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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 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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Physical Activity Readiness Questionnaire - The PAR-Q only exercise in a medically supervised environment.

  • 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 only exercise in a medically supervised environment.

  • 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 only exercise in a medically supervised environment.

  • 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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  • If the person filling out the PAR-Q answers you should not follow an activity program even if you wanted to? 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 you should not follow an activity program even if you wanted to? 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 Stratification - current use or those who have quit within the last 6 months (other tobacco use - pipe, cigars, etc.)


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


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  • Hypercholesterolemia Stratification

    • 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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  • Obesity Stratification - 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 Stratification - 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 …... Stratification

  • 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 Stratification

  • Palpitations Or Tachycardia

  • Intermittent Claudication

  • Heart Murmurs

  • Unusual Fatigue Or SOB With Usual Activities


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


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  • High Risk Stratification- 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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Definitions…... their potential risk, there are other decisions that the exercise leader must make.

  • 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 their potential risk, there are other decisions that the exercise leader must make. : Activities > 6 METs

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


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The Two Golden Questions their potential risk, there are other decisions that the exercise leader must make.

  • 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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What If They Are Already Cardiac Patients ? The Physician Need To Be Present ?

  • 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 The Physician Need To Be Present ?

    • 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 The Physician Need To Be Present ?

    • 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 : The Physician Need To Be Present ?

    • 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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