PRE-EXERCISE ASSESSMENTS

HEALTH 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 • The PAR-Q is preferred when
questionnaire should include: testing large numbers of
– Medical diagnosis individuals in a short period of
– Previous physical exam findings time in a basic fitness
– History of symptoms assessment. Participants are
directed to contact their physician
– Recent illness, hospitalization,
if they answer “yes” to one or
new medical diagnosis or
more questions.
surgical procedures
– Orthopedic problems
– Medication use and drug
allergies • The ACSM has low, moderate,
– Lifestyle habits and high risk strata based on the
presence (or absence) of different
– Exercise and work history
risk factors.
– Family history of disease
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 FACTORS
1. 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 High Risk

Risk
A. Moderate Not necessary† Not necessary Recommende
Exercise** d
A. Vigorous Exercise † Not necessary Recommended Recommende
†
d
B. Submaximal Test Not necessary Not necessary Recommende
d
B. Maximal Test Not necessary Recommended Recommende
‡ d
* 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