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1
EXS 145
Guidelines for Exercise Testing & Prescription
Andrew Weiler M.Ed
MCCD – Adjunct Faculty
SRPMIC – Employee Wellness Supervisor
Pot & Window LLC
10-22-13
Today
How to aid in development of safe exercise prescription/testing?
Absolute & Relative Contraindications
CAD Risk Factor Thresholds
ACSM Risk Stratification Categories
Exercise Testing: Risk & Supervision
AHA Risk Stratification Criteria
Probably not in the Fitness Center?
Blood Pressure
Please be sure to review Box 3-4 (p45) and Table 3.1 (p46)
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How to aid in development of safe exercise prescription/testing?
Identify and exclude individuals with medical contraindications to exercise
Identify increased risk due to:
Age
Symptoms
Risk factors
Clinically significant disease
How to aid in development of safe exercise prescription/testing?
Why?
Send for medical evaluation
Possibly including exercise testing
Refer to medically supervised programs
Identify special needs
Educate/council
How to aid in development of safe exercise prescription/testing?
Especially screen for:
Cardiovascular diseases (name a few?)
Pulmonary diseases
Metabolic diseases
Conditions aggravated by exercise:
Pregnancy
Orthopedic injury
Arthritis
Hypertension
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Screening
Don’t lose your clients (Two ways)
They are inconvenienced by screening
Died because you didn’t screen them.
“Professionally qualified exercise staff refers to appropriately trained
individuals who possess academic training, practical & clinical
knowledge, skills & abilities commensurate with the credentials
defined in Appendix D.”
The professionally guided preparticipation screening process involves: the review of more detailed
health/medical history information and specific risk stratification, and
detailed recommendations for physical activity/exercise, medical examination, exercise testing, and physician supervision.
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Absolute & Relative Contraindications Table 2-2, Box 3-5
Relative: Significantly increased risk for injury with
exercise Risks – benefits carefully considered
Absolute: Very high risk
Benefit > risk is unlikely
Who makes that call?
Personal trainer: Don’t exercise either!
Do you see why this is a reference tool? Major Signs/Symptoms Suggestive of Cardiovascular, Pulmonary,
and Metabolic Disease
5
Known Cardiovascular, Pulmonary, and Metabolic Disease An individual has known cardiovascular,
pulmonary, and/or metabolic disease if a physician has diagnosed one of the following conditions:
Cardiovascular disease (CVD): cardiac, peripheral artery (PAD), or cerebrovascular disease
Pulmonary disease: chronic obstructive pulmonary disease (COPD), asthma, interstitial lung disease, or cystic fibrosis
Metabolic disease: diabetes mellitus (type 1 or type 2), thyroid disorders, and renal or liver disease
CAD Risk Factor Thresholds for use With ACSM Stratification Table 2-2
Age: Men > 45 y.o. Women > 55 y.o.
Family History:
MI, coronary revascularization or sudden death in:
Male first-degree relative <55 y.o.
Female first-degree relative <65 y.o.
Cigarette smoking:
Smoker in last 6 months
Exposure to environmental smoke
Hypertension SBP >140 mmHg
DBP >90 mmHg
Anti-hypertensive medication Measurements on > two separate occasions
Sedentary Lifestyle >3 months F: < 3 days
I: < Moderate 40-60%VO2R
D:< 30 minutes
CAD Risk Factor Thresholds for use With ACSM Stratification Table 2-2
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Dyslipidemia
LDL >130 mg/dl
Total Chol > 200 mg/dl
Some say only as substitute for LDL
HDL < 40 mg/dl
Negative Risk Factor:
HDL> 60 mg/dl
Controversy: removes dyslipidemia or any RF?
CAD Risk Factor Thresholds for use With ACSM Stratification Table 2-2
Prediabetes (impaired fasting glucose):
FPG> 100 mg/dl <126 mg/dl
Confirmed on > 2 separate occasions
IGT on OGTT
Obesity:
BMI > 30 kg/M2
Waist girth: > 102 cm men > 88 cm women
Waist/Hip > 0.95 men, > 0.86 women
CAD Risk Factor Thresholds for use With ACSM Stratification Table 2-2
Undisclosed or Unavailable CVD Risk Factor Information
Health/fitness and exercise professionals and clinicians are encouraged to adopt a conservative approach to CVD risk factor identification for the purposes of risk stratification, especially when:
risk factor information is missing, and/or
the criteria for identifying the presence or absence of a specific risk factor cannot be determined or is not available.
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Undisclosed or Unavailable CVD Risk Factor Information (cont.)
If the presence or absence of a specific risk
factor is not disclosed or is unavailable, the risk factor should be counted as a risk factor except for prediabetes.
Missing or unknown criteria for prediabetes should be counted as a risk factor in the presence of age(≥45 years), particularly for those with a body mass index ≥25 kg·m-2
and for those who are younger, have a body mass index ≥25 kg·m-2, and have additional risk factors for prediabetes.
Risk Stratification Table 2-1
Bye bye helpful table 2-1, thank you for being so useful.
ACSM Risk Stratification Categories Table 2-1
Low Risk
Men < 45, Women <55 y.o.
Asymptomatic
< 1 CAD RF
Moderate risk:
Men > 45, Women >55 y.o.
Symptomatic (not really but I say yes)
> 2 CAD RF
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ACSM Risk Stratification Categories Table 2-1
High Risk
> sign/symptom table 2-3
Known cardiovascular, pulmonary, metabolic disease
Look at table 2-3 again:
Do you see why the GETP8 is a reference text?
More About Risk Stratification
Assessing risk becomes more important as prevalence increases
Signs/symptoms represents a higher-level concern for decision making than RFs
Low-risk (ACSM) isolated HTN
More About Risk Stratification
More about HTN
Aggravated by exercise
Commonly clustered with other risk factors: obesity, DM, CAD, HLP
Low-risk (ACSM) isolated HTN
< 160/100 mmHg = Moderate I
Ex testing not necessary
Physician clearance advisable
9
More About Risk Stratification
More about HTN
Low-risk (ACSM) isolated HTN < 160/100 mmHg = Intense I Ex testing necessary
Document hemodynamic response
Physician clearance advisable
Stage II HTN (documented)>160/100 mmHg MD clearance & test
More About Risk Stratification
Individuals stratified to need medical clearance:
Benefit from further assessment
Benefit from professionally-guided exercise programs
Risk Stratification (cont.)
Figure 2-3
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Figure 2.3 (p26) after risk factors = Table 2.2 p27 & Figure 2.4 (p28)
Great for a quiz
Funny: “need” for testing could be looked at as “Can I test him/her?”
Interpreted by qualified professionals
Results documented
Exercise Testing and Testing Supervision Recommendations Based Upon Risk Category
Figure 2-4
Atherosclerotic Cardiovascular Disease Risk Factors (cont.)
The table of risk factors contains clinically relevant established CVD risk factor criteria that should be considered collectively when making decisions about:
the level of medical clearance,
the need for exercise testing prior to initiating participation, and
the level of supervision for both exercise testing and exercise program participation.
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Exercise Testing and Participation Recommendations Based Upon Risk Category
Once the risk category has been established for an individual as low, medium, or high, appropriate recommendations may be made regarding:
the necessity for medical examination and clearance before initiating a physical activity/exercise program or substantially changing the FITT framework of an existing physical activity/exercise program,
Exercise Testing and Participation Recommendations Based Upon Risk Category (cont.)
the necessity for an exercise test before initiating a physical activity/exercise program or substantially changing the FITT framework of an existing activity program, and
the necessity for physician supervision when participating in a maximal or submaximal exercise test.
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Exercise Testing: Risk & Supervision
Risk of CV events increases with I
In all situations where testing is performed:
BLS all staff, ACLS at least some staff
“Whenever possible” test should be performed by ACSM certified staff because:
These credentials document the KSAs directly related to exercise testing
Box 2.2 Recommendations for a Medical Exam Prior to Initiating Physical Activity
• Moderate risk (> RFs: Table 2.2 & Figure 2.3) should be encouraged to consult with their physician prior to initiating a vigorous I exercise program s part of good medical care. • Progress slowly regardless of I prescribed.
• The majority of Mod risk can begin with light to moderate I without consulting MD.
• Individuals with known disease or signs/symptoms
(table 2.1) should consult MD prior to initiating an exercise program or being tested.
13
Table 2.3 New ACSM Recommendations for Exercise Testing Prior to Exercise Diagnosed CVD
Unstable/new or possible
symptoms of CVD (Table 2.2)
End-stage renal disease
Symptomatic of diagnosed
pulmonary disease: COPD
Asthma
Interstitial lung disease
Cystic fibrosis
DM & one of the following: > 35 y.o.
>10 year DMII
>15 year DMI
HLP >240 mg/dl
HTN >140/>90 mmHg
Smoking
F.H. 1st degree < 60 y.o.
Vascular disease Micro or PVD
Autonomic neuropathy
Disappointed:
“Information gathered from an exercise test may be useful in establishing a safe & effective Rx for lower-risk individuals.
Recommending an exercise test for lower-risk individuals may be considered if the purpose of the test is to design an effective Rx
This is a clinical exercise test $$$
Exercise Testing (ET)
ETing high risk clients can be supervised by non-physician health care professionals specifically trained in clinical exercise testing with a physician immediately available if needed.
ETing of Mod risk clients can be supervised by non-physician staff specially trained in clinical exercise testing.
Supervision dependent on:
local policies and circumstances (“Standard of Care”)
Staff training/preparation
Client’s health status
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Guidelines for ET and Emergencies.
All exercise facilities with/without MD supervision should:
Written plan with procedures & contacts
Should practice plan > quarterly
AED/Defib depending on staff competencies
BLS/AED (Healthcare)
ACLS
First Aid
Next Week: Class to start at 2:30pm
Please check announcement in Bb and your email during the week in case there are changes to our schedule.