ACSM’s ACSM’s Guidelines For Guidelines For Exercise Testing And Exercise Testing And

PrescriptionPrescription : Chapter 2 : Chapter 2

Health ScreeningHealth Screening& Risk Stratification& Risk Stratification

David Arnall, Ph.D., P.T., FACSM, ES

Reasons To Screen Your Reasons To Screen Your Exercising PopulationExercising Population

Identify and exclude individuals with medical contraindications to exercise

Identify individuals with risk factors who need to be seen by a physician before undertaking an exercise program.

Identify individuals with significant disease who should only exercise in a medically supervised environment.

Identify individuals with other special needs such as orthopedic problems, neurological conditions, etc.

Physical Activity Readiness Physical Activity Readiness Questionnaire - The PAR-QQuestionnaire - The PAR-Q

This questionnaire was first developed in Canada and is used widely to assess the readiness of individuals to undertake a moderately vigorous physical exercise program.

PAR-QPAR-Q

Common sense is your best guide in answering these few questions. Please read them carefully and check the yes or no box.

http://www.d.umn.edu/student/loon/soc/phys/par-q.html

Questions On The PAR-Q To Ask Questions On The PAR-Q To Ask Potential Exercising PersonsPotential Exercising Persons

1. Has your doctor ever said that you have heart trouble ?

2. Do you frequently have pains in your heart and chest ?

3. Do you often feel faint or have spells of severe dizziness?

4. Has a doctor ever said your blood pressure was too high?

5. Has your doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise, or might be made worse with exercise?

6. Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to?

7. Are you over age 65 and not accustomed to vigorous exercise?

If the person filling out the PAR-Q answers YES to any of the questions, they are advised to see their physician and find out if they are able to exercise safely in a community exercise program.

If the person filling out the PAR-Q answers NO truthfully to all of the questions, they are reasonably assured that they can have a fitness appraisal evaluation and begin an exercise program as long as they start out slowly and gradually advance the intensity of their exercise.

Coronary Risk Factors To Be Used Coronary Risk Factors To Be Used With ACSM’s Risk StratificationWith ACSM’s Risk Stratification

Family History - MI, coronary revascularization or sudden death before the age of 55 years in the father or other first-degree relative (son, brother) or before the age of 65 years in the mother or other first-degree relative (sister, daughter).

Cigarette Smoking - current use or those who have quit within the last 6 months (other tobacco use - pipe, cigars, etc.)

Hypertension - Blood pressure on two separate occassions > 140/90 or an individual who is on medications for hypertension

Hypercholesterolemia

Total Serum Cholesterol > 200 mg/dlLow-Density Lipoproteins > 130 mg/dlHigh-Density Lipoproteins < 35 mg/dlOn Lipid Lowering Medications

Impaired Fasting Glucose - > 110 mg/dl measured on 2 separate occassions.

Obesity - Body mass Index > 30 Kg/m2 or waist girth > 100 cm.

There are many health professionals which disagree about what marker of obesity to use. Therefore, use your best clinical judgement when evaluating this risk factor.

Sedentary Lifestyle - Persons who are not involved with a regular exercise program†.

† Persons not accumulating 30 + minutes of exercise on most days/week

Additional Concerns …...Additional Concerns …... Major Signs & Symptoms Of

Cardiopulmonary Disease Are :Chest Pressure/Pain Or Other

Anginal EquivalentsSOB At Rest Or Mild ExerciseDizziness Or SyncopeOrthopnea Or Paroxysmal

Nocturnal Dyspnea

Ankle EdemaPalpitations Or TachycardiaIntermittent ClaudicationHeart MurmursUnusual Fatigue Or SOB With

Usual Activities

ACSM Risk StratificationACSM Risk Stratification

Low Risk - Men under 45 yrs and women under 55 yrs. Who are asymptomatic and have no more than one risk factor (HTN, Obesity, Hypercholesterolemia, Family Hx.)

Moderate Risk - Men > 45 yrs and women > 55 yrs or if these persons have two or more risk factors.

High Risk - Persons with one or more signs or symptoms (ankle edema, orthopnea, SOB, angina, etc.) or known cardiovascular, pulmonary (COPD) or metabolic disease (DM).

Now that the patient has been screened and evaluated as to their potential risk, there are other decisions that the exercise leader must make.

Definitions…...Definitions…...

Moderate Exercise : This intensity is defined as any activity that is between 3-6 METs.

An exercise that is equivalent to brisk walking at 3-4 mph.

An exercise that can be comfortably sustained for 45 minutes.

Vigorous Exercise : Activities > 6 METs

A substantial cardiorespiratory challenge sustainable for 20-30 min.

The Two Golden QuestionsThe Two Golden Questions

Does my patient need a physical exam and an exercise test prior to starting an exercise program ?

Does the physician need to be present when I perform the exercise test ?

Does The Patient Need A Physical, Does The Patient Need A Physical, An Exercise Test & Does The An Exercise Test & Does The

Physician Need To Be Present ?Physician Need To Be Present ?Low Risk Mod. Risk High Risk

Mod. Ex NotNecessary

NotNecessary

Recomm.

VigorousExercise

NotNecessary

Recomm. Recomm.

Submax.Test

NotNecessary

NotNecessary

Recomm.

MaximalTest

NotNecessary

Recomm. Recomm.

What If They Are Already What If They Are Already Cardiac Patients ?Cardiac Patients ?

Low Risk Ejection fraction > 50% No resting or exercise-induced dysrhythmias Asymptomatic & have no angina with

exertion or recovery Functional work capacity > 7 METs Normal hemodynamics No clinical depression

Moderate Risk Ejection fraction between 40% - 49% Signs/symptoms including angina at

moderate levels of exercise (5-6.9 METs) or in recovery.

High RiskEjection fraction < 40%Survivor of cardiac arrest/sudden deathComplex ventricular arrhythmia at rest

or exerciseAbnormal hemodynamicsSigns/symptoms with low level exerciseFunctional capacity < 5 METsSignificant clinical depression

Risk factor stratification can be modified with :

exercise training risk factor reduction lipid lowering drugs, nitrates, -blockers surgical intervention (CABG, PTCA) thrombolysis (streptokinase, TPA) stress reduction - counseling & drugs

With cardiac patients, do I have an algorhythm to determine if they need a physical exam and an exercise test with a physician present prior to undertaking an exercise program ?

The answer is NO !! A physician must examine, test and clear a cardiac patient prior to exercising.