Aha Acsm Preparticipation Screening Questionnaire

Preparticipation Screening

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INTRODUCTION

The link between living a physically active lifestyle and the accompanying reduction in several chronic diseases is well established. Concrete activity is beneficial in the main prevention of cardiovascular illness (CVD), stroke, diabetes, obesity, osteoporosis, anxiety, low, and some cancers (34). Should an private decide to start participating in a more active lifestyle, it would be prudent to take certain precautions to minimize the possible risks associated with initiating or increasing do. Contemporary preparticipation screening guidelines have focused primarily on risk classification (i.e., low, moderate, high) for individuals initiating exercise. This chance classification framework was based on the possible number of CVD adventure factors or the presence of signs and symptoms and/or known cardiovascular, pulmonary, or metabolic disease. Thus, recommendations for a medical exam and exercise test were based on their chance classification and the proposed exercise intensity in an effort to avoid exposing inactive individuals, with known or hidden CVD, to unaccustomed vigorous activity that may increase the risk of sudden cardiac death (SCD) and acute myocardial infarction (AMI).

Recent evidence suggests that this blazon of screening (39) may erroneously over-refer individuals to seek out medical clearance before do when, in fact, they do not require information technology and may inadvertently create a barrier for an individual to prefer a physically active lifestyle. Although the overall goal of practice preparticipation screening has not changed (i.east., identify those at adventure for an adverse result during exercise), a new epitome has been created that volition encourage concrete activeness, while minimizing barriers, still ensuring the condom of the do participant.

Exercise professionals should always incorporate some form of preparticipation screening or health appraisal prior to performing fitness testing or initiating an exercise program for an individual. The goals for preparticipation screening are (a) to identify who should receive medical clearance prior to initiating an exercise program or increasing the frequency, intensity, and/or book of their current exercise program; (b) to identify those with clinically pregnant disease(southward) to determine if they would benefit from participating in a medically supervised practise program; and (c) to place those with medical weather condition who should be restricted from participating in an exercise programme until their disease conditions are abated or better controlled. Based on these goals, the exercise professional person will improve sympathize and apply the information from the preparticipation health screening algorithm (Fig. iii.1) past

Determining an individual's current physical action levels

Identifying signs and symptoms underlying CVD, metabolic disease, and renal disease (Tabular array iii.1) in that person

Identifying individuals with diagnosed CVD and metabolic disease

Using an individual'due south current level of exercise participation, affliction history, signs and symptoms, and desired exercise program intensity to guide recommendations for preparticipation medical clearance.

Effigy three.1. The American College of Sports Medicine Preparticipation Screening Algorithm. (From Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM's recommendations for exercise preparticipation wellness screening. Med Sci Sports Exerc. 2015;47[8]:2473–9. Used with permission.)

Table 3.1

Major Signs and Symptoms Suggestive of Cardiovascular, Metabolic, and Renal Disease

Signs or Symptoms	Clarification/Significance
Pain; discomfort (or other anginal equivalent) in the chest, neck, jaw, arms, or other areas that may consequence from myocardial ischemia	One of the cardinal manifestations of cardiac illness, in particular, coronary artery disease
	Fundamental features favoring an ischemic origin include the following: Character: constricting, squeezing, burning, "heaviness," or "heavy feeling" Location: substernal, across midthorax, anteriorly; in ane or both arms, shoulders; in neck, cheeks, teeth; in forearms, fingers in interscapular region Provoking factors: exercise or exertion, excitement, other forms of stress, common cold conditions, occurrence after meals
	Key features against an ischemic origin include the following: Character: ho-hum ache; "knifelike," sharp, stabbing; "jabs" aggravated by respiration Location: in left submammary area; in left hemithorax Provoking factors: later on completion of practice, provoked by a specific trunk motion
Shortness of breath at rest or with mild exertion	Dyspnea (divers as an abnormally uncomfortable sensation of animate) is ane of the chief symptoms of cardiac and pulmonary disease. It commonly occurs during strenuous exertion in salubrious, well-trained individuals and during moderate exertion in good for you, untrained individuals. Nonetheless, it should be regarded every bit abnormal when information technology occurs at a level of exertion that is not expected to evoke this symptom in a given private. Abnormal exertional dyspnea suggests the presence of cardiopulmonary disorders, in particular, left ventricular dysfunction or chronic obstructive pulmonary illness.
Dizziness or syncope	Syncope (defined every bit a loss of consciousness) is most commonly caused past a reduced perfusion of the brain. Dizziness and, in particular, syncope during exercise may event from cardiac disorders that prevent the normal rise (or an bodily autumn) in cardiac output. Such cardiac disorders are potentially life-threatening and include severe coronary artery disease, hypertrophic cardiomyopathy, aortic stenosis, and malignant ventricular dysrhythmias. Although dizziness or syncope soon after cessation of do should not be ignored, these symptoms may occur fifty-fifty in healthy individuals as a result of a reduction in venous return to the heart.
Orthopnea or paroxysmal nocturnal dyspnea	Orthopnea refers to dyspnea occurring at rest in the recumbent position that is relieved promptly by sitting upright or standing. Paroxysmal nocturnal dyspnea refers to dyspnea, get-go usually 2–5 h after the onset of sleep, which may exist relieved by sitting on the side of the bed or getting out of bed. Both are symptoms of left ventricular dysfunction. Although nocturnal dyspnea may occur in individuals with chronic obstructive pulmonary disease, it differs in that it is normally relieved following a bowel motility rather than specifically past sitting up.
Talocrural joint edema	Bilateral ankle edema that is most evident at dark is a feature sign of heart failure or bilateral chronic venous insufficiency. Unilateral edema of a limb frequently results from venous thrombosis or lymphatic blockage in the limb. Generalized edema (known as anasarca) occurs in individuals with the nephrotic syndrome, severe middle failure, or hepatic cirrhosis.
Palpitations or tachycardia	Palpitations (defined as an unpleasant awareness of the forceful or rapid beating of the middle) may be induced by various disorders of cardiac rhythm. These include tachycardia, bradycardia of sudden onset, ectopic beats, compensatory pauses, and accentuated stroke volume resulting from valvular regurgitation. Palpitations as well ofttimes result from anxiety states and high cardiac output (or hyperkinetic) states, such equally anemia, fever, thyrotoxicosis, arteriovenous fistula, and the so-called idiopathic hyperkinetic heart syndrome.
Intermittent claudication	Intermittent claudication refers to the hurting that occurs in the lower extremities with an inadequate blood supply (usually as a effect of atherosclerosis) that is brought on by exercise. The pain does not occur with standing or sitting, is reproducible from solar day to twenty-four hours, is more than severe when walking upstairs or up a hill, and is often described as a cramp, which disappears within i–2 min after stopping do. Coronary artery disease is more than prevalent in individuals with intermittent claudication. Patients with diabetes are at increased risk for this condition.
Known heart murmur	Although some may be innocent, eye murmurs may betoken valvular or other cardiovascular illness. From an exercise safety standpoint, it is especially of import to exclude hypertrophic cardiomyopathy and aortic stenosis as underlying causes because these are among the more than common causes of exertion-related sudden cardiac death.
Unusual fatigue or shortness of breath with usual activities	Although there may exist beneficial origins for these symptoms, they also may signal the onset of or alter in the condition of cardiovascular disease or metabolic disease.

These signs or symptoms must be interpreted within the clinical context in which they appear because they are not all specific for cardiovascular disease.

Modified from Gordon SMBS. Health appraisal in the non-medical setting. In: Durstine JL, editor. ACSM'south Resource Manual for Guidelines for Exercise Testing and Prescription. second ed. Philadelphia (PA): Lippincott Williams & Wilkins; 1993. p. 219–28.

It is important to note that an private with pulmonary disease or a sign or symptom indicative of pulmonary disease volition no longer be automatically referred for medical clearance. The presence of certain pulmonary diseases does not increase the risk of fatal or nonfatal cardiovascular complications during or immediately afterward practise. It is believed that the take a chance of a cardiovascular complication in someone with pulmonary disease is non because of the affliction simply because of the person'south sedentary lifestyle (15).

Two types of preparticipation screening will be presented in this affiliate. The commencement will be directed toward the exercise professional person working with a general, nonclinical population and the second for those professionals working in a clinical or cardiopulmonary rehabilitation setting. For those exercise professionals who are working in a nonclinical setting, information technology is important to empathise that there is a new process for performing preparticipation health screening. Previous screening methods relied heavily on CVD risk factor cess and subsequent risk classification. The new American Higher of Sports Medicine (ACSM) algorithm is based on (a) an individual'south electric current level of physical activeness; (b) the presence of signs or symptoms and/or known cardiovascular, metabolic, or pulmonary disease; and (c) the desired exercise intensity of the exercise prescription (ExR_x).

In the absence of a qualified exercise professional person, the private may use a self-screening method that will be explained later in this chapter. Likewise, if indicated during the screening process (see Fig. iii.1) that medical clearance should be sought from the appropriate health care provider, the manner of clearance should be determined by the health care provider using his or her clinical judgment. Information technology is important to notation that preparticipation health screening before initiating an practise programme should be distinguished from a periodic medical examination (34), which should be encouraged as part of routine wellness maintenance.

American College of Sports Medicine Preparticipation Screening Algorithm

The new ACSM preparticipation screening algorithm (29) is, in office, based on the knowledge that the relative take chances for SCD and AMI in adults with underlying CVD is transiently increased during a bout of vigorous intensity exercise (24,32) but that the absolute risk during exercise is low in a healthy, asymptomatic private (1,20,32,38). Bear witness from the Physicians' Health Study and Nurses' Health Study suggest that SCD occurs every 1.5 1000000 episodes of vigorous concrete activity (1) and 36.five one thousand thousand hours of moderate-to-vigorous concrete activity in women (38). Exercise-related cardiovascular events are often preceded by alarm signs and symptoms (32), and those events that ended in SCD were most often in people older than 35 years, where SCD could be attributed to underlying and often undiagnosed coronary avenue disease (CAD) (21). Furthermore, physically inactive individuals are at a greater total risk for cardiac events compared with their active counterparts (11,34). Previous preparticipation screening included the cess of CVD adventure factors. There is bereft show to propose that the presence of one or more CVD risk factors, without underlying disease, confers any boosted risk for an agin event during practice. With the high prevalence of CVD risk factors among adults (39) and the rarity of practice-related SCD and AMI, the power to predict cardiovascular events by assessing CVD risk factors becomes questionable, particularly in otherwise healthy adults (32,33). Therefore, the new screening algorithm is based not on CVD risk factors simply on whether or not the private is sedentary or physically agile.

The screening algorithm (meet Fig. 3.1) starts by identifying whether or not the person presently participates in regular exercise. Individuals who are classified equally currently exercising should accept been physically active during the by 3 months for at least 30 minutes, on 3 or more than days per week and exercising at a moderate intensity (40%–60% middle rate reserve [HRR] or 64%–76% maximal heart rate [HR_max]). The next level of classification is based on whether an individual has been told past a medico or other health care provider that he or she has a cardiovascular, metabolic, or renal disease or any signs or symptoms suggestive of cardiac, peripheral vascular, or cerebrovascular disease, Types ane and 2 diabetes mellitus, or renal disease.

Once an individual'due south disease condition has been determined, the exercise professional person should shift attending to an assessment of any signs and symptoms suggestive of these diseases (see Table three.ane). The presence of signs and symptoms should be done to better identify those who have an undiagnosed disease. This part of the procedure tin can often be hard because of the vague or ambiguous responses from people. The exercise professional should take the time to have a ane-on-one chat in order to analyze any such responses by asking additional questions to assist better differentiate whether a response is actually because of a pathological condition or considering of a misunderstanding of the signs or symptoms.

The concluding stride in using the preparticipation screening algorithm is to determine the desired practise intensity (run into Fig. 3.1) for the individuals' ExR_ten. Information technology has been established that vigorous do is more likely to cause an acute cardiac event compared with low-cal-to-moderate exercise in individuals (24,32). The exercise professional can utilize a health screening checklist (23) (Fig. iii.2) for guidance through this procedure. One time all the necessary information has been collected, individuals are grouped into one of six categories (left to correct) in the screening algorithm (see Fig. three.1).

1. Individuals who practice not participate in regular practise; take no known cardiovascular, metabolic, or renal affliction; and have no signs or symptoms suggestive of disease tin brainstorm an exercise program at a light-to-moderate intensity without medical clearance. The individual can increment across moderate intensity post-obit the principle of progression and those guidelines outlined in Affiliate 8.

2. Asymptomatic individuals who practise non participate in regular practise with a known cardiovascular, metabolic, or renal affliction should obtain medical clearance earlier starting an exercise plan. One time cleared to exercise, he or she should begin at a low-cal-to-moderate intensity and progress to higher intensities every bit tolerated.

3. Individuals who are symptomatic and do not currently exercise should seek medical clearance before participating in practise. Following medical clearance, the private may start an exercise program of lite-to-moderate intensity.

4. Those individuals who do participate in regular exercise and practice not have any known affliction or sign or symptom suggestive of disease do not demand any medical clearance and may begin an exercise plan starting at a moderate-to-vigorous intensity or continue with their current exercise programme.

5. Individuals who participate in regular exercise and are asymptomatic merely take a diagnosed cardiovascular, metabolic, or renal disease practise non demand medical clearance when starting a moderate-intensity do program. Even so, it is recommended that if the intensity of exercise increases to vigorous, the individual should seek medical clearance. In addition, if these individuals experience resting or exertional symptoms of illness or any change in wellness condition, they should visit with their health care providers.

vi. An individual who participates in regular practise but experiences any signs or symptoms suggestive of cardiovascular, metabolic, or renal disease should discontinue the current exercise programme and obtain medical clearance before standing exercising at any intensity.

FIGURE 3.2. Exercise Preparticipation Health Screening Questionnaire for Practise Professionals. (From Magal M, Riebe D. New preparticipation health screening recommendations: what exercise professionals need to know. ACSM's Health Fitness J. 2016;20[3]:22–7. Used with permission.)

Should an individual be identified for needing medical clearance, he or she should exist referred to an appropriate medico or health care provider. The type of medical clearance is left to the discretion of the provider. Because there is no standardized screening examination, procedures may vary from practitioner to practitioner and may exist as simple as a verbal consultation or more than in-depth with a resting or stress electrocardiogram/echocardiogram, detection of coronary artery calcification via computed tomography, or fifty-fifty nuclear medicine imaging or angiography. It is suggested that the exercise professional request written clearance with special instructions or restrictions (e.g., may non exercise over 8 metabolic equivalents [METs]). Continued communication between the provider and exercise professional is an essential component of this process and aids in the success of the private'south do program.

Self-Guided Methods

Traditionally, self-administered preparticipation health screening involved the use of the Concrete Activity Readiness Questionnaire (PAR-Q) and the American Heart Clan [AHA]/ACSM Health/Fettle Preparticipation Screening Questionnaire. With the advent of ACSM's new screening algorithm, the traditional questionnaires do not play as big a role in preparticipation screening considering they relied heavily on take chances factor nomenclature. Nevertheless, the PAR-Q was recently updated to the evidence-based Physical Action Readiness Questionnaire for Everyone (PAR-Q+) (Fig. 3.3) and now includes a number of additional follow-up questions that guide the practice professional person in his or her preparticipation recommendations (36). The updated version was created to reduce barriers to practice as well as to reduce the number of false positive screenings (17) and utilizes follow-up questions that allow the exercise professional to amend tailor the ExR_x for the individual based on medical history and possible signs and symptoms. The PAR-Q+ may be used as a self-guided tool, but considering of the additional questions, it may be prudent to have a qualified do professional assess the results.

FIGURE 3.3. Concrete Activity Readiness Questionnaire for Everyone (PAR-Q+). (Reprinted with permission from the PAR-Q+ Collaboration and the authors of the PAR-Q+ [Dr. Darren Warburton, Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Shannon Bredin].)

Practise professionals who work with patients with known CVD in exercise-based cardiac rehabilitation settings or medical fitness facilities are advised to conduct a much more than in-depth stratification process (forty) that is different from the previously presented preparticipation screening for the full general public. Risk stratification criteria outlined in Box 3.1 from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) (two) provide a guideline to help in the assessment of clinical populations. The AACVPR guidelines provide recommendations for telemetry monitoring and exercise supervision for patients' signs and symptoms or known affliction. Clinical exercise professionals should be aware that the AACVPR guidelines practice not take into account an individual with comorbidities (east.one thousand., Type two diabetes mellitus, morbid obesity, severe pulmonary illness, and debilitating neurological or orthopedic conditions) and how their condition may require a modification in the patient's monitoring or supervision during exercise. For example, a patient with CVD may require telemetry monitoring. If that same patient has Type ii diabetes, the practise professional person would need to be aware of glucose monitoring likewise as potential neuropathies.

Box 3.1	American Association of Cardiovascular and Pulmonary Rehabilitation Risk Stratification Criteria for Patients with Cardiovascular Illness
Lowest Risk
Characteristics of patients at lowest risk for exercise participation (all characteristics listed must be present for patients to remain at lowest risk):
Absence of circuitous ventricular dysrhythmias during practice testing and recovery
Absenteeism of angina or other significant symptoms (due east.k., unusual shortness of breath, light-headedness, or dizziness during exercise testing and recovery)
Presence of normal hemodynamics during exercise testing and recovery (i.e., appropriate increases and decreases in center rate and systolic claret pressure with increasing workloads and recovery)
Functional capacity ≥vii metabolic equivalents (METs)
Nonexercise Testing Findings
Resting ejection fraction ≥50%
Uncomplicated myocardial infarction or revascularization procedure
Absence of complicated ventricular dysrhythmias at rest
Absence of congestive heart failure
Absence of signs or symptoms of post-event/post-procedure myocardial ischemia
Absenteeism of clinical low
Moderate Take a chance
Characteristics of patients at moderate risk for exercise participation (any 1 or combination of these findings places a patient at moderate risk):
Presence of angina or other significant symptoms (east.thousand., unusual shortness of breath, low-cal-headedness, or dizziness occurring merely at loftier levels of exertion [≥7 METs])
Mild-to-moderate level of silent ischemia during exercise testing or recovery (ST-segment depression <2 mm from baseline)
Functional capacity <5 METs
Nonexercise Testing Findings
Rest ejection fraction xl%–49%
Highest Risk
Characteristics of patients at high chance for exercise participation (whatever 1 or combination of these findings places a patient at loftier risk):
Presence of complex ventricular dysrhythmias during exercise testing or recovery
Presence of angina or other significant symptoms (e.thou., unusual shortness of breath, light-headedness, or dizziness at low levels of exertion [<5 METs] or during recovery)
High level of silent ischemia (ST-segment depression ≥2 mm from baseline) during practise testing or recovery
Presence of abnormal hemodynamics with practice testing (i.e., chronotropic incompetence or flat or decreasing systolic blood pressure with increasing workloads) or recovery (i.e., severe postexercise hypotension)
Nonexercise Testing Findings
Rest ejection fraction <40%
History of cardiac abort or sudden expiry
Complex dysrhythmias at rest
Complicated myocardial infarction or revascularization process
Presence of congestive center failure
Presence of signs or symptoms of mail-effect/post-procedure myocardial ischemia
Presence of clinical low