Chapter 2-3

Health AppraisalPre-Assessment Screening & Risk Factor Assessments

Informed Consent

•First step in HRPF assessment and must precede the health risk appraisal where exchange of private information and exercise is involved.

•Informed Consent is a process of documentation that attests to the fact that clear communications have taken place between the individual who is desiring the assessment and the professional administering them.

~Explain the purpose of the assessments

~Describe the procedures to be used

~Describe the risks and discomforts associated with the assessments.

~Describe the benefits obtained from the assessments

~Describe alternatives (if applicable)

~Describe the responsibilities required of the client

~Encourage the client to ask questions at any time

~Explain how data will be handled (confidentiality)

~Explain that the client can withdraw his or her consent and stop the assessment process at any time.

Box 21, page 12

Essential Steps of the Informed Consent

• 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.

Pre-assessment Screening – Step 2

Rationale for Screening

• Identify those with medical contraindication (see box 2.2 p. 15).

• Identify those who should receive medical evaluation by MD prior to testing.

• Identify those who should perform HRPF assessments administered by professional in clinical setting.

• Identify those with other health risk/medical concerns.

Rationale for pre-testing and screening

• Risk of both cardiovascular and musculoskeletal injuries are associated with exercise.• The risks increase with the intensity of the exercise.

• The risks increases also in those individuals with known or previous injuries/diseases.• Therefore, it is crucial to know the medical history of

individuals perform Health-Related Physical Fitness Testing

• 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, and to

evaluate progress.

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.

• Conduct pre-participation health screening using one or more of several different instruments:– Comprehensive health history

questionnaire (p. 17-18).– Physical Activity Readiness

Questionnaire (PAR-Q).– ACSM Risk Stratification Guidelines

Types of Screening Instruments

• 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

• The PAR-Q is preferred when testing large numbers of individuals in a short period of time in a basic fitness assessment. Participants are directed to contact their physician if they answer “yes” to one or more questions.

• The ACSM has low, moderate, and high risk strata based on the presence (or absence) of different risk factors. See page 21 (ACSM)

1. Age: Men >= 45, Women >= 55

2. 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).

3. Cigarette smoking: (current cigarette smoker or those who quit within the previous 6 months).

4. Sedentary lifestyle: (persons not participating in at least 30 minutes of moderate physical activity (40%-60% VO2) on at least 3 days of the week for at least 3 months.

ACSM Risk Stratification: Counting Risk FactorsTable 2.1, pp. 19

5. Obesity: Body mass index of >30 kg/m2, or waist girth of >102 cm – (40 in. men and >88 cm – (35 in. women).

6. Hypertension: (SBP 140 >mm Hg or DBP >90 mm Hg, confirmed on at least 2 separate occasions, or on antihypertensive medication).

7. Dyslipidemia: LDL chloesterol > 130 or HDL <40 or on lipid- lowering medication. If total cholesterol is all that is available use >200 mg/dl

8. Prediabetes: Impaired fasting blood glucose = >100 mg/dl and <125 mg/dl, (confirmed by measurements on at least 2 separate occasions).

Negative Risk Factor

• HDL - > 60 mg/dl

• For individuals having high HDL, one positive CVD risk factor is subtracted from the sum of positive risk factors.

ACSM: Check for these major signs or symptoms (Table 2.2, p. 20 ACSM)

• 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.

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.

Using Screening Results for Risk Stratification

• Once symptom and risk factor screening has been conducted using questionnaires, the individual considering exercise testing and prescription should be stratified according to disease risk. Stratification according to disease risk is important for several reasons:– To identify those in need of referral to a healthcare

provider for more extensive medical evaluation.– To ensure the safety of exercise testing and participation.– To determine the appropriate type of exercise test or

program.

ACSM Risk Stratification LevelsTable 2.3 pg. 20

Low risk: asymptomatic and meet no more than one risk factor threshold).

Moderate risk : asymptomatic and meet the threshold for two or more risk factors.

High risk: individuals with one or more signs/symptoms or known cardiovascular, pulmonary, or metabolic disease including diabetes mellitus.

ACSM Recommendations for (A) Current Medical Examination* and Exercise Testing Prior to Participation

and (B) Physician Supervision of Exercise Tests pg. 22

Low Risk Moderate Risk

High Risk

A. Moderate Exercise**

Not necessary Not necessary Recommended

A. Vigorous Exercise † †

Not necessary Recommended Recommended

B. Submaximal Test Not necessary Not necessary Recommended

B. Maximal Test Not necessary Not necessary Recommended

* Within the past year.

** 3-6 METS; brisk walking; pace that can be sustained for 45 minutes; 40-60% maximal oxygen uptake.

† † >6 METS; substantial cardiorespiratory challenge; >60% maximal oxygen uptake.

‡ Physician should be in close proximity and readily available.

Blood Pressure

Blood Pressure

• Blood pressure is the force of blood against the walls of the arteries and veins created by the heart as it pumps blood to every part of the body.

Expressed in millimeters of mercury (mmHg)

• Systolic BP is the maximum pressure in the arteries during the contraction (systole) phase

• Diastolic BP is the minimum pressure in the arteries during the relaxation (diastole) phase of the heart.

Blood Pressure Guidelines

Normal <120 <80

Systolic (mm Hg) Diastolic (mm Hg)

Pre-hypertensive 120-139 80-89 Stage I 140-159 90-99

Stage II >160 >100

Blood Pressure

• See course materials for blood pressure techniques.

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