Health Screening

For some medical conditions, there may be a relatively higher associated health risk with physical activity (PA). Although the risk of acute musculoskeletal injury during exercise is well recognised, the major concern for primary care practitioners remains the increased risk of sudden cardiac death (heart attacks) and acute coronary events for high-risk individuals. Hence, fitness professionals must understand that before prescribing a given dose of exercise, a pre-participation health screening and a risk stratification process should be conducted to identify if clients are at significant risk while not creating a barrier to exercise participation. The identification of risk factors for adverse exercise-related events can be achieved through a two-tier approach including a self-guided screening and/or a professionally guided screening.

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Self-guided Screening for Physical Activity

The fitness professional should initially ask the client to complete a risk evaluation ( with assistance from the exercising individual or by allied health professionals). For instance, subjects may follow the recommendation of the Surgeon General’s Report on Physical Activity and Health (1996): “previously physically inactive men over age 40 and women over age 50, and people at high risk for cardiovascular disease (CVD) should first consult a physician before embarking on a programme of vigorous physical activity to which they are unaccustomed” (1). Clients may also be asked to complete some validated questionnaires such as the American Heart Association (AHA)/ the American College of Sports Medicine (ACSM) Health/ Fitness Facility Pre-participation Questionnaire or the revised Physical Activity Readiness Questionnaire (PAR-Q) before participation. These questionnaires are simple and easy to use by the layperson to determine if his or her risk is such that a primary care practitioner should be consulted before initiating physical activity, particularly if the intended exercise intensity is vigorous.

Presentation (Above) On The Application of ACSM's Updated Exercise Preparticipation Health Screening Algorithm

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ACSM's Updated Recommendations for Exercise Pre-participation Health Screening | Webinar

ACSM's Updated Recommendations for Exercise Preparticipation Health Screening - Recent studies have suggested that using the current ACSM exercise preparticipation health screening recommendations can result in unnecessary physician referrals, possibly creating a barrier to exercise participation. The purpose of this webinar is to provide more information on the updated recommendations Presenters: Carol Ewing Garber, Ph.D., FACSM, Linda Pescatello, Ph.D., FACSM, and Deb Riebe, Ph.D., FACSM

Professionally Guided Screening for Physical Activity

A superior and more thorough assessment can be performed by the primary care practitioner into an individuals’ Coronary Vascular Disease (CVD) risk factors, signs and symptoms, and to identify a greater extent of chronic diseases that may need particular care before exercise participation.

ACSM proposed a risk stratification scheme (summarised in Figure 1) which assigns individuals into one of its three risk categories (Table 1) according to specific criteria (Tables 2 - 4). Once the risk category has been established, appropriate recommendations before initiating an exercise or significantly progressing the intensity and volume of an existing exercise may be made regarding the necessity for further medical workups and diagnostic exercise testing.

Reviewing the clients history

Preparticpation Health Screening & Risk.

Figure 1. Logic Model for the ACSM Risk Stratification Scheme. Adopted from the Preparticipation Health Screening and Risk Stratification. In Walter R Thompson; Neil F Gordon; Linda S Pescatello. ACSM’s guidelines for exercise testing and prescription. 8th ed. American College of Sports Medicine; 2010.

Table 1. The ACSM Risk Stratification Categories

ACSM risk categories

Adopted from the Preparticipation Health Screening and Risk Stratification. In Walter R Thompson; Neil F Gordon; Linda S Pescatello. ACSM’s guidelines for exercise testing and prescription. 8th ed. American College of Sports Medicine; 2010

The ACSM recommendations on exercise testing are summarised in Table 5. It should be noted that the methodology of pre-participation risk assessment is both complex and controversial, and other organisations such as the European Society of Cardiology, the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation also published their own guidelines for risk stratification (2-5). Many of them rely on expert consensus in the absence of existing scientific evidence. Primary care practitioners should choose the most applicable tools and instruments for their own settings and populations when making decisions about the level of screening before exercise participation (2,6). Alternatively, primary care practitioners may also ascertain a global coronary and cardiovascular risk score for their patients, such as the Framingham Risk Score or the Systematic Coronary Risk Evaluation (SCORE), for combining the individual’s risk factor measurements into a single quantitative estimate of the absolute risk of atherosclerotic cardiovascular death within 10 years (7-8).

Table 2. Cardiovascular Disease Risk Factors for Use with the ACSM Risk Stratification

* Modified from the Preparticipation Health Screening and Risk Stratification. In Walter R Thompson; Neil F Gordon; Linda S Pescatello. ACSM’s guidelines for exercise testing and prescription. 8th ed. American College of Sports Medicine; 2010.

+ If HDL is high, subtract one risk factor from the sum of positive risk factors.

# The above BMI classification is promulgated by the World Health Organisation (Western Pacific Region Office) for reference by Asian adults and is not applicable to children under the age of 18 or pregnant women.

CVD & ACSM risk stratification

Table 3. Cardiovascular Disease, Pulmonary Diseases and Metabolic Diseases Suggesting High Risk for Physical Activity*

Table 4. Major Signs and Symptoms Suggestive of Cardiovascular Disease, Pulmonary Disease or Metabolic Disease*^

^ These signs or symptoms must be interpreted within the clinical context in which they appear because they are not all specific for significant cardiovascular, pulmonary, or metabolic disease.

Table 5. The ACSM recommendations on exercise testing based on the ACSM risk stratification

References

U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996.
Borjesson M, Urhausen A, Kouidi E, Dugmore D, Sharma S, Halle M, Heidbüchel H, Björnstad HH, Gielen S,Mezzani A, Corrado D, Pelliccia A, Vanhees L. Cardiovascular evaluation of middle-aged/senior individuals engaged in leisure-time sport activities: position stand from the sections of exercise physiology and sports cardiology of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2010;Jun 19.
Balady GJ, Chaitman B, Driscoll D, Foster C, Froelicher E, Gordon N, Pate R, Rippe J, Bazzarre T.Recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Circulation 1998;Jun 9;97(22):2283-93.
Fletcher GF, Balady GJ, Amsterdam EA, Chaitman B, Eckel R, Fleg J, Froelicher VF, Leon AS, Piña IL, RodneyR, Simons-Morton DA, Williams MA, Bazzarre T. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001;Oct 2;104(14):1694-740.
American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitationand Secondary Prevention Programs. 4th ed. Champaign, (IL): Human Kinetics Publishers; 2004.
Walter R Thompson; Neil F Gordon; Linda S Pescatello. ACSM’s guidelines for exercise testing and prescription.8th ed. American College of Sports Medicine; 2010.
Wilson PWF, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heartdisease using risk factor categories. Circulation 1998;97:1837-47.
Conroy RM, Pyo¨ ra¨ la¨ K, Fitzgerald AP, Sans S, Menotti A, deBacker G, et al. Estimation of ten-year risk offatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 2003; 24:987–1003. 22