ACSM’s Guidelines For
Exercise Testing And
Prescription : Chapter 2
Health Screening
& Risk Stratification
David Arnall, Ph.D., P.T., FACSM, ES
Reasons To Screen Your
Exercising Population
Identify and exclude individuals with
medical contraindications to exercise
Identify individuals with risk factors
who need to be seen by a physician
before undertaking an exercise
program.
Identify individuals with significant
disease who should only exercise in a
medically supervised environment.
Identify individuals with other special
needs such as orthopedic problems,
neurological conditions, etc.
Physical Activity Readiness
Questionnaire - The PAR-Q
Thisquestionnaire was first
developed in Canada and is used
widely to assess the readiness of
individuals to undertake a
moderately vigorous physical
exercise program.
PAR-Q
Common sense is your best guide
in answering these few questions.
Please read them carefully and
check the yes or no box.
http://www.d.umn.edu/student/loon/soc/phys/par-q.html
Questions On The PAR-Q To Ask
Potential Exercising Persons
1. Has your doctor ever said that
you have heart trouble ?
2. Do you frequently have pains
in your heart and chest ?
3. Do you often feel faint or have
spells of severe dizziness?
4. Has a doctor ever said your
blood pressure was too high?
5. Has your doctor ever told you
that you have a bone or joint
problem such as arthritis that
has been aggravated by exercise,
or might be made worse with
exercise?
6. Is there a good physical
reason not mentioned here why
you should not follow an activity
program even if you wanted to?
7. Are you over age 65 and not
accustomed to vigorous exercise?
Ifthe person filling out the PAR-Q
answers YES to any of the questions,
they are advised to see their
physician and find out if they are
able to exercise safely in a
community exercise program.
If the person filling out the PAR-Q
answers NO truthfully to all of the
questions, they are reasonably
assured that they can have a fitness
appraisal evaluation and begin an
exercise program as long as they
start out slowly and gradually
advance the intensity of their
exercise.
Coronary Risk Factors To Be Used
With ACSM’s Risk Stratification
Family History - MI, coronary
revascularization or sudden death
before the age of 55 years in the
father or other first-degree relative
(son, brother) or before the age of 65
years in the mother or other first-
degree relative (sister, daughter).
Cigarette Smoking - current use or
those who have quit within the last 6
months (other tobacco use - pipe,
cigars, etc.)
Hypertension - Blood pressure on
two separate occassions > 140/90 or
an individual who is on medications
for hypertension
Hypercholesterolemia
Total Serum Cholesterol > 200 mg/dl
Low-Density Lipoproteins > 130 mg/dl
High-Density Lipoproteins 110
mg/dl measured on 2 separate
occassions.
- Body mass Index > 30
Obesity
Kg/m2 or waist girth > 100 cm.
There are many health professionals
which disagree about what marker
of obesity to use. Therefore, use
your best clinical judgement when
evaluating this risk factor.
Sedentary Lifestyle - Persons who
are not involved with a regular
exercise program†.
† Persons not accumulating 30 + minutes of
exercise on most days/week
Additional Concerns …...
MajorSigns & Symptoms Of
Cardiopulmonary Disease Are :
Chest Pressure/Pain Or Other
Anginal Equivalents
SOB At Rest Or Mild Exercise
Dizziness Or Syncope
Orthopnea Or Paroxysmal
Nocturnal Dyspnea
Ankle Edema
Palpitations Or Tachycardia
Intermittent Claudication
Heart Murmurs
Unusual Fatigue Or SOB With Usual
Activities
ACSM Risk Stratification
Low Risk - Men under 45 yrs and
women under 55 yrs. Who are
asymptomatic and have no more
than one risk factor (HTN, Obesity,
Hypercholesterolemia, Family Hx.)
Moderate Risk - Men > 45 yrs and
women > 55 yrs or if these persons
have two or more risk factors.
High Risk - Persons with one or more
signs or symptoms (ankle edema,
orthopnea, SOB, angina, etc.) or
known cardiovascular, pulmonary
(COPD) or metabolic disease (DM).
Now that the patient has been
screened and evaluated as to
their potential risk, there are
other decisions that the exercise
leader must make.
Definitions…...
Moderate Exercise : This intensity
is defined as any activity that is
between 3-6 METs.
An exercise that is equivalent to
brisk walking at 3-4 mph.
An exercise that can be comfortably
sustained for 45 minutes.
Vigorous Exercise : Activities > 6
METs
A substantial cardiorespiratory
challenge sustainable for 20-30 min.
The Two Golden Questions
Does my patient need a physical exam
and an exercise test prior to starting an
exercise program ?
Does the physician need to be present
when I perform the exercise test ?
Does The Patient Need A Physical,
An Exercise Test & Does The
Physician Need To Be Present ?
Low Risk Mod. Risk High Risk
Mod. Ex Not Not Recomm.
Necessary Necessary
Vigorous Not Recomm. Recomm.
Exercise Necessary
Submax. Not Not Recomm.
Test Necessary Necessary
Maximal Not Recomm. Recomm.
Test Necessary
What If They Are Already
Cardiac Patients ?
Low Risk
Ejection fraction > 50%
No resting or exercise-induced dysrhythmias
Asymptomatic & have no angina with
exertion or recovery
Functional work capacity > 7 METs
Normal hemodynamics
No clinical depression
Moderate Risk
Ejection fraction between 40% - 49%
Signs/symptoms including angina at
moderate levels of exercise (5-6.9 METs)
or in recovery.
High Risk
Ejection fraction < 40%
Survivor of cardiac arrest/sudden death
Complex ventricular arrhythmia at rest
or exercise
Abnormal hemodynamics
Signs/symptoms with low level exercise
Functional capacity < 5 METs
Significant clinical depression
Risk factor stratification can be
modified with :
exercise training
risk factor reduction
lipid lowering drugs, nitrates, -blockers
surgical intervention (CABG, PTCA)
thrombolysis (streptokinase, TPA)
stress reduction - counseling & drugs
With cardiac patients, do I have an
algorhythm to determine if they
need a physical exam and an exercise
test with a physician present prior to
undertaking an exercise program ?
The answer is NO !! A physician
must examine, test and clear a
cardiac patient prior to exercising.