PreExercise Assessments

1
Pre-Exercise Assessments

• KNR 240
• Fall 04

2
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.
• 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.

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Key Issues In Chapter 3

• 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.

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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.
• 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

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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. (See p. 49)
• The ACSM and AHA published a slightly more
  complex questionnaire in 1988 that asks for
  history, symptoms and risk factors. (See PFA
  3.1, p.71-72).

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ACSM AHA Pre-Participation Screening
Questionnaire

• All individuals interested in participating in
  organized exercise programs should be evaluated
  for heart disease risk factors.
• See these seven guidelines on p. 48-49 text and
  p. 24 ACSM.
• The ACSM/AHA questionnaire addresses these
  guidelines by the questions asked on p. 72.
• Additionally, the ACSM recommends that
  pre-participation questionnaires include a list
  of S/S for CV/pulmonary disease. (See p. 50
  text, Box 2-1, p. 25 ACSM)

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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
  gt200 mg/dl or HDL cholesterol of lt35 mg/dl, or on
  lipid-lowering medication. If LDL cholesterol is
  available, use gt130 mg/dl rather than the total
  cholesterol of gt200 mg/dl). If HDL cholesterol is
  gt60 mg/dl, subtract one risk factor from the sum
  of positive risk factors (negative risk factor).

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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 gt100 cm).
• 7. Sedentary lifestyle (persons not
  participating in a regular exercise program or
  meeting the minimal physical activity
  recommendations from the U.S. Surgeon Generals
  reportaccumulating 30 minutes or more of
  moderate physical activity on most days of the
  week).

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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.

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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.

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ACSM AHA Pre-Participation Screening
Questionnaire

• Once symptom and RF 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.

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ACSM Risk Stratification Levels

• Low-Risk
• Men lt45, and women lt55 years of age, who are
  asymptomatic and meet no more than one risk
  factor threshold.
• Moderate-Risk
• Men gt/ 45 and women gt/ 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.

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ACSM Recommendations for (A) Current Medical
Examination and Exercise Testing Prior to
Participation and (B) Physician Supervision of
Exercise Tests
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.
gt6 METS substantial cardiorespiratory challenge
gt60 maximal oxygen uptake. Physician should
be in close proximity and readily available.
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Medical Exam and Exercise Testing

• The depth of the medical or physical exam for any
  individual depends on disease risk
  stratification.
• See Table 3.1, p. 53 text and Table 2-2, p. 27
  ACSM.
• Although most people can safely participate in
  some form of exercise, there are some who should
  not exercise. The risks outweigh the benefits.
• See Table 3.2, p. 55 text and Box 3-6, p. 50 ACSM.

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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 are on pages 54 - 56.

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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.

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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 persons 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 subjects 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.
• Refer to pages 57 and 58 for sample Informed
  Consent Forms.
• Box 1.2, p. 11 - ACSM standards for health and
  fitness facilities. These standards should be
  regarded as a benchmark of competency that
  probably will be used in a court of law to assess
  performance and service.

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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.

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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

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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 nights 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

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Health-Related Fitness Testing Batteries

• There are different physical fitness testing
  batteries that have been developed by the YMCA,
  the Canadian Society for exercise physiology, the
  Cooper institute for Aerobics Research, the
  AAHPERD, and the Presidents Council on Physical
  Fitness and Sports.
• a. Refer to pages 64-66 for these batteries.
• Each of these batteries are valid, reliable, and
  economical, and they have sound norms.
• The norms for the various tests in these
  batteries are in Appendix A.
• Descriptions of how to conduct each of the tests
  are found in chapters 4, 5, and 6.

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Physical Fitness Testing Batteries

• Pre-test guidelines (see page 64)
• Test session organization (see page 64)
• Health-related fitness testing batteries
• YMCA
• CPAFLA
• AAHPERD
• FITNESSGRAM
• PCPFS Presidents Challenge