activity intervention (Petrella et al., 2003) that was endorsed by the College of Family Physicians of Canada showing that while family physicians were able to increase physical activity among their patients, systemic factors limited more general adoption and sustainability of behaviour change(2003). In response to this outcome, Dr. Petrella led a 5-year multi-partner and multidisciplinary team (ARTEMIS) in Canada and Finland to determine how to develop, deliver, and extend the reach of lifestyle interventions; specifically to prevent type 2 diabetes and cardiovascular disease (Noble et al., 2013). This program of research showed that physicians and their staff could provide patient coaching imbedded in practice using pragmatic existing workflows and resources as well as innovative technologies (eLearning coach training, smartphone app (available on the Apple Store and Google Play Store), web portal, podcasts and blogs) to extend the reach of this research to those at risk wherever they were and whenever they wanted it. With this evidence, Healthesteps.ca was created see: www.healthesteps.ca). This signature initiative of Canada’s Diabetes Strategy was funded by the Public Health Agency of Canada with focus on delivery to vulnerable groups including older adults, rural, remote, Indigenous peoples and men.
Dr Petrella and his team recognized the reluctance of men to engage in healthy lifestyle and weight loss programs (Gavarkovs et al., 2015) which may reflect the fact that overweight men tend to be less aware than women of their overweight status (Sabinsky et al., 2007) and tend to associate increased body size with muscularity and masculinity (Stibbe, 2004). With funding from the Movember Foundation and a mobilizing a cadre of Canadian and European investigators, Dr Petrella recently launched a program called Hockey Fans in Training.org (Hockey FIT) which uses the power of being a fan of Major Junior Hockey teams in Canada, to bring overweight and obese men together in a male-friendly space to get fit, eat better, and lose weight (Gill et al., 2016a). This program saw successful 12 week weight loss of 8 pounds (Petrella et al., 2016) and included improvement in other important health behaviours, including physical activity (Gill et al., 2016b). This program used a pragmatic approach that is scheduled to expand to a 32-site definitive randomized controlled trial in partnership with the Canadian Hockey League, YMCA Canada and others.
Among older Canadians, risk of dementia has become a significant social, health and economic priority. As Medical Director for the Canadian Centre for Activity and Aging at Western University, Dr Petrella, his team and others reported a lack of consensus regarding optimal preventive and management exercise or cognitive training programs for the prevention of dementia (Gregory et al., 2013). In response, Dr Petrella and his team of Canadian and Japanese collaborators developed and launched the HealtheBrain program (Gregory et al., 2016a)(Gregory et al., 2016a)(Gregory et al., 2016a)which uses an innovative “mind-motor” exercise program for older adults (complex walking patterns) train the mind and the body; the program can be delivered using the HealtheBrain Smartphone app (available for Apple and Android devices) or it can be incorporated into the HealtheSteps program. Improvements in measures of cognitive function, vascular health, mobility and underlying brain pathways (Gill et al., 2016c; Gregory et al., 2016b; Heath et al., 2016; Silva et al., 2016) will further expand the evidence for physical activity in this condition for a large and growing population at risk.
Dr. Petrella’s research program is driven by the needs and preferences of Canadians to maintain good health and improve chronic disease risk factors at the points of care in which they live and work. His approach is supported by culturally and gender sensitive and accessible programs, tools and innovative technologies. Exercise is Medicine Canada will be paying attention to take advantage of this important work.
Notable Achievements in Lifestyle/Chronic Disease Prevention
- Conducted the largest survey of family practice lifestyle management (Petrella et al, Arch Intern Med, 2007)
- Developed the first prescriptive exercise & counseling program (STEP) for family physicians in Canada (Petrella et al., Am J Prev Med, 2003) – recognized as best paper and endorsed by the College of Family Physicians of Canada, and -disseminated to clinical settings across Canada and abroad.
- The ARTEMIS Team grant led to a number of papers that provide the foundation for this application (e.g., Stuckey…Petrella, BMC Public Health, 2013; Petrella et al., BMC Public Health, 2014; Stuckey…Petrella, J Clin Hyperten, 2015).
Dr. Kaberi Dasgupta is a Physician Scientist whose research examines ‘step counts’ in terms of predictors, impacts, and interventions; specifically, ‘step count prescriptions.’ The concept of ‘step count tracking’ owes much to public health messages in Japan in the 1960s that encouraged the accumulation of 10,000 steps/day. Canadian researcher Dr. Catrine Tudor-Locke developed the ‘First Step Program’ in the late 1990s and early 2000s; this was a group-based strategy that encouraged patients with type 2 diabetes to set goals and track their steps (Tudor-Locke et al., 2004). A 2007 JAMA review (Bravata et al., 2007) demonstrated that group-based interventions could increase step counts by an average of 2,000 to 3,000 steps/day.
In a Lancet publication, Yates and colleagues demonstrated that among adults with prediabetes, both a 2,000 steps/day baseline increment and an equivalent 1-year increase were respectively associated with a 10% and 8% reduction in vascular disease events such as heart attack and stroke at a mean follow-up of 6 years (Yates et al., 2014).
Actually, achieving higher step counts, however, remains challenging, particularly in sedentary adults with type 2 diabetes and/or hypertension. Dasgupta and colleagues have demonstrated, for example, that neighbourhoods with improved walkability are associated with higher within-neighbourhood physical activity levels for patients with type 2 diabetes but not with higher overall activity levels (Hajna et al., 2016). This study used geographical positioning systems technology with integrated accelerometers (physical activity monitors), geographical information systems, and digital maps. Furthermore, analysis of Canadian Health Measures Survey data did not demonstrate higher step counts in participants living in more walkable neighbourhoods, even though their self-reported utilitarian walking was higher (Hajna et al., 2016). This in particularly interesting in light of work showing BMI reductions with moves from low to high walkable neighbourhoods as well as BMI increases with moves from high to low walkable neighbourhoods (Wasfi et al., 2016) higher step counts in more walkable neighbourhoods in Europe and Japan; and studies by Booth and colleagues indicating lower incident diabetes in more walkable neighbourhoods (Creatore et al., 2016). The mechanisms underlying the impacts of walkability remain to be clarified.
In terms of intervention studies, Dasgupta leads the ‘Step Monitoring to improve ARTERial health SMARTER’ trial that is evaluating the impact of physician-delivered step count prescriptions on steps and cardiometabolic risk factors in type 2 diabetes and/or hypertension over 1 year (Dasgupta et al., 2014). This trial, funded by the Canadian Institutes of Health Research, demonstrates that a physician-delivered step count prescription strategy leads to higher step counts, better glycemic control, and lower insulin resistance in patients with hypertension and/or type 2 diabetes. The findings have been published in the journal Diabetes, Obesity, and Metabolism (Dasgupta et al., 2017). In this randomized controlled trial that included 369 patients with type 2 diabetes and/or hypertension, participants in the active treatment arm received a pedometer, log book, and step count prescriptions from their treating physicians 3 to 4 times over a 1-year period. They reviewed their log books at each visit, set goals, and formalized these through a step count prescription, signed by their doctor. The control arm visited their physicians at a similar frequency and received general advice to be active. By the end of the trial, participants in the active arm were completing 1,200 more steps/day than in the control arm, a 20% increase over baseline levels. Those with type 2 diabetes had a 0.4% reduction in haemoglobin A1C levels, a measure of glycemic control. Supervised exercise programs are typically associated with 0.6% reductions and oral antihyperglycemic medications reduce A1C by 0.5% to 1%. In participants not on insulin, the SMARTER intervention led to a 1-point greater reduction in HOMA-IR (insulin resistance) in the active vs. control arm. This is the first trial to demonstrate behavioural and biological impact of a physician-delivered step count prescription.
Training Health Care Professionals
In 2005, Jonathon Fowles began a 10-week exercise program for people with diabetes at the local hospital, based on a familiar model of ‘cardiac rehab’ including resistance and aerobic exercise. This initiative had tremendous success in producing positive outcomes for patients (Riddell & Fowles, 2010). As a consequence, Dr. Fowles was contacted by the Diabetes Care Program of Nova Scotia and was asked to develop a physical activity and Exercise resource to assist Diabetes Educators throughout the province in physical activity counseling and Exercise recommendations. The ‘Diabetes Physical Activity and Exercise Toolkit’ was developed and disseminated throughout the province, complete with training workshops to support implementation (Fowles & Shields, 2011). The Lawson Foundation, funded evaluation of the effectiveness of these workshops for diabetes care professionals (typically nurses and dietitians). Results for improving confidence, prescription practice and perceptions toward physical activity counseling have been published (Dillman et al., 2010) (Shields et al., 2013). It was also demonstrated that brief counselling using the strategies employed in the workshops and outlined in the Diabetes Physical Activity Toolkit were effective at increasing patient physical activity and exercise behaviour (Fowles et al., 2014a). What was also evaluated in this work, was that clinical outcomes were significant when an exercise professional was integrated into the diabetes care and provided instruction to patients (Fowles et al., 2014b). The success of this initiative – to train diabetes care providers in PA counseling – was underscored when the toolkit and workshop training strategy was signed over to and endorsed by the Canadian Diabetes Association in 2012 (Fowles et al., 2012) to make physical activity and exercise a key component of diabetes education in Canada. Over 1500 diabetes care providers were trained in the workshops and practice around physical activity counseling has changed dramatically since the initial inception in 2008 (Gray et al., 2017).
The work in diabetes care was being nationally implemented with the Canadian Diabetes Association at the time when the Canadian Society for Exercise Physiology was bringing Exercise is Medicine to Canada. As a primary focus of the Exercise is Medicine initiative is to train primary care providers in physical activity counseling and exercise prescription, the work from the diabetes initiative was a great foundation to develop full day workshops to train primary care providers to prescribe exercise. Once again, the Lawson Foundation stepped forward to fund workshops across the country. Over 500 medical professionals were trained in full day EIMC workshops. Presentations were delivered to over 2500 health care providers in 1 hour medical rounds and conference presentations. The workshops present the evidence that Exercise is Medicine, address the challenges for physical activity counseling in a time pressured primary care environment using brief counseling and motivational interviewing framework, and also address some introductory specifics around aerobic exercise prescription and monitoring and basics of resistance exercise. Modifying recommendations for different chronic conditions and information on referral to exercise professionals are also key components of the EIMC workshops. It was clear from this work that physicians and other allied health professionals have low confidence and face many barriers to do physical activity counselling and exercise prescription in practice. Evaluations of the effectiveness in changing practice are in progress, but preliminary findings demonstrate that the workshops: increase provider confidence, reduce barriers to counsel on physical activity and increase intentions to prescribe in practice (O’Brien, 2016). The 3-month follow-up from the workshops also indicate that physicians who attend the workshops report 20-25% improved confidence and this confidence translates to greatly increased proportion of physicians that complete exercise prescriptions in most appointments (Fowles et al. 2015, 2016 abstracts). It is clear that physical activity counseling and exercise prescription should be integrated into medical school curricula and should continue to be offered as a professional development topic for the ongoing support of addressing physical activity and exercise as a primary therapeutic agent for the prevention and treatment of chronic disease within the Canadian health care system.
A Medically Certified Fitness Centre
Sue Boreskie is Chief Executive Officer of the Reh-Fit Centre in Winnipeg and is a Certified Exercise Physiologist. She is a strong proponent for Exercise is Medicine. Sue Boreskie describes the Reh-Fit Centre, Canada’s first certified medical fitness facility, as a Centre that could provide the template for facilities across the country to help them achieve the goals of EIMC.
The Reh-Fit opened in 1979 in Winnipeg, Manitoba to enhance the health and well-being of its members and the community by providing innovative health and fitness services through assessment, education, and exercise in a supportive environment. Since then the Reh-Fit Centre has helped build community health by encouraging thousands of clients to develop and maintain healthy lifestyles to improve quality of life and longevity while relieving pressure on our healthcare system.
The concept started in the 70’s when a cardiologist at St. Boniface Hospital realized that it did not make sense to have his patients bedridden. He started exercising his and other physicians’ patients in the stress lab at the hospital Interest in the initiative grew quickly and they soon needed to find another place to exercise. They moved to the basement of the University of Manitoba Frank Kennedy Building, known as the “Gritto Grotto”. Later this group of patients fundraised and built what is now known as the Reh-Fit Centre. It was the first community-based cardiac rehabilitation program in the country.
The current Reh-Fit Centre continues to operate with an interdisciplinary collaborative team that takes referrals from the health care community and also communicates with the individual’s primary care provider. It has also allowed anyone in the community to join in order to maintain good health and fitness. The same concept of exercise as the prescription has been adapted for many other chronic conditions e.g. stroke, cancer, falls prevention, Parkinson’s, and diabetes to name a few. The Reh-Fit Centre has formed partnerships with local health care organizations to deliver services and works with researchers to expand the knowledge associated with exercise as a key factor for good health.
What began as a realization that bed rest was not the answer has become the widely accepted notion that exercise is both a preventative measure against disease and a medicine for most types of chronic diseases.
The current CEO of the Reh-Fit Centre, Sue Boreskie, heard keynote speaker Dr. Eddie Phillips speak on a new initiative that the American College of Sports Medicine had created, “Exercise is Medicine”. What was described in the presentation was what the Reh-Fit had been doing, but now it had a name. It was an easy decision that Reh-Fit needed to help spread this message.
In November 2010, The Reh-Fit Centre became a member of the Exercise is Medicine network. After meeting Dr. Phillips at the conference, Sue Boreskie invited him in May 2011 to work with the Reh-Fit staff team and to meet with health care personnel in Manitoba. This began a dialogue on bringing the principles behind Exercise is Medicine to all of Manitoba. Through newsletters, annual reports, a website, and other informational resources, we have continued to stress that physical activity in the right dose is unparalleled in its ability to prevent and treat chronic disease. We supplied physicians with posters, brochures, and referral pads encouraging them to provide their patients with physical activity prescriptions for maintaining and improving their health – prescriptions that can be filled at the Reh-Fit Centre if guidance and support were needed.
In May 2012, Reh-Fit achieved recognition by the Medical Fitness Association as Canada’s first Certified Medical Fitness Facility. The hope was that this outside review and certification would give Manitobans the confidence they need to come to the Reh-Fit for a new prescription for health. Ms. Boreskie subsequently learned that the Canadian Society for Exercise Physiology was starting an advisory committee to deliver EIM throughout Canada. Sue proudly sits on the advisory committee today, helping build the capacity to implement initiatives to get people active across the country.
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Fowles JR, Shields C, d’Entremont L, McQuaid S, Barron B & Dunbar P. (2014b). Implementation of Resources to Support Patient Physical Activity through Diabetes Centres in Nova Scotia: The Effectiveness of Enhanced Support for Exercise Participation. Canadian Journal of Diabetes 38, 423-431.
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Gavarkovs AG, Burke SM & Petrella RJ. (2015). Engaging Men in Chronic Disease Prevention and Management Programs: A Scoping Review. American Journal of Men's Health.
Gill DP, Blunt W, De Cruz A, Riggin B, Hunt K & Zou G. (2016a). Hockey Fans in Training (Hockey FIT) pilot study protocol: A gender-sensitized weight loss and healthy lifestyle program for overweight and obese male hockey fans. BMC Public Health 16, 1096.
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Gill DP, Gregory MA, Zou G, Liu-Ambrose T, Shigematsu R, Hachinski V, Fitzgerald C & Petrella RJ. (2016c). The Healthy Mind, Healthy Mobility Trial: A Novel Exercise Program for Older Adults. Medicine & Science in Sports & Exercise 48.
Gray E, Shields CA & Fowles JR. (2017). Building competency and capacity for effective physical activity promotion in diabetes care in Canada. Can J Diabetes in press. Apr 5. pii: S1499-2671(16)30522-6. doi: 10.1016/j.jcjd.2016.11.005. [Epub ahead of print]
Gregory MA, Gill DP & Petrella RJ. (2013). Brain Health and Exercise in Older Adults. Current Sports Medicine Reports 12, 256-271.
Gregory MA, Gill DP, Shellington EM, Liu-Ambrose T, Shigematsu R, Zou G, Shoemaker K, Owen AM, Hachinski V, Stuckey M & Petrella RJ. (2016a). Group-based exercise and cognitive-physical training in older adults with self-reported cognitive complaints: The Multiple-Modality, Mind-Motor (M4) study protocol. BMC Geriatrics 16, 1-14.
Gregory MA, Gill DP, Zou G, Liu-Ambrose T, Shigematsu R, Fitzgerald C, Hachinski V, Shoemaker K & Petrella RJ. (2016b). Group-based exercise combined with dual-task training improves gait but not vascular health in active older adults without dementia. Archives of Gerontology and Geriatrics 63, 18-27.
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Heath M, Shellington E, Titheridge S, Gill DP & Petrella RJ. (2016). A 24-hour week multi-modality exercise program improves executive control in older adults with a self-reported cognitive complaint: Evidence from the antisaccade task. Journal of Alzheimer's Disease In press.
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The Inaugural Meeting of the Exercise is Medicine
Canada Task Force
|Ms. Kelly Drager, MSc RD
||Dietitians of Canada
|Jonathon Fowles, PhD
||Canadian Society for Exercise Physiology
|Mr. Len Frank
||Executive Director, Leduc Beaumont Devon Primary Care Network
|Renata Frankovich, MD
||Canadian Academy of Sport and Exercise Medicine
||Ministry of Health, BC
||Public Health Agency of Canada
|Brian MacIntosh, PhD
||Canadian Society for Exercise Physiology
||Canadian Cancer Society, BC/Yukon
|Preston Wiley, MD
||Canadian College of Family Physicians
||Canadian Physiotherapy Association
||Heart and Stroke Foundation of Canada
|Lori Zehr, PhD
||Canadian Society for Exercise Physiology
|Ms. Susan Yungblut
||National Taskforce Exercise Is Medicine
CSEP Past Presidents Making Substantial Contributions to Exercise is Medicine Research
|| Area of Research
||Epidemiology, heredity, risk factors for chronic disease
||Dragonboat paddling for breast cancer
||Fitness, physical activity for older Canadians
||Epidemiology, lifestyle risk of chronic disease
||Fitness, brain health in older Canadians
||Fitness, cardiac rehabilitation, physical activity
||Altitude, metabolism, pulmonary response to exercise
||Exercise in pregnancy
A Partial List of Contributions to Exercise is Medicine by Roy Shephard
and training effect
|(Kavanagh et al., 1983)
||Race and environment affect heart disease
|(Shephard et al., 1976)
|Development of the Canadian Home Fitness Test
|(Kavanagh & Shephard, 1977
||Training and aging
|(Shephard et al., 1981)
||Evaluation of the PAR-Q
|(Shephard et al., 1981)
||Employee fitness programs
Current Membership of the National Advisory Council for EIMC, as of June 1 2017
|| Jonathon Fowles, PhD
|Canadian Academy of Sport and Exercise Medicine
|| Renata Frankovich, MD
|Canadian Chiropractic Association / Royal College of Chiropractic Sports
|| Scott Howitt, CK,
| Canadian Kinesiology
|| Kristin Campbell,
| Canadian Nurses
| Canadian Society for
|| Nota Klentrou, PhD
| Canadian Society for
Psychomotor Learningin Sport and Exercise
|| Michelle Fortier, PhD
| College of Family
Physicians of Canada
|| Tatiana Jevremovic,
| Dieticians of Canada
|| Lindsay Harris, RD
| EIMC on Campus
|| Taniya S. Nagpal,
BHSc, PhD(c) & Jamie Riggs, MD
| Reh-fit Centre
|| Sue Boreskie, MPE,
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