Chapter 02
Preliminary Health Screening and
Risk Classification
Preliminary Health Screening and
Risk Classification
• Protocol: (see step-by-step protocol, p.25)
1) Conduct a Preliminary Health Evaluation
2) Determine Health /Disease Risks
3) Determine the need for pre-exercise / pretesting comprehensive health evaluation
Data collected in the screening and risk classification helps to determine the
extent of the physician’s evolvement in the patient’s exercise therapy.
Preliminary Health Evaluation
• Purpose:
• Detect disease presence
• Assess disease risk
• Components:
•Minimal Components
• Informed Consent
• Par-Q
• Checklist for Signs and Symptoms of Disease
• CHD Risk Factor Assessment
• Classification of Disease Risk
•Comprehensive Components (additions to above)
• Medical History Questionnaire
• Lifestyle Profile
• Blood Lipids and Blood Pressure Assessment
• 12 Lead Resting ECG
Preliminary Health Evaluation
Preliminary Health Evaluation
•Informed Consent: Before conducting any physical
fitness tests or exercise programs, participant should
complete and sign the informed consent (see appendix
A.9, “Informed Consent,” p. 381-382).
•Procedure:
•Explain the purpose of the informed consent
•Verbally summarize / read each section of the
consent
•Ask the patient if they have questions or concerns
•Have patient initial each section of the consent as
it is reviewed.
•Have patient and witness sign consent
Preliminary Health Evaluation
•PAR-Q: The PAR-Q has seven questions designed to identify
individuals who need medical clearance from their physicians before
taking any physical fitness tests or starting an exercise program (see
Appendix A.1, “Physical Activity Readiness Questionnaire (PAR-Q),”
p. 364).
•Procedure:
•Explain the purpose of the PAR-Q
•Have patient fill out form
•If the Patient answers “Yes” to any questions, ask if they have
seen a physician about the concern
•If not, refer to a Physician (who could choose to use the PAR
med-X Appendix A-4, p. 370-373), or PARmed-X for Pregnancy
to communicate with you)
•If they have, determine if there is an exercise restriction /
limitation.
Class practice on PAR-Q……
Administering PAR-Q
1) Inform Client of purpose
2) Read/Review questions
with client
3) “Yes” questions followed
up with whether
physician is aware
4) If physician is aware,
has client been cleared
for exercise without
restrictions. If so, note,
if not, note said
restrictions, and request
follow-up.
5) If physician is unaware,
note, and request
physician follow-up.
6) Send form, notations,
PARmed-X form with
client to physician
Preliminary Health Evaluation
•Checklist for Signs and Symptoms of Disease: As part
of the pretest health screening, you should ask your
clients if they have any of the conditions or symptoms
listed in appendix A.3, “Checklist for Signs and
Symptoms of Disease,” page 368-9 (next slide). Clients
with any of the signs or symptoms on the checklist
should be referred to their physician to obtain a signed
medical clearance prior to any exercise testing or
participation. The Physical Activity Readiness Medical
Examination (PARmed-X) was designed for this
purpose.
•Components:
•Cardiovascular
•Pulmonary
•Metabolic
•Musculoskeletal
•Risk Factor Assessment
Preliminary Health Evaluation
Preliminary Health Evaluation
•CHD Risk Factor Assessment: To assess your client’s
coronary risk profile, evaluate each item in Table 2.2
carefully. Guidelines for classification of blood pressure
and blood cholesterol levels in adults are presented in
Tables 2.3 and 2.4, respectively.
•Components: (Contains Negative Risk Factors and Positive Risk Factor)
•Age
•Family History
•Cigarette Smoking status
•Hypertension Status (Table 2.3)
•Blood Cholesterol Status (Table 2.4)
•Blood Glucose Status
•Body Composition Status
•Physical Activity Status
Preliminary Health Evaluation
CHD Risk Factor Assessment
Preliminary Health Evaluation
Preliminary Health Evaluation
•Classification of Disease Risk: On the basis of the
results from the coronary risk factor analysis, you
should classify individuals as low, moderate, or high
risk.
• Low Risk - category comprises individuals who
are asymptomatic with no more than one major
risk factor (see Table 2.2).
• Moderate Risk - individuals who are
asymptomatic having two or more risk factors.
• High Risk - individuals who have one or more
signs or symptoms of cardiovascular, pulmonary, or
metabolic disease or individuals with known
cardiovascular, pulmonary, or metabolic disease
(Appendix A.3, “Checklist for Signs and Symptoms of Disease,”
page 368-9 ).
Preliminary Health Evaluation
•Medical History Questionnaire: You should require
your clients to complete a comprehensive medical
history questionnaire that includes questions
concerning personal and family health history (Appendix
A.2, “Medical History Questionnaire,” p. 366-7).
Components:
•examine the client’s record of personal illnesses,
surgeries, and hospitalizations (section A);
•assess previous medical diagnoses and signs and
symptoms of disease that have occurred within the
past year or are currently present (section B);
•and analyze your client’s family history of
diabetes, heart disease, stroke, and hypertension
(section C).
Preliminary Health Evaluation
•Medical History Questionnaire (continued): After
completing the Questionnaire, you should determine if
the patient has any of the conditions that require
medical referral (see “Absolute and Relative
Contraindications to Exercise Testing” [Gibbons et al. 2002]
on p. 26). If any of these conditions are noted, refer
your client to a physician for a physical examination
and medical clearance prior to exercise testing or
starting an exercise program
•Class practice
(use form in text, p.366-7)
Medical History Questionnaire……
on
Preliminary Health Evaluation
•Lifestyle Evaluation:
• The lifestyle assessment provides useful
information regarding the individual’s risk factor
profile.
•These factors can be used to pinpoint patterns
and habits that need modification and to assess
the likelihood of the client’s adherence to the
exercise program.
•You can obtain a lifestyle profile for your clients
by using either the Lifestyle Evaluation form or the
Fantastic Lifestyle Checklist provided in appendix
A.7, page 377-8 (next slide).
Preliminary Health Evaluation
Preliminary Health Evaluation
Clinical Tests
For a comprehensive health screening, you will
need to evaluate information and data obtained
from the physician’s medical examination and
clinical tests. Clinical tests provide data about your
client’s blood chemistry, blood pressure,
cardiopulmonary function, and aerobic capacity.
Preliminary Health Evaluation
Clinical Test Components
1. Physical examination: recommended for
moderate- and high-risk clients
2. Blood chemistry profile: allows insight into
blood glucose and lipid levels
3. Resting blood pressure: allows insight into
pressure the heart is generating or withstanding
when filling and emptying at rest
4. Graded exercise test: allows ability to monitor
physiologic responses to a stressor
Preliminary Health Evaluation
Physical Exam
• Focus should be signs and symptoms of CHD
• Should also include assessment:
–
–
–
–
–
•
Weight
Orthopedic issues
Cardiac function (rate, regularity)
Blood pressure (various positions)
Heart, lung, and major artery sounds
Signature authority from MD indicating approval to
start or continue with directions for any concerns or
limitations to exercise or exercise testing
Preliminary Health Evaluation
Who needs to obtain a physical exam before
exercise program participation (testing and exercise)
•men ≥45 yr of age or women ≥55 yr of age;
•individuals of any age with two or more major
risk factors;
•individuals of any age with one or more signs or
symptoms of cardiovascular or pulmonary disease;
or,
•individuals of any age with known cardiovascular,
pulmonary, or metabolic disease.
Preliminary Health Evaluation
•Classification of Disease Risk: On the basis of the
results from the coronary risk factor analysis, you
should classify individuals as low, moderate, or high
risk.
• Low Risk - category comprises individuals who
are asymptomatic with no more than one major
risk factor (see Table 2.2).
• Moderate Risk - individuals who are
asymptomatic having two or more risk factors.
• High Risk - individuals who have one or more
signs or symptoms of cardiovascular, pulmonary, or
metabolic disease or individuals with known
cardiovascular, pulmonary, or metabolic disease
(Appendix A.3, “Checklist for Signs and Symptoms of Disease,”
page 368-9 ).
Preliminary Health Evaluation
When to Require Medical Exam and when
Physician Supervision is Recommended
See Also: Absolute and Relative Contraindications to Exercise
Testing, p. 22, text
Preliminary Health Evaluation
Absolute and Relative Contraindications - p. 22, text
•
•
•
•
Do not allow client to proceed
Refer client to physician
Require physician to release prior to testing
May require the presence of physician during
testing
• May require exercise supervision
Preliminary Health Evaluation
Blood Chemistry Profile
Information obtained from
a complete blood analysis
is used to assess your
client’s overall health
status and readiness for
exercise. Table 2.5
provides normal values for
selected blood variables. If
any of these values fall
outside of the normal
range, refer your clients to
their physician.
Preliminary Health Evaluation
Blood Chemistry Profile
• The National Cholesterol
Education Program (NCEP):
– Fasting lipoprotein profile
assessment every 5 years
for those > 20 yrs.
• Table 2.6 is NCEP’s listing of
•
three risk categories that modify
LDL-C treatment goals.
Refer clients for professional help
if they have high(160-189 mg/dl) or
very high (> 190 mg/dl) LDL-C
levels.
Preliminary Health Evaluation
Blood Pressure
•
•
•
SBP: arterial pressure during systole (ejection, emptying; higher
number)
DBP: arterial pressure during diastole (relaxation, filling; lower number)
Pulse pressure: SBP − DBP
Preliminary Health Evaluation
Blood Pressure - Prehypertension
Although prehypertension is not considered a disease,
prehypertensive individuals are encouraged to modify their
lifestyle in order to reduce their risk of developing
hypertension by:
• losing body weight if overweight;
• adopting a healthy eating plan that includes a diet rich in
fruits, vegetables, and low-fat dairy products but reduced in
cholesterol, saturated fat, and total fat;
• restricting dietary sodium intake to no more than 2.4 g (100
mmol) per day;
• engaging in aerobic physical activities at least 150 min/wk;
• and limiting alcohol consumption to no more than 1 oz (29.6
ml) per day for men and 0.5 oz (14.8 ml) per day for women.
(see also meds on bottom of pg. 30-31)
Preliminary Health Evaluation
Additional Clinical Tests
• For individuals with known or suspected
CHD
– GXT / Physician Supervised GXT
– 12 Lead ECG
– Echocardiogram, Chest X-Ray
– Comprehensive Blood Chemistry Analysis
Preliminary Health Evaluation
Graded Exercise Test
•
•
•
•
Helps assess functional aerobic capacity
Beneficial for setting exercise prescriptions
Should be administered by trained, certified personnel
Use risk stratification to determine contraindications, need for MD presence.
(Review Table 2.8; slide #23) Individuals with absolute contraindications
should not be given a graded exercise test unless their condition has been
stabilized or medically treated.
• In cases in which the benefits outweigh the risks, individuals with relative
contraindications may perform exercise tests. These tests, however, should
use low-level endpoints and be administered with caution (ACSM 2010)
• The ACSM (2014) recommends a medical exam but not a maximal exercise
test for individuals of moderate CVD risk before beginning a exercise
program greater than six METS. For High risk individuals, a medical exam
and physician supervised GXT prior to engaging in moderate to high
intensity exercise. For low risk individuals, submaximal testing can be
performed without the presence of a physician.
Preliminary Health Evaluation
Testing Procedures – Blood Pressure
Measure resting BP in the supine and exercise (sitting or standing)
positions prior to testing. The client should be wearing a short-sleeved
or sleeveless garment and should be seated in a quiet room. Take BP
measurements rapidly, and completely deflate the cuff for at least 30
sec between consecutive readings. For more accurate results, obtain
two or three determinations of pressure from each arm.
Sources of error in measuring BP are numerous – see list on p. 34
Protocol – Review p. 33; FYI pp. 34--37 on BP equipment
Class practice on blood pressure assessment……
Preliminary Health Evaluation
Testing Procedures – Heart Rate
• The average resting heart rate for adults is 60 to 80 beats per
minute (bpm), with the average resting heart rate of women
typically 7 to 10 bpm higher than that of men. Heart rates as low as
28 to 40 bpm have been reported for highly conditioned endurance
athletes, whereas poorly trained, sedentary individuals may have
heart rates that exceed 100 bpm.
• Do not use resting heart rate as a measure of cardiorespiratory
fitness.
Preliminary Health Evaluation
Testing Procedures – Heart Rate
The following general guidelines may be used to classify
resting heart rate:
• <60 bpm = bradycardia (slow rate)
• 60 to 100 bpm = normal rate
• >100 bpm = tachycardia (fast rate)
Before you measure resting heart rate, your client should rest for 5 to
10 min in either a supine or a seated position.
You can measure heart rate using auscultation, palpation, heart rate
monitors, or ECG recording.
Preliminary Health Evaluation
Testing Procedures – Heart Rate
Auscultation
When measuring resting heart rate by auscultation, place
the bell of the stethoscope over the third intercostal space
to the left of the sternum. The sounds arising from the
heart are counted for 30 or 60 sec. The 30 sec count is
multiplied by 2 to convert it to beats per minute.
Preliminary Health Evaluation
Testing Procedures – Heart Rate
Palpation
With use of the palpation technique for determining heart
rate, the pulse is palpated at one of the following sites:
■Brachial artery — on the anteromedial aspect of the arm
below the belly of the biceps brachii, approximately 2 to 3
cm (1 in.) above the antecubital fossa.
■Carotid artery — in the neck just lateral to the larynx
■Radial artery — on the anterolateral aspect of the wrist
directly in line with the base of the thumb .
■ Temporal artery — along the hairline of the head at the
temple.
Preliminary Health Evaluation
Testing Procedures – Electrocardiogram (ECG)
• The electrocardiogram (ECG) is a composite record of
•
the electrical events in the heart during the cardiac
cycle.
In addition to providing baseline data, the resting ECG is
used to detect such contraindications to exercise testing
as evidence of previous myocardial infarction, ischemic
ST-segment changes, conduction defects, and left
ventricular hypertrophy.
Preliminary Health Evaluation
Testing Procedures – Electrocardiogram (ECG)
Repeated cardiac cycles as seen on an ECG
tracing:
P-wave: atrial depolarization
PR interval: delay of impulse at AV
node
QRS complex: ventricular
depolarization
ST segment: early ventricular
repolarization
T-wave: ventricular repolarization
Normal Components of the EKG Waveform
Preliminary Health Evaluation
Testing Procedures – Electrocardiogram (ECG)
Three limb leads, three augmented, and unipolar leads.
A lead is a pair of electrodes
placed on the body and
connected to an ECG recorder.
An axis is an imaginary line
connecting the two electrodes.
A standard 12-lead ECG consists
of three limb leads, three
augmented unipolar leads, and
six chest leads. Each of the 12
ECG leads records a different
view of the heart’s electrical
activity.
Preliminary Health Evaluation
Testing Procedures – Electrocardiogram (ECG)
• Bipolar (limb) leads (two electrodes per lead):
– Lead I: right arm to left arm
– Lead II: right arm to left leg
– Lead III: left arm to left leg
• Unipolar leads (one electrode per lead):
– 6 chest (precordial) leads
– 3 augmented leads (uses limb lead electrodes)
Preliminary Health Evaluation
Testing Procedures – Electrocardiogram (ECG)
Three limb leads, three augmented, and unipolar leads.
The three augmented unipolar leads
are aVF (feet), aVL (left), and aVR
(right). The augmented unipolar lead
compares the voltage across one of
the limb electrodes with the average
voltage across the two opposite
electrodes. Lead aVL, for example,
records the voltage across an
electrode placed on the left arm and
the average voltage across the other
two limb electrodes
Preliminary Health Evaluation
Testing Procedures – Electrocardiogram (ECG)
Three limb leads, three augmented, and unipolar leads.
The six chest leads (V1 to V6)
measure the voltage across a
specific area of the chest, with
the average voltage across the
other three limb leads. Figure
2.3 illustrates electrode
placement for the chest leads,
V1 through V6.
Preliminary Health Evaluation
Testing Procedures – Electrocardiogram (ECG)
One the participant has been
adequately screened, then one
may proceed with exercise testing
and exercise prescription /
programming.
Video Link
END OF PRESENTATION