ped 145 guidelines for exercise testing & prescription · guidelines for exercise testing &...

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EXS 145

Guidelines for Exercise Testing & Prescription

Andrew Weiler M.Ed

MCCD – Adjunct Faculty

SRPMIC – Employee Wellness Supervisor

Pot & Window LLC

10-22-13

Today

How to aid in development of safe exercise prescription/testing?

Absolute & Relative Contraindications

CAD Risk Factor Thresholds

ACSM Risk Stratification Categories

Exercise Testing: Risk & Supervision

AHA Risk Stratification Criteria

Probably not in the Fitness Center?

Blood Pressure

Please be sure to review Box 3-4 (p45) and Table 3.1 (p46)

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Identify and exclude individuals with medical contraindications to exercise

Identify increased risk due to:

Age

Symptoms

Risk factors

Clinically significant disease


Why?

Send for medical evaluation

Possibly including exercise testing

Refer to medically supervised programs

Identify special needs

Educate/council


Especially screen for:

Cardiovascular diseases (name a few?)

Pulmonary diseases

Metabolic diseases

Conditions aggravated by exercise:

Pregnancy

Orthopedic injury

Arthritis

Hypertension

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Screening

Don’t lose your clients (Two ways)

They are inconvenienced by screening

Died because you didn’t screen them.

“Professionally qualified exercise staff refers to appropriately trained

individuals who possess academic training, practical & clinical

knowledge, skills & abilities commensurate with the credentials

defined in Appendix D.”

The professionally guided preparticipation screening process involves: the review of more detailed

health/medical history information and specific risk stratification, and

detailed recommendations for physical activity/exercise, medical examination, exercise testing, and physician supervision.

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Absolute & Relative Contraindications Table 2-2, Box 3-5

Relative: Significantly increased risk for injury with

exercise Risks – benefits carefully considered

Absolute: Very high risk

Benefit > risk is unlikely

Who makes that call?

Personal trainer: Don’t exercise either!

Do you see why this is a reference tool? Major Signs/Symptoms Suggestive of Cardiovascular, Pulmonary,

and Metabolic Disease

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Known Cardiovascular, Pulmonary, and Metabolic Disease An individual has known cardiovascular,

pulmonary, and/or metabolic disease if a physician has diagnosed one of the following conditions:

Cardiovascular disease (CVD): cardiac, peripheral artery (PAD), or cerebrovascular disease

Pulmonary disease: chronic obstructive pulmonary disease (COPD), asthma, interstitial lung disease, or cystic fibrosis

Metabolic disease: diabetes mellitus (type 1 or type 2), thyroid disorders, and renal or liver disease

CAD Risk Factor Thresholds for use With ACSM Stratification Table 2-2

Age: Men > 45 y.o. Women > 55 y.o.

Family History:

MI, coronary revascularization or sudden death in:

Male first-degree relative <55 y.o.

Female first-degree relative <65 y.o.

Cigarette smoking:

Smoker in last 6 months

Exposure to environmental smoke

Hypertension SBP >140 mmHg

DBP >90 mmHg

Anti-hypertensive medication Measurements on > two separate occasions

Sedentary Lifestyle >3 months F: < 3 days

I: < Moderate 40-60%VO2R

D:< 30 minutes


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Dyslipidemia

LDL >130 mg/dl

Total Chol > 200 mg/dl

Some say only as substitute for LDL

HDL < 40 mg/dl

Negative Risk Factor:

HDL> 60 mg/dl

Controversy: removes dyslipidemia or any RF?


Prediabetes (impaired fasting glucose):

FPG> 100 mg/dl <126 mg/dl

Confirmed on > 2 separate occasions

IGT on OGTT

Obesity:

BMI > 30 kg/M2

Waist girth: > 102 cm men > 88 cm women

Waist/Hip > 0.95 men, > 0.86 women


Undisclosed or Unavailable CVD Risk Factor Information

Health/fitness and exercise professionals and clinicians are encouraged to adopt a conservative approach to CVD risk factor identification for the purposes of risk stratification, especially when:

risk factor information is missing, and/or

the criteria for identifying the presence or absence of a specific risk factor cannot be determined or is not available.

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Undisclosed or Unavailable CVD Risk Factor Information (cont.)

If the presence or absence of a specific risk

factor is not disclosed or is unavailable, the risk factor should be counted as a risk factor except for prediabetes.

Missing or unknown criteria for prediabetes should be counted as a risk factor in the presence of age(≥45 years), particularly for those with a body mass index ≥25 kg·m-2

and for those who are younger, have a body mass index ≥25 kg·m-2, and have additional risk factors for prediabetes.

Risk Stratification Table 2-1

Bye bye helpful table 2-1, thank you for being so useful.

ACSM Risk Stratification Categories Table 2-1

Low Risk

Men < 45, Women <55 y.o.

Asymptomatic

< 1 CAD RF

Moderate risk:

Men > 45, Women >55 y.o.

Symptomatic (not really but I say yes)

> 2 CAD RF

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ACSM Risk Stratification Categories Table 2-1

High Risk

> sign/symptom table 2-3

Known cardiovascular, pulmonary, metabolic disease

Look at table 2-3 again:

Do you see why the GETP8 is a reference text?

More About Risk Stratification

Assessing risk becomes more important as prevalence increases

Signs/symptoms represents a higher-level concern for decision making than RFs

Low-risk (ACSM) isolated HTN


More about HTN

Aggravated by exercise

Commonly clustered with other risk factors: obesity, DM, CAD, HLP

Low-risk (ACSM) isolated HTN

< 160/100 mmHg = Moderate I

Ex testing not necessary

Physician clearance advisable

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More about HTN

Low-risk (ACSM) isolated HTN < 160/100 mmHg = Intense I Ex testing necessary

Document hemodynamic response

Physician clearance advisable

Stage II HTN (documented)>160/100 mmHg MD clearance & test


Individuals stratified to need medical clearance:

Benefit from further assessment

Benefit from professionally-guided exercise programs

Risk Stratification (cont.)

Figure 2-3

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Figure 2.3 (p26) after risk factors = Table 2.2 p27 & Figure 2.4 (p28)

Great for a quiz

Funny: “need” for testing could be looked at as “Can I test him/her?”

Interpreted by qualified professionals

Results documented

Exercise Testing and Testing Supervision Recommendations Based Upon Risk Category

Figure 2-4

Atherosclerotic Cardiovascular Disease Risk Factors (cont.)

The table of risk factors contains clinically relevant established CVD risk factor criteria that should be considered collectively when making decisions about:

the level of medical clearance,

the need for exercise testing prior to initiating participation, and

the level of supervision for both exercise testing and exercise program participation.

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Exercise Testing and Participation Recommendations Based Upon Risk Category

Once the risk category has been established for an individual as low, medium, or high, appropriate recommendations may be made regarding:

the necessity for medical examination and clearance before initiating a physical activity/exercise program or substantially changing the FITT framework of an existing physical activity/exercise program,

Exercise Testing and Participation Recommendations Based Upon Risk Category (cont.)

the necessity for an exercise test before initiating a physical activity/exercise program or substantially changing the FITT framework of an existing activity program, and

the necessity for physician supervision when participating in a maximal or submaximal exercise test.

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Exercise Testing: Risk & Supervision

Risk of CV events increases with I

In all situations where testing is performed:

BLS all staff, ACLS at least some staff

“Whenever possible” test should be performed by ACSM certified staff because:

These credentials document the KSAs directly related to exercise testing

Box 2.2 Recommendations for a Medical Exam Prior to Initiating Physical Activity

• Moderate risk (> RFs: Table 2.2 & Figure 2.3) should be encouraged to consult with their physician prior to initiating a vigorous I exercise program s part of good medical care. • Progress slowly regardless of I prescribed.

• The majority of Mod risk can begin with light to moderate I without consulting MD.

• Individuals with known disease or signs/symptoms

(table 2.1) should consult MD prior to initiating an exercise program or being tested.

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Table 2.3 New ACSM Recommendations for Exercise Testing Prior to Exercise Diagnosed CVD

Unstable/new or possible

symptoms of CVD (Table 2.2)

End-stage renal disease

Symptomatic of diagnosed

pulmonary disease: COPD

Asthma

Interstitial lung disease

Cystic fibrosis

DM & one of the following: > 35 y.o.

>10 year DMII

>15 year DMI

HLP >240 mg/dl

HTN >140/>90 mmHg

Smoking

F.H. 1st degree < 60 y.o.

Vascular disease Micro or PVD

Autonomic neuropathy

Disappointed:

“Information gathered from an exercise test may be useful in establishing a safe & effective Rx for lower-risk individuals.

Recommending an exercise test for lower-risk individuals may be considered if the purpose of the test is to design an effective Rx

This is a clinical exercise test $$$

Exercise Testing (ET)

ETing high risk clients can be supervised by non-physician health care professionals specifically trained in clinical exercise testing with a physician immediately available if needed.

ETing of Mod risk clients can be supervised by non-physician staff specially trained in clinical exercise testing.

Supervision dependent on:

local policies and circumstances (“Standard of Care”)

Staff training/preparation

Client’s health status

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Guidelines for ET and Emergencies.

All exercise facilities with/without MD supervision should:

Written plan with procedures & contacts

Should practice plan > quarterly

AED/Defib depending on staff competencies

BLS/AED (Healthcare)

ACLS

First Aid

Next Week: Class to start at 2:30pm

Please check announcement in Bb and your email during the week in case there are changes to our schedule.

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