The future exercise professional will have to have a certain level of academic preparation, and will need at least one type of fitness certification in order to practice their craft. Some outside the fitness industry suggest that exercise instruction by its nature contains a certain amount of risk to the general public by practicing what is essentially an adjunct health trade with no entry level competency. Within the next 3-5 years, there will be mandatory certification within the field, and it will be looked upon favorably by the industry, the medical profession, and the public at large. Why? Because certification and continuing education gives credibility to any profession where health issues are concerned. People know that physicians and nurses all take continuing education courses. By having a system of continuing education in place for the fitness profession, the public has a sense of assurance that quality is maintained.

Future Implications:
Within the next decade, all fitness professionals will be required by their profession, or state law, to be certified by one or more agencies. Although this will never insure total quality, it will bring the profession up to standards with other allied health professions.

Paradigm 4: IDENTIFY OUTCOMES MEASUREMENTS FOR HEALTH PROMOTION SERVICES
Outcomes measures is the buzzword for rehabilitation in the '90's. Outcomes may be described as applying improvement measures (either by statistics, or temporal trends) to elements of patient care. How did their weight change each month? What were their changes in blood pressure after each yoga class? The numbers are the crucial factors in helping to show the importance of any exercise program on certain physical functions. It is the way rehab specialists will receive reimbursement money in the future. It is also something that the fitness industry must learn quickly if they are to compete in tomorrow's marketplace. In rehab, outcomes represents getting the patient back to functional status in a reasonable time frame. For health promotion and therapeutic exercise, the outcomes may be very different. An example would be treating a patient with a knee injury, which may take 6-10 visits to orthopedic rehab. A weight management patient with yo-yo diet syndrome may need a year's worth of services from a dietitian, exercise specialist, and counselor in order to facilitate emotional growth, and a long-term weight loss. Outcomes must be based on the patient's ability to stick with the program (detailed below), and their improvement at specific intervals during the regime.

Future Implications:
Why are outcomes important to consumers? There is a feel with many insiders that many types of rehab programs are too expensive (an average visit to the physical therapist is $100.00), and may not be that effective. Historically, many rehab practitioners have not had to show success with their programs. With the advent of managed care contracts, all health care practitioners will be required to provide proper outcomes for their services. This is the highest level of quality assurance that any consumer can expect.

Paradigm 5: STANDARDIZE ASPECTS OF EXERCISE PROGRAMMING
Is strength training good for cardiac patients? Can osteoporotic women engage in vigorous water workouts? What is the difference between mall walking and treadmill exercise?

Fitness is many things to many people. And for the most part it should be that way. In order to work successfully with the health care industry, the fitness profession should at least have some basic way of performing its functions for specific medical patients. This may entail having a general outline for exercise programs for each type of medical condition served. It starts with an evaluation. The basic aspects of exercise should be outlined for specific medical conditions. An example would be a program for adult onset diabetic patients. The goal is weight loss and metabolic control (reducing blood sugar and lipid levels). If these goals are achieved through a 3 day per week health club membership, or a 6 day per week home walking and stretching program, its not important as the overall physical and psychological results. However, since the goal is better metabolic control, the structure of the program should be fairly constant. An example is:

1. Assessments (pre program)
2. Supervision (at every session)
3. Regular monitoring (blood pressure, blood sugars, body weight, body fat, heart rate, etc.)
4. Program compliance (maintaining regular workouts)
5. Follow-up assessments

Paradigm 6: UNDERSTAND EXERCISE AS PART OF AN HOLISTIC APPROACH TO HEALTH AND WELLNESS
In 1994, American Western Insurance Company started offering insurance premiums for alternative therapies for patients. Some of these practices include: Acupuncture, Ayurvedic Medicine, Homeopathics, massage, Midwifery, Reflexology, Trager Work®, Wellness Medicine, and yoga (Firshein). This type of insurance reimbursement is a giant step forward in thinking towards insurance, physician gatekeepers, and what constitutes a medical necessity.

Exercise may be the critical link between alternative therapies and conventional medicine. The reason for this is in research. For the past 40 years, exercise physiology research has crossed over into general medicine, epidemiology, molecular biology, and a host of other areas. It has strengthened the relationship between regular physical activity and longevity, reduction of disease risk, increase in the quality of life, and reduction in economic costs associated with a sedentary lifestyle.

Although exercise has formed a close link with medicine and the medical way of research, exercise is still part of the health model, and views the body not by segments (medical viewpoint), but as a whole (holistic viewpoint).

It should be remembered that a patient who is in treatment for a specific condition (high blood pressure), will receive a total exercise package designed not just to reduce blood pressure, but to reduce body weight, teach proper exercise performance, posture enhancement, and lifestyle management. Exercise may be the liaison between the allopathic and holistic communities if in the next few years the numbers of people who participate in exercise increase.

Paradigm 7: HEALTH PROMOTION MUST NOT REPEAT THE SAME MISTAKES AS THE CURRENT MEDICAL PROFESSION
In his 1993 article, LaForge points out three areas of the current health care system that have contributed to rising health costs, and a decrease in the quality of care. They are listed as the three "O's":

• overspecialization. In the past 15 years, the amount of medical specialists has grown more than the per-capita population. This has created a glut of services in areas where the niche may not be large enough to fill. One in particular is the orthopedic surgeon who only performs knee or shoulder surgery. This type of practice has diminished the role of the family practitioner (both medically and financially), and has shifted the emphasis of medicine from hands-on patient care, to high technology procedural care.

  At the present, there is no such thing as a "specialist' in the exercise profession. Some may have training in cardiac rehab, or work hardening, but the basic principles of exercise are universal, and most exercise professionals have the ability to work with a wide variety of fitness conditions.

• overbuilding. It is not uncommon to see construction happening at many hospitals in any given city in the US. This may not be as applicable to the exercise profession as the other components of the three "O's", but it may serve as a guide post as to the fact that many hospitals have forced layoffs of employees, and had a resurgence of building happen.

• overspending. This may be the biggest area of health care cost inflation. In many areas, new MRI machines have dictated a portion of the clinic or hospital's costs in hopes of recouping that investment within one or two years of continued service. According to Payer, this has led to efforts at cost controls (in the form of DRG's), and have even changed the way physicians diagnose disease.

  There is a tendency to think that if the fitness industry could become more high-tech and have in increased sophistication, it may attract more members to its clubs, and increase its market share overall. This is not true. Historically, those who provide the best service, and the best results to clients in fitness and health programs have been, and will continue to be successful in attracting new types of clients and programs to their businesses.

Paradigm 8: REMEMBER THAT FITNESS IS A SERVICE INDUSTRY
Where health promotion and fitness differ from medicine is that, in most instances, the member never leaves a health club with anything tangible in their hands (unless it is a protein bar). This is because exercise has never been a drug, and it can never be accurately measured in terms of its total effects. Therefore, the professional must keep in mind that in the future they must promote and provide health and fitness programs that will do what they proporte to do - lose weight, improve sports performance, help increase functional strength, among others. Since the product is not tangible, and the effects are transient, then it is only through diligence and perseverance that people make and keep the gains that they have worked for during their program's tenure. This leads us to the next trend.

Paradigm 9: KEEP PARTICIPANTS ADHERANT TO LONG-TERM EXERCISE PROGRAMS
One reason that over 90% of weight loss programs fail to maintain results with clients is that they provide services for patients at the onset, and the follow-up is minimal. Education and handouts for a 10 week program will not help with questions and motivational lapses at 35 weeks.

The new element in the profession of fitness is to make sure that patients keep on track with their exercise programs. This entails having a quality program for them to attend in the first place - good instructors, an element of fun, able to see some short term results, and personal attention. Also, it is up to the instructor to make sure that patients are called on the phone if they miss a few sessions, or arrangements are made for exercise instruction during vacations and business trips, and everyone who is part of a fitness program, be they seniors, or new mothers, or cancer patients, receives an element of permanence to their participation. This will be key to the success of all future health and exercise programs within the health club industry. An important element of adherence was discussed by Funnel (1991) in her article on diabetes patient empowerment. Her message confirms that when patients/clients are given their share of the responsibility for their own health care, they will do better over the long run vs. patients/clients who have little to say in their medical and health decisions. If this philosophy is applied to exercise programs, clients will (after a period of instruction), become part of the health team, and hopefully they will have acquired the skills to continue exercise and health habits even when they are not exercising at the club.

Paradigm 10: READ CHANGES IN MEDICINE, BUSINESS AND HEALTH, AND PREPARE FOR THEM.
The last, and perhaps the best forecast that consumers need to see happen for the fitness profession is that they should be looking at the current trends in health care. Futurist John Naisbitt recently wrote that wellness programs may have a tremendous cost-savings for American citizens. Therefore, the influx of these types of programs into hospitals, health clubs, and rehab facilities seems a logical extension of a cost savings plan.