PRE-EXERCISE ASSESSMENTSHEALTH SCREENING AND

STRATIFICATION Prepared and presented by:

Mohammad H. Kraizem

RATIONALE FOR PRE-TESTING AND SCREENING• Nearly 75,000 Americans suffer a MI during or after exercise each

year. ▪ Most are sedentary men with risk factors beginning a new exercise program.

• According to the ACSM, ▪ “the incidence of cardiovascular problems during physical activity is reduced by

nearly 50% when individuals are first screened and those identified with risk factors are diverted to other professionally established activity programs.

• Risk of both cardiovascular and musculoskeletal injuries are associated with exercise.• The risks increase with the intensity of the exercise.

• The risks increases also in those individuals with known or previous injuries/diseases.• Therefore, it is crucial to know the medical history of

individuals perform Health-Related Physical Fitness Testing

RATIONALE FOR PRE-TESTING AND SCREENING

▪ Physical fitness testing is useful for the following:▪ Identifying adverse S/S or

conditions that might compromise well-being during exercise.

▪ Provides an opportunity for individuals to be educated and motivated to adopt more healthful lifestyles

▪ Helps in establishing goals to progress toward.

KEY ISSUES

▪ Always obtain a medical history or pre-exercise health risk appraisal on each participant.

▪ Stratify individuals according to their disease risk.

▪ Refer high-risk individuals to a healthcare provider for medical evaluation and a graded exercise test.

RATIONALE FOR SCREENING

▪ Identify those with medical contraindication.

▪ Identify those who should receive medical evaluation by MD prior to testing.

▪ Identify those who should perform HRPF(Health-related physical fitness) assessments administered by professional in clinical setting.

▪ Identify those with other health risk/medical concerns.

PRE-PARTICIPATION HEALTH SCREENING

▪ All facilities that offer exercise equipment or services should conduct pre-participation health screening of all new members and/or prospective users, regardless of age.

▪ Conduct pre-participation health screening using one or more of several different instruments:▪ Comprehensive medical/health questionnaire.▪ Physical Activity Readiness Questionnaire (PAR-Q).▪ ACSM Risk Stratification Guidelines

Types of Screening Instruments• A comprehensive medical/health

questionnaire should include:

– Medical diagnosis

– Previous physical exam findings

– History of symptoms

– Recent illness, hospitalization, new medical diagnosis or surgical procedures

– Orthopedic problems

– Medication use and drug allergies

– Lifestyle habits

– Exercise and work history

– Family history of disease

• The PAR-Q is preferred when testing large numbers of individuals in a short period of time in a basic fitness assessment. Participants are directed to contact their physician if they answer “yes” to one or more questions.

• The ACSM has low, moderate, and high risk strata based on the presence (or absence) of different risk factors.

PRE-PARTICIPATION HEALTH SCREENING

▪ The PAR-Q is preferred when testing large numbers of individuals in a short period of time. Participants are directed to contact their physician if they answer “yes” to one or more questions.

▪ The ACSM and AHA published a slightly more complex questionnaire in 1988 that asks for history, symptoms and risk factors.

ACSM & AHA PRE-PARTICIPATION SCREENING QUESTIONNAIRE

▪ All individuals interested in participating in organized exercise programs should be evaluated for heart disease risk factors.▪ The ACSM/AHA questionnaire addresses these

guidelines by the questions asked .

▪ Additionally, the ACSM recommends that pre-participation questionnaires include a list of S/S for CV/pulmonary disease.

ACSM RISK STRATIFICATION: COUNTING RISK FACTORS1. Family history (MI, coronary revascularization, or sudden death before 55 yrs in father or other male first-degree relative, or before 65 yrs in mother or other female first degree relative).

2. Cigarette smoking (current cigarette smoker or those who quit within the previous 6 months).

3. Hypertension (sBP 140 mm Hg or dBP 90 mm Hg, confirmed on at least 2 separate occasions, or on antihypertensive medication).

4. Hypercholesterolemia (serum cholesterol of >200 mg/dl or HDL cholesterol of <35 mg/dl, or on lipid-lowering medication. If LDL cholesterol is available, use >130 mg/dl rather than the total cholesterol of >200 mg/dl). If HDL cholesterol is >60 mg/dl, subtract one risk factor from the sum of positive risk factors (negative risk factor).

ACSM RISK STRATIFICATION: COUNTING RISK FACTORS (CONT)

•5. Impaired fasting glucose (fasting blood glucose of 110 mg/dl, confirmed by measurements on at least 2 separate occasions).

•6. Obesity (body mass index of 30 kg/m2, or waist girth of >100 cm).

•7. Sedentary lifestyle (persons not participating in a regular exercise program or meeting the minimal physical activity recommendations from the U.S. Surgeon General’s report—accumulating 30 minutes or more of moderate physical activity on most days of the week).

ACSM: CHECK FOR THESE MAJOR SIGNS OR SYMPTOMS

•1. Pain, discomfort (or other anginal equivalent) in the chest, neck, jaw, arms, or other areas that may be due to ischemia.

•2. Shortness of breath at rest or mild exertion.

•3. Dizziness or syncope.

•4. Orthopnea (discomfort in breathing which is brought on or aggravated by lying flat) or paroxysmal nocturnal dyspnea (acute difficulty in breathing appearing suddenly at night, usually waking the patient after an hour or two of sleep).

•5. Ankle edema.

ACSM: CHECK FOR THESE MAJOR SIGNS OR SYMPTOMS (CONT)

• 6. Palpitations (forcible or irregular pulsation of the heart, perceptible to the individual, usually with an increase in frequency or force, with or without irregularity in rhythm) or tachycardia (rapid beating of the heart, typically over 100 beats per minute at rest).

• 7. Intermittent claudication (a condition caused by lack of blood flow and oxygen to the leg muscles, characterized by attacks of lameness and pain, brought on by walking).

• 8. Known heart murmur.

• 9. Unusual fatigue or shortness of breath with usual activities.

ACSM & AHA PRE-PARTICIPATION SCREENING QUESTIONNAIRE▪ Once symptom and Risk Factors screening have

been conducted, the individual needs to be stratified according to disease risk. This is important for several reasons:▪ To identify those in need of referral to a health-care

provider for more extensive medical evaluation▪ To ensure safety of exercise testing and participation▪ To determine the appropriate type of exercise test of

program.

ACSM RISK STRATIFICATION LEVELS

▪ Low-Risk▪ Men <45, and women <55 years of age, who are

asymptomatic and meet no more than one risk factor threshold.

▪ Moderate-Risk▪ Men >/= 45 and women >/= 55 years of age or those who

meet the threshold for two or more risk factors

▪ High-Risk▪ Individuals with one or more signs or symptoms or with

known cardiovascular, pulmonary, or metabolic disease including diabetes mellitus.

ACSM RECOMMENDATIONS FOR (A) CURRENT MEDICAL EXAMINATION* AND EXERCISE TESTING PRIOR TO PARTICIPATION AND (B) PHYSICIAN SUPERVISION OF EXERCISE TESTS

Low Risk Moderate Risk

High Risk

A. Moderate Exercise**

Not necessary† Not necessary Recommended

A. Vigorous Exercise † † Not necessary Recommended Recommended

B. Submaximal Test Not necessary Not necessary Recommended

B. Maximal Test Not necessary Recommended‡

Recommended

* Within the past year.

** 3-6 METS; brisk walking; pace that can be sustained for 45 minutes; 40-60% maximal oxygen uptake.

† Not essential, but not viewed as inappropriate.

† † >6 METS; substantial cardiorespiratory challenge; >60% maximal oxygen uptake.

‡ Physician should be in close proximity and readily available.

MEDICAL EXAM AND EXERCISE TESTING

▪ The depth of the medical or physical exam for any individual depends on disease risk stratification.

▪ Although most people can safely participate in some form of exercise, there are some who should not exercise. The risks outweigh the benefits.

PRE-EXERCISE ASSESSMENTS AND RISK STRATIFICATION▪ Obtaining and Understanding the medical history is a very

important part of the pretest evaluation!

▪ Careful evaluation prior to exercise testing or exercise participation is important

▪ To assure safety▪ To aid in the diagnosis of potential CV disease, ▪ To assess heart and lung fitness, ▪ To provide a baseline from which to follow progress▪ To develop early rapport with the participant.

▪ IN GENERAL, most individuals, except for those with known serious disease, can begin a moderate exercise program such as walking (40-60% VO2 max) without a medical evaluation or exercise test.

▪ WHENEVER IN DOUBT- GET MEDICAL CLEARANCE!

▪ Recommendations for CV screening for competitive athletes given by the AHA.

INFORMED CONSENT▪ Generally, legal claims against exercise professionals are based

on either alleged violations of contract law or tort principles. ▪ A legal contract is a promise or performance bargained for and given in

exchange for another.▪ A tort is a wrongful act or damage (not involving a breach of contract) for

which a civil action can be brought.

▪ Most tort claims affecting the exercise professional are based on allegations of either negligence or malpractice, and commonly involve the following:

▪ Failure to monitor an exercise test properly▪ Failure to evaluate physical impairments competently▪ Failure to prescribe a safe exercise intensity or program▪ Failure to provide appropriate supervision▪ Rendition of advice later construed to represent medical diagnosis▪ Failure to refer participants to physician▪ Failure to respond adequately to an untoward event▪ Failure to disclose certain information in the informed-consent process.

INFORMED CONSENT▪ By law, any subject, patient, or client who is exposed to possible

physical, psychological, or social injury must give informed consent prior to participation in a program.

▪ Informed consent can be defined as the knowing consent of an individual or that person’s legally authorized representative, with free power of choice and the absence of undue inducement or any element of force, fraud, deceit, duress, or other form on constraint or coercion.

▪ Informed consent should be read and signed by the subject, in the presence of a witness..

▪ Informed Consent should be written so as to be easily understood by all subjects.

▪ Should use separate forms for diagnostic testing and for exercise programming.

▪ All forms should be approved by legal counsel.

▪ All forms should include the following:▪ A general statement of the background of the

program and objectives▪ A fair explanation of the procedures to be followed▪ A description of any and all risks attendant to the

procedures▪ A description of the benefits that can reasonably be

expected▪ An offer to answer any of the subject’s queries▪ An instruction that the subject, client, or patient is

free to withdraw consent and to discontinue participation in the program at any time without prejudice to the person

▪ An explanation of the procedures to be taken to ensure the confidentiality of the information derived from the participant.

CONCEPTS AND PURPOSES IN PHYSICAL FITNESS TESTING▪ The purpose of measurement is to determine status. Status

identification is ideally conducted prior to beginning an exercise program.

▪ When conducting physical fitness tests, the following important test criteria should be considered:

▪ Validity- refers to the degree to which the test measures what it was designed to measure; a valid test is one that measures accurately what it is used to measure.

▪ Reliability- deals with how consistently a certain element is measured by the particular test; concerned with the repeatability of the test- if a person is measured two separate times by the same tester or by two different people, the results should be close to the same.

▪ Norms- represent the achievement level of a particular group to which the measured scores can be compared; norms provide a useful basis for interpretation and evaluation of test results.

▪ Economy- refers to ease of administration, the use of inexpensive equipment, the limitation of time needed to administer the test, and the simplicity of the test so that the person taking it can easily understand the purpose and results.

CONCEPTS AND PURPOSES IN PHYSICAL FITNESS TESTING

▪ Thus, a good physical fitness test accurately measures what it is supposed to measure, can be consistently used by different people, produces results that can be compared to a data set, and is relatively inexpensive, simple, and easy to administer.

▪ Testing of participants before, during, and after participation is important for several reasons:▪ To assess current fitness levels (both strengths and

weaknesses)▪ To identify special needs for individualized counseling▪ To evaluate progress▪ To motivate and educate

RECOMMENDATIONS FOR FITNESS-EVALUATION TESTS

▪ The evaluation procedure has a recommended order for both safety and efficiency.

▪ Instructions to be given to the participant prior to their appointment:

▪ Completion of medical/health status questionnaire. Can save time if have client fill out at home prior to coming to the testing site.

▪ Complete and precise instructions should be given▪ Subject should come dressed in proper attire.▪ Avoid eating or drinking for 3 hours prior to the test.▪ Avoid alcohol, tobacco, and coffee for at least 3 hours before the test▪ Avoid exercise the day of the test▪ Try to get a good night’s sleep prior to the test▪ Avoid alcohol or vigorous exercise 24 hours prior to blood draws, and a 12

hour fast is recommended.▪ Diabetics should keep their usual eating and insulin routines▪ Continue meds as usual

THE TESTING SESSION ORDER SHOULD PROCEED AS FOLLOWS:

▪ 5-minute rest▪ HR, BP, blood draw▪ Body composition measurements▪ Test for CRE▪ Musculo-skeletal testing