1 Chapter 1: Pre-test screening and assessment
Melissa Markofski
Background
Pre-participation screening
Physical exercise places physiological demands on the body, especially the cardiorespiratory and skeletal muscle systems. This increases the chance for an individual to experience an injury or cardiovascular event. In symptom-limited maximal exercise testing, the rate of cardiac event is about six events per 10,000 tests. It is expected that sub-maximal exercise testing would have an even lower event rate.
To minimize this risk, we perform pre-participation screenings. Ideally, these screenings include a health history and physical activity readiness questionnaire. In this course we will use the PAR-Q+ as our self-guided pre-participation screening questionnaire. http://eparmedx.com/wp-content/uploads/2022/01/ParQPlus2022ImageFile.pdf
ACSM atherosclerotic cardiovascular disease risk (CVD) factor and defining criteria
Criteria used to determine elevated risk for CVD risk. Summary from ACSM's Guidelines for Exercise Testing and Prescription 11th edition (the REP 3rd ed textbook is outdated and wrong! Use these, as this is what the ACSM-EP exam uses)
| Criteria | Definition | Additional notes |
|---|---|---|
| Age | Males: > 44 Females: > 54 |
|
| Family history | History of cardiovascular events (myocardial infarction, coronary revascularization, sudden cardiac death) | Risk factor is met when one of these three events occurred before 55 years of age in a male or 65 years of age in a female first degree relative |
| Tabacco use | Current tobacco user, quit within the last 6 months, or regularly exposed to secondhand smoke | No current criteria for vaping tobacco exposure, but results from recent and on-going research studies supports that vaping tobacco causes changes in endothelial cells consistent with CVD |
| Physical activity | Sedentary lifestyle | Not participating in 30 mins of moderate exercise at least 3 times per week |
| Body weight | Obesity BMI >29.9 kg/m^2 or a waist circumference >102 cm in males or >88 cm for females |
If person has BMI >/= 30 and high waist circumference, it counts as one risk factor |
| Blood pressure | Hypertension SBP >129mmHg and/or DBP >79mmHg |
These are the most recent AHA guidelines! Use these! (ACSM-EP exam uses these) |
| Blood lipids | Dyslipidemia: client is taking blood lipid-lowering medication or LDL>129 mg/dL HDL<40 mg/dL (men); <50mg/dL (women) |
If total cholesterol is the only measure available, use >199 mg/dL as the criteria instead |
| Glucose metabolism | Diabetes Fasting glucose >99 mg/dL or 2 hr OGTT >139 mg/dL Or HbA1c >5.7% |
Test is usually repeated to confirm, or blood glucose and HbA1c are used together to diagnose diabetes |
| HDL cholesterol (Negative risk factor) | HDL cholesterol >59 mg/dL | Negative risk factor: subtract 1 risk factor from the above positive risk factors |
Heart rate and pulse rate
Heart rate is a measurement of the contraction of the heart. It is most commonly measured by a device that can sense the electrical activity of the heart, such as an electrocardiogram (ECG/EKG) or a sensor worn over the heart (Polar monitor). Although the terms “heart rate” and “pulse rate” are used interchangeably, there are circumstances where the two numbers will vary. It is unlikely to observe a difference in these numbers in healthy individuals, but there are health issues that can result in differences between heart rate and pulse. For example, if someone had some sort of arterial occlusion or severe injury to a major artery, the pulse rate may vary (or even be absent) in the affected limb.
Additional optional reading: Polar “Difference between heart rate and pulse”
Blood pressure measures and classifications
All participants should have their blood pressure measured to help assess risk. Pre-2017 ACSM guidelines recommended blood glucose and cholesterol screening, but this recommendation was removed from the latest guidelines. Exercise will increase the individual’s systolic blood pressure (SBP) while they are exercising. This transient increase in SBP is not of concern. However, if the participant’s SBP is high prior to an exercise session the exercise session could increase SBP to an excessively high level.
AHA blood pressure recommendations
American Heart Association (AHA) recommended blood pressure levels. Updated 2017: Be sure to use these thresholds. Adapted from https://www.heart.org/-/media/data-import/downloadables/pe-abh-what-is-high-blood-pressure-ucm_300310.pdf
| Blood pressure category | Systolic BP | Diastolic BP | |
|---|---|---|---|
| Normal BP | <120 mmHg | AND | <80 mmHg |
| Elevated BP | 120-129 mmHg | AND | <80 mmHg |
| Stage 1 hypertension | 130-139 mmHg | OR | 80-89 mmHg |
| Stage 2 hypertension | 140+ mmHg | OR | 90 mmHg or higher |
| Hypertensive crisis (call medical provider immediately) | >180 mmHg | AND/OR | >120 mmHg |
Pre-participation screenings
When reviewing the pre-participation screening documents, one of the things we are looking for is risk for cardiometabolic diseases. We want to identify people who may have contraindications to exercise. Exercise reduces the risk of developing cardiometabolic diseases, and individuals who are at an elevated risk should be encouraged to exercise if it is safe to do so (they may need to check with their medical care providers to confirm any exercise restrictions).
Individuals who are regularly exercising and have no diagnosis, signs, or symptoms of a cardiometabolic or renal disease have little restrictions on their exercise testing and prescription plan. It is recommended that individuals who are not participating in regular exercise and have a cardiometabolic or renal disease, or signs and symptoms of a cardiometabolic or renal disease, not participate in exercise testing or training until they receive medical clearance. If the person does not have cardiometabolic or renal disease, or any signs or symptoms, they may start with light to moderate exercise.
Exercise recommendations for individuals who are not currently exercising
Summary of current ACSM guidelines recommendations for physical activity for people who are not currently exercising but would like to start
| Medical clearance recommended? | General exercise plan | |
|---|---|---|
| No diagnosis, signs, or symptoms of cardiometabolic or diseases | Not recommended | Start with light to moderate exercise and progress as recommended by ACSM guidelines |
| Known cardiometabolic or renal disease but no signs or symptoms | Recommended | After medical clearance is received, start with light to moderate intensity exercise and may progress if tolerated |
| Signs and/or symptoms of cardiometabolic or renal disease | Recommended | After medical clearance is received, start with light to moderate intensity exercise and may progress if tolerated |
Class activity
Activity 1: Blood pressure measures
Equipment: Stethoscope, sphygmometer
Participant: Partner up so that everyone has a chance to 1) have their blood pressure read; and 2) practice blood pressure readings
Additional reading: More in-depth instructions can found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3936692/pdf/jceh_26_84_076.pdf
Videos: This is a good video for technique (in a healthy person, you do not need to automatically pump the cuff up to 200. 20 above the last sound you hear is acceptable) https://www.youtube.com/watch?v=Gmic13mvsgo
This is a good video for common sources of error in BP measures: https://www.youtube.com/watch?v=gUHALsLeeoM
Instructions for resting BP measures:
Note: do not put the stethoscope in your ears until you are sure the stethoscope head is not going to bump or rub against anything
- Have the participant sit in a chair, with legs uncrossed, feet on the floor, and measurement arm outstretched and relaxing on the table at about the level of the heart. Refrain from speaking with the participant during the measurement.
- Selected the sphygmometer with the cuff that fits the participant. When the cuff is wrapped around their bare upper arm (1-2″ above the crease of the elbow), it should fit within the guidelines of the cuff
- Place the stethoscope head over the participants brachial artery near the cubital fossa. If you need to hold it in place, be sure you use your fingers and not your thumb.
- Pump up the cuff. You should pump it up about 20mmHg past where you hear the last sound
- Slowly release the pressure from the cuff. Note the number that corresponds to the first sounds you hear (this is SBP) and the last sound you hear (this is DBP)
- Fully deflate the cuff
- Remove the cuff and inform the participant of their blood pressure
Exercise blood pressure: Repeat the seven steps above, but either immediately after the person does 20 jumping jacks, or while they are actively cycling on the stationary bicycle.
Activity 2: Heart rate and pulse rate measurements
Equipment: Polar HR monitor (watch and chest strap)
Participant: Partner up so that everyone has a chance to practice pulse readings
Additional reading: HR strap placement (with pictures!) from Polar https://support.polar.com/en/support/tips/How_to_wear_a_heart_rate_sensor_with_textile_strap
Instructions for heart rate measure using a Polar HR monitor:
- Have the participant fit the strap around their ribcage at the point just below the pectoral muscles. If their skin is dry or the weather is dry, the person may need to wet the strap electrodes with water or ECG gel
- Turn on the Polar watch, hold within 3 feet of the participant, and make sure the watches received a signal.
- Once a signal is received, it will take about 10-15 seconds for the reading to appear
Instructions for radial pulse measure:
- Use two fingers to palpate the participant’s wrist along the radius (in most people, the radial artery runs approximately on top of the radius)
- When you feel the pulse, start your count for 15 seconds
- Multiple your 15-second count by four to calculate beats per minute (BPM)
Activity 3: PAR-Q+
Equipment: PAR-Q+ (or PARmed-X for pregnant individuals)
Participant: Everyone will complete their own PAR-Q+ or PARmed-X
Additional reading: PAR-Q+: http://eparmedx.com/wp-content/uploads/2022/01/ParQPlus2022ImageFile.pdf
PARmed-X (for pregnancy): https://vancouver.ca/files/cov/par-q-plus-form-for-pregnancy-before-exercising.pdf
Instructions: Complete your PAR-Q+ or PARmed-X and place it facedown in the red basket. This counts as your data collection sheet for the day.
Questions
