2 Chapter 2: 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/2013/03/January2020PARQPlus_Image.pdf

 

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 new guidelines! Use these and not the ones in your book (ACSM-EP exam uses these)
Blood lipids Dyslipidemia: client is taking blood lipid-lowering medication or
LDL>129 mg/dL
HDL<41 mh/dL
If total cholesterol is the only measure available, use >199 mg/dL as the criteria instead
Glucose metabolism Diabetes
Fasting glucose >125 mg/dL or 2 hr OGTT >199 mg/dL
Or HbA1c >6.4%
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

 

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.

 

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.

 

  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: One person to measure blood pressure, one person to have their blood pressure measured.

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 

Resting blood pressure:

  1. 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.
  2. 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
  3. 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.
  4.  Pump up the cuff. You should pump it up about 20mmHg past where you hear the last sound
  5. 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)
  6. Fully deflate the cuff
  7. 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.

Additional reading: More in-depth instructions can found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3936692/pdf/jceh_26_84_076.pdf

Video #1: ACSM Blood Pressure Assessment Technique

Video #2: How to: Measure Blood Pressure (Another example)

  • This video discusses more of the technique in taking a BP measurement (in a healthy person, you do not need to automatically pump the cuff up to 200mmHg. Instead, 20mmHg above the last sound you hear is acceptable).

Video #3: 7 Simple Tips To Get An Accurate Blood Pressure Reading

  • This is a good video for common sources of error in BP measures.

Virtual Lab Activity 1:

Practice reading blood pressure: Watch the video: Blood Pressure: Audio-Visual Coordination Skills

Follow along with the video and practice accurately identifying the systolic and diastolic BP sounds.

Activity 2: Heart rate and pulse rate measurements

Equipment: Polar HR monitor (watch and chest strap)

Participant: One person (yourself) or two people (practice measurement on someone else)

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:

  1. 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
  2. Turn on the Polar watch, hold within 3 feet of the participant, and make sure the watches received a signal.
  3. Once a signal is received, it will take about 10-15 seconds for the reading to appear

Instructions for radial pulse measure:

  1. 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)
  2. When you feel the pulse, start your count for 15 seconds
  3. Multiple your 15-second count by four to calculate beats per minute (BPM)

 

Note: For some exercise tests, it is important to do the pulse count for a specific interval of time and not multiply it. For example, if using pulse to approximate exercise recovery the rate of return to resting values will vary based on the individual’s fitness and it is important to not take a “short cut” by using a shorter duration for the pulse count and multiplying the value. 

Virtual Lab Activity 2:
Practice measuring radial pulse: Follow the instructions above for finding your radial pulse measure.
1. Find your resting pulse (sit for ~5min before measuring your pulse).
2. Find a post-exercise pulse rate (perform a short cardio activity such as 20 jumping jacks, then measure your pulse).

 

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/2013/03/January2020PARQPlus_Image.pdf

PARmed-X: http://www.csep.ca/cmfiles/publications/parq/parmed-xpreg.pdf

Instructions: Complete your PAR-Q+ or PARmed-X.

Virtual Lab Activity 3:
Complete PAR-Q+ or PARmed-X: This does not need to be turned in. Use this to self-assess your readiness for physical activity.

 

Questions