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ACSM’s Guidelines For Exercise Testing And Prescription : Chapter 2 Health Screening & Risk Stratification


ACSM’s Guidelines For Exercise Testing And Prescription : Chapter 2 Health Screening & Risk Stratification. David Arnall, Ph.D., P.T., FACSM, ES. Reasons To Screen Your Exercising Population. Identify and exclude individuals with medical contraindications to exercise

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ACSM’s Guidelines For Exercise Testing And Prescription : Chapter 2 Health Screening & Risk Stratification

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ACSM’s Guidelines For Exercise Testing And Prescription : Chapter 2Health Screening& Risk Stratification

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


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Reasons To Screen Your Exercising 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.


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  • 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.


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Physical Activity Readiness Questionnaire - 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.


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PAR-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


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Questions On The PAR-Q To Ask Potential Exercising Persons

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

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


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

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


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  • 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?


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  • 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?


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  • 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.


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  • 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.


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Coronary Risk Factors To Be Used With 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).


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


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


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  • Hypercholesterolemia

    • Total Serum Cholesterol > 200 mg/dl

    • Low-Density Lipoproteins > 130 mg/dl

    • High-Density Lipoproteins < 35 mg/dl

    • On Lipid Lowering Medications


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


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  • 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.


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

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


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Additional Concerns …...

  • Major Signs & Symptoms Of Cardiopulmonary Disease Are :

    • Chest Pressure/Pain Or Other Anginal Equivalents

    • SOB At Rest Or Mild Exercise

    • Dizziness Or Syncope

    • Orthopnea Or Paroxysmal Nocturnal Dyspnea


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  • Ankle Edema

  • Palpitations Or Tachycardia

  • Intermittent Claudication

  • Heart Murmurs

  • Unusual Fatigue Or SOB With Usual Activities


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ACSM 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.)


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


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  • 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).


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


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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.


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  • Vigorous Exercise : Activities > 6 METs

  • A substantial cardiorespiratory challenge sustainable for 20-30 min.


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The 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 ?


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Does The Patient Need A Physical, An Exercise Test & Does The Physician Need To Be Present ?


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What If They Are Already 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


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  • Moderate Risk

    • Ejection fraction between 40% - 49%

    • Signs/symptoms including angina at moderate levels of exercise (5-6.9 METs) or in recovery.


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  • High Risk

    • Ejection fraction < 40%

    • Survivor of cardiac arrest/sudden death

    • Complex ventricular arrhythmia at rest or exercise

    • Abnormal hemodynamics

    • Signs/symptoms with low level exercise

    • Functional capacity < 5 METs

    • Significant clinical depression


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  • 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


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  • 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.