1. 1 Health Screening Sources - ACSM Resource Manual 6th ed (American College of Sports Medicine) –Ch 10 –Ch 18 (p 284-290) –Ch 19 (p 297-304) –Ch 51 Readings - CPAFLA - (Canadian Physical Activity, Fitness and Lifestyle Appraisal) –Ch 1, 4, 5, –7-1 to 7-10 –8-7 to 8-15

2. 2 Outline - Health Screening Role Of Appraiser Goals of Health Screening –HS Forms - details and limitations –Overview of Risk Factors we are screening for Physical Screening Tests –Resting Blood Pressure and Heart Rate Safety and Legal Concerns

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4. 4 Wellness Continuum Figure 1.1

5. Role of the Appraiser The appraisal can trigger changes and influence the personal health practices of clients. However, counseling sessions and dialogue with the client can be just as important.

6. 6 Role Of Appraiser Appraise clients physical activity and lifestyle habits Design program (along with client) to improve fitness, coping skills and sense of mastery in life Refer clients to other health professionals Rely on these professionals to provide information and support for the goals you have assisted the client in developing Client Based Approach, Appraiser is part of a team of Professionals

7. Characteristics of the Appraisal Historical performance related single procedure for all clients emphasis on fitness focus on prescribed exercise (FITT) tests and measures assumed readiness for change appraisal-reappraisal Current health related Procedural options emphasis on physical activity consider broader lifestyle issues information and advice recognizes/helps “non- movers” various contact scenarios

8. Options and Scenarios - CPAFLA Full appraisal - CPAFLA 7 Step Model Partial appraisal, with regrets –Client fails part of pre-screening Partial appraisal by choice Help, tips and advice only Follow up options –Single session –Appraisal and reappraisal –Appraisal and ongoing contact

9. 9 CPAFLA 7 Step Model Step 1: Rapport and Structure Step 2: Gathering Information Step 3: Conduct the Health-Related Fitness Appraisal Step 4: Interpret Physical Activity and Lifestyle Questionnaires and Health-Related Fitness Appraisal Results Step 5: Generate and Evaluate Alternatives for Change Step 6: Develop an Action Plan Step 7:Follow Up

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11. 11 Dose Response to Activity Figures 1-3 and 1-4 in CPAFLA Improvements will vary depending on change in volume of activity and clients place on benefit curve in relation to each component evaluated Figure 4-1 CPAFLA - Dose Response and Health Benefit Zones Emphasize knowledge of client and approach to counseling

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15. CPAFLA Health Benefit Zones Excellent - Associated with optimal health benefits Very Good - Associated with considerable benefits Good - Associated with many health benefits Fair - Associated with some benefits, but also some health risks Needs improvement - Associated with considerable health risks

16. 16 Pre-participation Screening Most prospective participants are apparently healthy Primary safety goal of health screening is to identify those who should receive further medical evaluation prior to exercise testing or training –identify medical conditions –identify possible contraindicated activities –Is referral to a medically supervised exercise program needed? Information gathered can assist in designing an individualized exercise program Following screening protocol will fulfill legal and insurance requirements

17. 17 Instructions to Client Recommendations prior to screening –Do not eat for at least 2 hrs prior –Refrain from caffeine for 2 hrs prior –Refrain from alcohol for 6 hrs prior –Should not smoke during 2 hrs prior –Exercise should be avoided for 6 hrs prior –If client is taking medication for CV or metabolic function active component of assessment should not be done (ie aerobic tests - mCAFT, coopers) –Pregnant women require doctors consent

18. 18 Pre-participation Screening CPAFLA guidelines Forms –PAR-Q PARMED X if client fails PAR-Q –LIFESTYLE checklist –Physical Screening - HR, BP and observations –Activity history –* KIN 343 adds health history to above requirements Physical Screening –HR –BP –Observations

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21. 21 Health Screening Forms PAR-Q - developed in BC, used worldwide –Brief, Self administered Appraiser can not assist or interpret for client –Contact physician if YES answered to one or more questions - use PARMED X formPARMED X Sensitivity - nearly 100% –% with medical contraindications who answer Yes Specificity - ~ 80% –% of persons without medical conditions who answer NO

22. 22 Limitations of PAR-Q Limited sensitivity and specificity for predicting exercise ECG abnormalities Inability to screen out persons with 2 or more major CAD risk factors Automatic referral if over 69 Inability to Identify medications that may affect exercise safety Inability to Identify pregnancy Absence of questions that identify adverse health behaviors

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25. 25 343 adds - Health History Important to assess risk for CAD and other chronic diseases Several risk factors depend on behavior Participants health behaviors should be assessed Personal History is used to –Clarify risk of CAD events during exercise –Prioritize interventions –Encourage change in lifestyle and reduce disease –Develop or modify exercise program

26. 26 Pre-participation Screening ACSM guidelines –Minimum required is self administered questionnaire such as PAR-Q –Does not require medical exam for asymptomatic, apparently healthy men under 45 and women under 55 with fewer than two CAD risk factors (see slides 24 and 25 for details) For vigorous exercise above 60% VO 2 max –Also, medical exam unnecessary for anyone asymptomatic and apparently healthy to undergo moderate exercise at 40-60% VO 2 max

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30. 30 Other Risks to Consider Chronic obstructive pulmonary disease –bronchitis, asthma, emphysema Metabolic disorders –diabetes, hyper/hypothyroidism Musculoskeletal –herniated disk, arthritis Other conditions –pregnancy, hernia, illness, infection

31. 31 Other Considerations The properties of drugs must be understood and discussed with a physician –May alter HR / BP; ECG response, exercise capacity Link between dietary habits and development of disease Past and current exercise behaviours / habits What do they enjoy? Type A behaviour? Eating Disorders? Age and Exercise Intentions? –how old is this person and how vigorously does he or she want to exercise?

32. 32 Physical Screening Tests Client may be unaware of a risk factor! blood pressure heart rate observation

33. 33 Blood Pressure indications that fail screening CPAFLA - systolic > 145 - diastolic > 95 - On BP medication ACSM - systolic > 140 - diastolic > 90

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36. 36 ClassificationSystolic (mmHg)Diastolic (mmHg) Normal< 120< 80 Pre Hypertension120 - 13080 - 89 Stage 1140 - 15990 - 99 Stage 2> 160> 100 Risk of CVD, beginning at 115 / 75 mmHg, doubles with each increment of 20 / 10 mmHg Classification of Blood Pressure for Adults

37. 37 Heart Rate indications that fail screening CPAFLA and ACSM HR > 100 bts/min at rest ACSM cautions about HR < 60 in an untrained individual at rest

38. 38 Observation indicating failure of screening shortness of breath coughing persistently pregnant lower extremity swelling posture limp flexibility and strength?

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40. 40 Safety and Legal Concerns The main concern of a fitness program is that it be conducted safely for everyone permitted to participate in the program. The first step is obviously to screen and exclude those individuals who should not be exercising prior to checking with a physician. It is then imperative to ensure that the program is designed so those individuals cleared for exercise are able to perform their exercise in a safe manner. Fortunately, the same kinds of things done to make the program safe also help protect the program legally.

41. 41 INFORMED CONSENT: Voluntary acknowledgement of purpose, procedures, and assumption of known (informed) dangers/risk(s) –Although getting the participant's consent does not prevent legal actions or protect against negligence, it does indicate that the program is concerned with the participant and has acted in good faith. This may be enough for legal protection.

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43. 43 WAIVERS: Voluntary abandonment of a right to file a lawsuit. Waives all claims to damage including negligence. –Waivers are becoming more common and are better written. It is possible for some waivers to stand up even if the program (person) was negligent. I believe this is rather worrying from an ethical viewpoint, but spending the money up front to get a well-written legal waiver drawn up does make good fiscal sense.

44. 44 SAFETY PROCEDURES: These procedures include regular check of the equipment and facilities and periodic reviews of the procedures used by the staff in classes and during testing. A written record of maintenance and safety checks should be kept. “If it isn’t written down….it wasn’t done”. Written records showing when the review, training, and practice were carried out should be kept in the central office.

45. 45 EMERGENCY PROCEDURES: A written emergency procedure should be established and staff members trained to carry out the procedure. Local emergency services to be used should be contacted to help establish the procedures, and comprehend and agree with the procedures that are to be followed.

46. 46 LIABILITY If you were responsible for an exercise program, a set of equipment, etc. and something goes wrong then you and your employer are liable. If negligence can then be proven then criminal charges and/or civil damages may be applied. The program and its staff have a responsibility to perform the procedures as described in a professional manner, watch for any danger signs that might indicate a problem, and take appropriate actions to stop the activity before problems occur. If problems do occur, the staff should be trained to take the appropriate actions to deal with minor problems, and how to get immediate help for major problems.

47. 47 NEGLIGENCE Is defined as an omission to do something that a prudent and reasonable person (fitness instructor) would do, or do something that a prudent and reasonable person (fitness instructor) would not do. No amount of informed consent procedures can justify negligence: Participants and areas need supervision. Staff personnel need training in appropriate emergency procedures. Failure to do so, or failure to act in a manner fitting a fitness professional, constitutes negligence.

48. 48 If injury or death occurs as a result of the negligence, then the leader and program are legally liable (as stated above others may also be found liable). These concepts fall under the law of tort (a civil wrong, a method of compensation based on the moral principle of responsibility for injury caused by fault). Legal liability can arise out of an omission, which means failing to act when the action could be reasonably expected in a specific instance, or out of an act of commission, which means performing an act in a negligent manner.

49. 49 To establish a claim of negligence, four elements must exist: 1. DUTY OF CARE: A duty must exist for a person or group to provide an appropriate standard of care and to take reasonable precautions to safeguard against foreseeable dangers. 2. BREACH OF DUTY OF CARE: An act or omission must occur whereby a duty is not undertaken or complied with. 3. DAMAGE There must be an injury or loss resulting from the breach. The injury may be personal injury, damage to property or damage to a person's reputation. 4. CAUSATION: It must be established that a sufficient causal relationship existed between the breach of duty and the resulting injury or loss.