1. Chapter 02 Preliminary Health Screening and Risk Classification

2. Preliminary Health Screening and Risk Classification
Protocol:
Conduct a Preliminary Health Evaluation
Determine Health /Disease Risks
Determine the need for pre-exercise / pre-testing 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.

3. 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

4. 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.6, “Informed Consent,” p. 330).
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

5. 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. 316).
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 PARmed-X, 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……

6. 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 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 Assesment

7. 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)
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

8. Preliminary Health Evaluation CHD Risk Factor Assessment

9. 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 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 (see p. 320).

10. 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. 318).
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).

11. 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. 22). 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 on Medical History Questionnaire……

12. 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.5, page 326.

13. 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.

14. 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.

15. 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

16. Preliminary Health Evaluation
Absolute and Relative Contraindications
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

17. Preliminary Health Evaluation
Comprehensive Health Evaluation and Clinical Tests

18. 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.

19. Preliminary Health Evaluation
Clinical Test Components
Physical examination: recommended for moderate- and high-risk clients
Blood chemistry profile: allows insight into blood glucose and lipid levels
Resting blood pressure: allows insight into pressure the heart is generating or withstanding when filling and emptying at rest
Graded exercise test: allows ability to monitor physiologic responses to a stressor

20. 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.

21. 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

22. 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.

23. 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 or very high LDL-C levels.

24. 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

25. 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.

26. 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, see Table 2.7. 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 (2010) recommends a maximal exercise test for older men (≥45 yr) and women (≥55 yr) before they begin a vigorous (>6 METs [metabolic equivalents] or >60% of functional aerobic capacity) exercise program.

27. 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. 27
Protocol – Review p. 28; FYI pp on BP equipment
Class practice on blood pressure assessment……

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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

34. Three limb leads, three augmented, and unipolar leads.
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.

35. 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)

36. Three limb leads, three augmented, and unipolar leads.
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

37. Three limb leads, three augmented, and unipolar leads.
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.

38. 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.
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