Chapter 2- Preparticipation Physical activity screening guidelines Flashcards
Preparticipation physical activity screening
Involves gathering and
analyzing demographic and health-related information on a client along
with some medical/health assessments such as the presence of signs and
symptoms in order to aid decision making on a client’s physical activity
future (3). The preparticipation physical activity screening is a dynamic
process in that it may vary in its scope and components depending on the
client’s needs from a medical/health standpoint (e.g., the client has some
form of cardiovascular, metabolic, and/or renal disease, abbreviated as
CMR) as well as the presence of signs and symptoms suggestive of CMR
disease (e.g., chest pain of an ischemic nature) and their physical activity
program goals (they currently participate in moderate physical activity for
the past 3 months
Importance of screening clients for participation in physical activity programs
-To identify those with medical contraindications (exclusion criteria) for
performing physical activity
-To identify those who should receive a medical/physical
evaluation/exam and clearance prior to performing a physical activity
program
-To identify those who should participate in a medically supervised
physical activity program
-To identify those with other health/medical concerns (i.e., orthopedic 72 injuries, etc.)
PAR-Q
-useful tool for
individuals to gauge their own “medical” readiness to participate in
physical activity programs
-However, since the PAR-Q may be best used to screen those who are at high risk for exercise and thus may need a medical exam, it may not be as effective in screening low- to moderate risk individuals - Thus, the PAR-Q has recently morphed into the PAR-Q+ with some word changes among the seven YES/NO questions to
better classify all individuals
ePARmed-X+Physician Clearance Follow-Up Questionnaire
-form was designed to be
used in those cases where a YES answer on one of the seven questions in
the PAR-Q+ necessitates further medical clearance using the self-guided
method.
-It is also worth noting, that not while required, the ePARmedX+Physician Clearance Follow-Up Questionnaire (Fig. 2.2) could be used
for medical clearance in a professionally supervised preparticipation
physical activity screening
Health History Questionnaire purpose
s necessary to use with a client to establish his or
her medical/health risks for participation in a physical activity program
(13,28). The HHQ, along with other medical/health data, is also used in the
process of preparticipation physical activity screening. The HHQ should
be tailored to fit the needs of the program as far as asking for the specific
information needed from a client.
What does the health history questionnaire assess?
- Family history of CMR disease
- Personal history of various diseases and illnesses including CMR disease
- Surgical history
- Past and present health behaviors/habits (such as history of cigarette smoking and physical activity)
- Current use of various drugs/medications
-Specific history of various signs and symptoms suggested of CMR
disease among other things
Medical examination/ clearance
For
-Clients who are
at a higher risk for exercise complications
Preparticipation Physical Activity Screening Process
1.individual’s past physical activity history
-The individual can be queried about his or her physical activity history
using the HHQ and/or by questioning.
- Evaluate for CMR disease
- assessed using the HHQ and/or by questioning. - in the process is
the assessment of the individual’s presence of signs and symptoms that can be suggestive of CMR disease
CMR disease
Cardiovascular
Metabolic
Renal
Preparticipation table for clients with no physical activity history
Physical activity history
No
For no CMR disease
- NO s/s you can start at light to moderate physical activity
- S/S present requires medical clearance then lt/mod physical activity
For CMR disease
- No S/S medical clearance then light/moderate PA
- IF s/s present medical clearance then light/moderate PA
Preparticipation table for clients with physical activity history
Physical activity history yes
For no CMR disease
-No S/S continue to moderate/vigorous physical activity
-S/S present stop for medical clearance
For CMR disease
- No S/S a medical clearance for vigorous physical activity is required
- Sign/symptoms present would require stoppage and medical clearance
Physical activity
Has to be within the last three months
Moderate physical activity
- 40-60% HRR
- 3-6 METS
- 12-13 RPE
CMR related disease/ conditions
- Heart attack
- Heart surgery
- cardiac catheterization or coronary angioplasty
- Pacemaker/implantable cardiac defibrillator/rhythm disturbance
- Heart valve disease
- Heart failure
- Heart transplantation
- Congenital heart disease (congenital refers to birth)
- Diabetes, type 1 and 2
- Renal disease such as renal failure
Signs/ symptoms of CMR disease
- Pain or discomfort in the chest, neck, jaw, arms, or other areas that may be due to ischemia or lack of oxygenated blood flow to the tissue, such as the heart
- Dyspnea: shortness of breath
- Syncope: fainting, and dizziness during exercise may indicate poor blood flow to the brain due to inadequate cardiac output from a number of cardiac disorders
- Orthopnea: trouble breathing while lying down.
-Ankle edema, or swelling, that is not due to injury is suggestive of heart
failure, a blood clot, insufficiency of the veins, or a lymph system blockage (27). Generalized edema (known as anasarca) occurs in individuals with the nephrotic (from the kidneys) syndrome, severe heart failure, or hepatic (from the liver) cirrhosis.
- palpitations/tachycardia: both refer to rapid beating or fluttering of the heart
- Intermittent claudication refers to severe calf pain when walking
- Heart murmurs: unusual sounds caused by blood flowing through the heart
- unusual fatigue/shortness of breath
Bilateral ankle edema
most evident at night is a characteristic sign of heart failure or bilateral chronic venous insufficiency.
Unilateral edema
often results from venous thrombosis or lymphatic blockage in the limb
Vigorous exercise
-greater than or equal to 60% of your client’s functional capacity (≥6 METs, ≥14 on a 6–20 RPE scale, and cause substantial increases in heart rate and breathing)
Certification for exercise testing
AHA Advanced
Cardiac Life Support Certification) as well as experience in exercise
testing interpretation and emergency plan practice
Characteristics of patients at lowest risk for exercise participation
- absence of complex ventricular dysrhythmias during exercise testing and recovery
- absence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, or dizziness, during exercise testing and recovery
- Presence of normal hemodynamics during exercise testing and recovery (i.e., appropriate increases and decreases in heart rate and systolic blood pressure with increasing workloads and recovery)
- functional capacity greater than or equal to 7 METs
Non exercise test finding
- resting ejection fraction less than or equal to 50%
- uncomplicated myocardial infraction or revascularization procedure
- absence of complicated ventricular dysrhythmias at rest
- absence of congestive heart failure
- absence of signs or symptoms of post event/post procedure myocardial ischemia
- absence of clinical depression
Characteristics of patients at moderate risk for exercise participation
Exercise test findings
- presence of angina, shortness of breath, light headedness, or dizziness occurring only at high levels of exertion 7 or more METS
- mild-moderate level of silent ischemia during exercise testing or recovery
- functional capacity less than or equal to 5 METS
Nonexercised Test findings
- Rest ejection fraction 40%-49%
Characteristics of patients at high risk for exercise participation
Exercise test findings
- presence of complex ventricular dysrhythmias during exercise testing/recovery
- Presence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, dizziness at low levels of exertion [
absolute contraindications
- acute myocardial infarction within 2 days
- ongoing unstable angina
- uncontrolled cardiac arrhythmia with hemodynamic compromise
- active endocarditis
- symptomatic severe aortic stenosis
- decompensated heart failure
- acuter pulmonary embolism, pulmonary infarction, or deep venous thrombosis
- acute myocarditis or pericarditis
- acute aortic dissection
- physical disability that precludes safe and adequate testing
contraindications
clinical characteristic that individuals may have that may make physical activity
and thus, exercise testing, more risky than if the individual did not have
that clinical characteristic.
For instance, if an individual has unstable
angina, or chest pain (unstable angina refers to chest pain that is not well
controlled or predictable), then if they exercise their heart may become
ischemic which could lead to a myocardial infarction, or heart attack
Relative contraindications
- known obstructive left main coronary coronary stenosis
- moderate to severe aortic stenosis with uncertain relation to symptoms
- tachyarrhythmias with uncontrolled ventricular rates
- acquired advanced or complete heart block
- recent stroke or transient ischemia attack
- mental impairment with limited ability to cooperate
- resting hypertension with systolic >200 mm Hg or diastolic >110 mm Hg
- uncorrected medical conditions, such as significant anemia, important electrolyte imbalance, and hyperthyroidism
Absolute vs relative
Absolute
- absolute refers to those
criteria that are absolute contraindications; individuals with those biomarkers should not be allowed to participate in any form of physical
activity program and/or exercise test
Relative
-clinical contraindications that are listed as relative may be accepted or allowed into a physical activity assessment and/or program if it is deemed that the benefits for the individual outweigh the risks to the individual.
-For instance, if your client has a resting blood pressure of 210/105 mm Hg, it may be decided to allow your client (medical director decision,
likely) into the physical activity program because the benefits to the individual may outweigh the risks of exercising with such as high blood pressure because the individual is controlled and stable in terms of their
blood pressure.
CVD risk factors/ defining criteria
- Age: 45 year or more for male and 55 years or older for females
-family history: at least one male relative has had one of the three specific events prior to age 55 years or
before age 65 years in a female relative
- smoking: currently smokes, quit smoking w/in 6 months, and second hand smoke on regular basis
- sedentary lifestyle- not participating in a regular exercise program nor meeting the minimal recommendations of 30 minutes or more of moderate physical activity on 3 days ∙ week 1 for a least 3 months
-obesity: a BMI greater than or equal 30 kg ∙ m−2 or a waist circumference of greater than 102 cm (~40 in) for men and greater than 88 cm (~35 in) for women.
- hypertension: RBP equal to or above 140 mm Hg systolic or equal to or above 90 mm Hg diastolic or if the client is currently taking any of the numerous antihypertensive
medications. Very importantly, these resting blood pressures must have been assessed on at least two separate occasions
-Dyslipidemia: having a low-density lipoprotein cholesterol (LDL-C) equal or above 130 mg ∙ dL−1, an HDL-C of less than 40 mg ∙ dL−1
, or if the client is taking a lipid-lowering medication. Use equal or
greater than 200 mg ∙ dL for total cholesterol. Must be measured on two separate occasions
-Diabetes: fasting plasma glucose ≥126 mg ∙ dL−1 (7.0 mmol ∙ L−1) or 2 h plasma glucose values in oral glucose tolerance test (OGTT) ≥200 mg ∙ dL −1 (11.1 mmol ∙ L−1) or HbA1C ≥6.5%.
There must be at least two separate abnormal results for the risk factor to be counted. Remember, FBG of 126 mg ∙ dL−1 or greater would indicate the individual has diabetes which would automatically place him or her in the high-risk level
-High-serum HDL-C: equal or greater than 60 mg ∙ dL−1
(this is a negative risk factor that would offset one positive risk factor). HDL-C participates in reverse cholesterol transport and thus may lower the risk of cardiovascular disease.
Case study:
Sam J., your client, decides he wants to exercise in your program. You take him through your routine preactivity screening. He presents to you with the following information: His father died of a heart attack at the age of 52 yr. His mother was put on medication for hypertension 2 yr ago at the age of 69 yr. He presents no signs or symptoms of CMR disease and is a nonsmoker. His personal data shows that he is 38 yr old. He weighs 170
lb and is 5 ft 8 in tall. His body fat percentage was measured at 22% via 103
skinfolds. His cholesterol is 270 mg ∙ dL−1, HDL is 46 mg ∙ dL−1, and his resting blood glucose is 84 mg ∙ dL−1. His resting heart rate is 74 bpm, and his resting blood pressure measured 132/82 and 130/84 mm Hg on two
separate occasions. He has a sedentary job in a factory and stands on his feet all day. He complains that as a supervisor on the job, he never gets a rest throughout his shift and often is required to work overtime. He routinely plays basketball once each week with his work buddies and then
goes out for a few beers.
Physical Activity History
-He plays some basketball once a week and thus is not physically active by the ACSM definition.
Presence of Cardiovascular, Metabolic, and/or Renal Disease
-None noted.
Major Symptoms or Signs suggestive of Cardiovascular, Metabolic, and/or Renal Disease
-None noted.
ACSM Preparticipation Physical Activity Screening Status
-Medical clearance is not necessary before starting a physical activity program of a light to moderate intensity. He may progress to more
vigorous-intensity exercise following ACSM GETP (3,25).
Sam has a risk factor profile that is hyperlipidemic or dyslipidemic (his total cholesterol is 270 mg ∙ dL
−1 or mg%).
In addition, he is currently
sedentary. Thus, a prudent EP-C would stress to this client the importance
of adopting a physically active lifestyle with moderate physical activity to
start. In addition a health care provider may wish to explore further Sam’s
dyslipidemia and treatment
Contraindications Case Study
Sam J. has a medical evaluation with his personal physician prior to
joining your vigorous exercise program. His physician performs a medical
evaluation (physical exam) and reports the following: Sam J. has no signs
and symptoms of CMR disease and has the known risk factors you already
uncovered (dyslipidemia and sedentary lifestyle as well as a family
history). His physical exams results are unremarkable except for the
relative contraindications listed below.
Absolute Contraindications
-None.
Relative Contraindications
-Sam suffers some from rheumatoid arthritis that is not usually made worse
by exercise. In addition, Sam suffered a musculoskeletal injury to his low back last year that forced him to miss 1 wk of work. However, his low
back area has been problem free as of the last 6 mo.
Contraindication Analysis
-Sam may not suffer from any technical contraindications that would
prevent him from performing an exercise test for exercise prescription
purposes as well as participating in an exercise program. Remember,
relative contraindications are considered in terms of cost and benefit to your client. Certainly, as a prudent EP-C, you will want to conduct the exercise test for prescriptive purposes being careful not to exacerbate Sam’s previous back injury. In addition, Sam having rheumatoid arthritis
should signal you to take it easy with your client. A cautious physical activity program should be recommended for him that limits his use of his core and lower back muscles.
