Health Appraisal/Screening & Risk Stratification Chapter 6

1. Health Appraisal/Screening & Risk StratificationChapter 6

2. Pre-participation Health Screening Purpose • Identification individuals w/ • medical contraindications to exercise • ↑d risk for disease • age, symptoms, &/or risk factors • medical evaluation & exercise testing before starting an exercise program • clinically significant disease • participate in medically supervised exercise pgm • other special needs

3. Parts of Informed Consent for Exercise Training • Purpose & explanation of procedure • Risks • Benefits • Alternatives available • Confidentiality & use of information • Inquiries & freedom of consent

4. Parts of Informed Consent for Exercise Training • Purpose & explanation of procedure • What are they consenting to • What does it consist of or include • What are they agreeing to • Expectations of program & participant • State that participant has been advised

5. Consent • Legally effective agreement of the participant or the participant’s legally authorized representative based on information that is given to the participant or the representative in language that is understandable.

6. Parts of Informed Consent for Exercise Training • Risks • Adverse Δs during exercise • Abnormal BP • Fainting • Disorders of rhythm • Stroke • Heart attack • Death • Efforts made to minimize occurrences • Knowing of these risks, it is my desire to proceed

7. Parts of Informed Consent for Exercise Training • Benefits • May or may not obtain health or fitness benefits • But, list likely benefits of exercise training

8. Parts of Informed Consent for Exercise Training • Alternatives available • Not attend • Do on own • Go elsewhere

9. Parts of Informed Consent for Exercise Training • Confidentiality & use of information • Information is privileged & confidential • Will not be released w/o written consent • Information only used by program staff • Research & statistics w/o PHI (Personal History Information)

10. Parts of Informed Consent for Exercise Training • Signatures • Patient • Witness • Staff member • Parent/Guardian

11. Valid Informed Consent • Be of lawful age • Not be mentally incapacitated • Know & fully comprehend the importance & relevance of the material risks • Give consent voluntarily & not under any mistake of fact or duress

12. Informed Consent - Administration • Private, quiet setting • Document completion • Reading • Verbal explanation • Opportunity to ask questions • Signing and dating • Presentation of copy

13. Informed Consent - Limitations • Does not provide legal immunity • Does provide evidence that client was made aware • Negligence – not covered • Legal counsel

14. Pre-activity Screening • Gathering • Demographics • Health-related information • Aid decision making for assessment & exercise

15. Preparticipation Health Screening & Risk Stratification • American College of Sports Medicine (ACSM) • American Heart Association (AHA) • American Association of Cardiovascular & Pulmonary Rehabilitation (AACVPR)

16. Therefore; Preparticipation Health Screening Include • Medical contraindications to exercise • ↑d risk for disease • Age • Symptoms • Risk factors • Clinically significant disease • Special needs

17. Health Screening Self-administered questionnaires Sophisticated diagnostic tests

18. Health Screening Nature & extent of appraisal • Age • Sex • Perceived health status of participants • Resources • Economic • Personnel • Equipment

19. Components of Pre-Activity Screening • Medical History/Health Habits Questionnaire • Physical Activity Readiness Questionnaire (PAR-Q) • Medical/Health Exam

20. Health History Questionnaire • Family Hx • History of diseases & illnesses • Surgical History • Past & present health habits • Medications • Signs & symptoms • (next slide – review p 25)

21. Physical Activity Readiness Questionnaire (PAR-Q)( Recommended as a minimum standard for entry into moderate-intensity exercise programs Designed to identify small number of adults for whom PA might be inappropriate (next slide – review p 26)

23. Physical Assessment & Laboratory Tests • Resting HR • Resting BP • Lung Capacity • FVC • FEV1 • MVV • Blood Tests • TC • LDL • HDL • TC/HDL Ratio • Glucose

24. Absolute Contraindications to Exercise Testing • Acute MI (w/n 2 days) • Unstable angina • Uncontrolled arrhythmias • Active endocarditis • Severe AS • Symptomatic HF • Acute pulmonary embolus or pulmonary infarction • Acute non-cardiac disorders • Acute myocarditis or pericarditis • Physical disability • Inability to obtain consent

25. Relative Contraindications to Exercise Testing • Left main disease or equivalent • Moderate stenotic valve disease • Electrolyte abnormalities • Tachyarrhythmias or bradyarrhythmias • A-Fib with uncontrolled ventricular rate • HOCM • Mental impairment – can’t cooperate • High-degree AV block • Severe HTN: SBP > 200 mmHg; DBP > 110 mmHg

26. Risk Stratification Risk Factors Signs & symptoms

27. Initial ACSM Risk Stratification • Low risk • Younger individuals • Asymptomatic • no more than 1 risk factor threshold from Table 2-1 (p 20)

28. Initial ACSM Risk Stratification • Moderate risk • Older individuals • men 45 years of age • women  55 years of age) • threshold for 2 or more risk factors from Table 2-1 (p 20)

29. Initial ACSM Risk Stratification • High Risk • one or more signs/symptoms listed in Table 2-3 (p 23-24) • known cardiovascular, pulmonary, or metabolic disease

30. Coronary Artery Disease Risk Factor Thresholds for Use w/ ACSM Risk Stratification* • Family History • Myocardial Infarction, coronary revascularization, or sudden death • before 55 years of age in father or other male first-degree relative (I.e., brother or son), or • before 65 years of age in mother or other female first- degree relative (I.e., sister or daughter) • Cigarette Smoking • Current cigarette smoker, or • those who quit w/n the previous 6 months Table 2-2. ACSM Guidelines for Ex Testing & Rxn

31. Coronary Artery Disease Risk Factor Thresholds for Use w/ ACSM Risk Stratification* (Continued) • Hypertension • Systolic BP of 140 mmHg, or • Diastolic 90 mmHg, confirmed by measurements on at least 2 separate occasions, or • on antihypertensive medication • Dyslipidemia • low-density lipoprotein cholesterol >130 mg/dL (3.4 mmol/L) , or • high-density lipoprotein cholesterol of <40 mg/dL (1.03 mmol/L), • or on lipid-lowering medication. • If total serum cholesterol of >200mg/dL (5.2 mmol/L) rather than LDL >130 mg/dL (3.4 mmol/L) Table 2-2. ACSM Guidelines for Ex Testing & Rxn

32. Coronary Artery Disease Risk Factor Thresholds for Use w/ ACSM Risk Stratification* (Continued) • Impaired Fasting Glucose • Fasting bld glu of 100 mg/dL (5.6 mmol/L) confirmed by measurements on at least 2 separate occasions • Obesity† • Body Mass Index of 30 kg.m2, or • waist girth of ≥102cm for men & ≥88cm for women • Sedentary lifestyle • Persons not participating in a regular exercise pgm, or NOT meeting the minimal PA recommendations‡ from the U.S. Surgeon General’s report Table 2-2. ACSM Guidelines for Ex Testing & Rxn

33. Coronary Artery Disease Risk Factor Thresholds for Use w/ ACSM Risk Stratification* (Continued) • Negative • High serum HDL cholesterol • >60 mg/dL (1.6 mmol/L) Table 2-2. ACSM Guidelines for Ex Testing & Rxn

34. Major Signs or Symptoms Suggestive of Cardiovascular & Pulmonary Disease • Anginal equivalent • Pain, discomfort in the chest, neck, jaw, arms, or other areas that may be due to ischemia • Shortness of breath at rest or w/ mild exertion • Dizziness or syncope • Orthopnea or paroxysmal nocturnal dyspnea • Ankle edema • Palpitations or tachycardia • Intermittent claudication • Known heart murmur • Unusual fatigue or shortness of breath w/ usual activities Table 2-3. ACSM Guidelines for Ex Testing & Rxn

35. Table 2-1. ACSM Recommendations for (A) Current Medical Examination* and Exercise Testing Prior to Participation and (B) Physician Supervision of Exercise Tests Low Risk Moderate Risk High Risk A. Moderate exercise NN NN R Vigorous exercise NN R R B. Submaximal test NN NN R Maximal test NN R R NN - Not Necessary R - Recommended

36. Initial ACSM Risk Stratification for Preliminary Decision Making • Low risk • Younger individuals, asymptomatic, no more than 1 risk factor threshold • Moderate risk • Older individuals (men 45 years of age; women  55 years of age), threshold for 2 or more risk factors from Table 2-1 • High Risk • One or more signs/symptoms, or known cardiovascular, pulmonary, or metabolic disease Table 2-4. ACSM Guidelines for Ex Testing & Rxn