LO2 of Unit 4 – Understand pre-exercise health screening methods
Understand pre-exercise health screening methods
Learning outcomes
By the end of this section, you will be able to:
2.1 Identify methods of health screening prior to gym-based exercise
2.2 Describe risk stratification models
2.3 Describe how to categorise client risk for exercise
2.4 Explain when to refer or signpost clients to medical professionals/exercise specialists
2.1
Identify methods of health screening prior to gym-based exercise – Learners must identify health screening methods, informed consent, and risk modification models.
Pre-activity screening
Individuals attend fitness centres for many reasons such as losing weight and improving appearance. Although most people can engage regularly in moderate to vigorous fitness activities without any negative health consequences, there may be occasions where physical exertion could exacerbate any unforeseen, underlying pathology i.e., high blood pressure.
It is therefore necessary, as well as being professional practice, to ensure individuals who want to participate in a regular exercise programme are ready to exercise and have a clean bill of health to do so.
Pre-activity screening is used to identify individuals who may have medical conditions which put them at a higher risk of an adverse event during physical activity/ exercise. There are a number of industry accepted methods that allow you to ensure all reasonable steps have been taken to quickly evaluate each person’s health status prior to beginning an exercise programme. Methods include:
1: Health History Questionnaire and Physical Activity Readiness Questionnaires (PAR-Q)
2: Gaining medical clearance
3: Informed consent
4: Interview
5: Observation
6: Physical measurements.
Health History Questionnaire (HHQ)
The Health History Questionnaire (HHQ) is opportunity to gather information that will assist the fitness professionals in evaluating a client’s current level of health and fitness. The HHQ covers basic information like known medical diagnoses, family history, potential disease symptoms & current health habits.
Physical activity readiness questionnaire (PARQ)
The Physical Activity Readiness Questionnaire (PAR-Q) is another assessment commonly used to assesses risk factors & overall readiness for someone who is about to begin an exercise program.
A person who answers ‘No’ to all questions can begin a physical activity program at light-moderate intensity. An individual who answers ‘Yes’ to any one or more needs additional attention before beginning a physical activity programme. This follow-up is usually going to involve either a medical check or another health professional to determine the balance of risk versus benefit for that individual.
Gaining medical clearance
If the client answers YES to one or more questions on the PAR-Q then it should initiate further investigation. Unless you have the correct qualifications or expertise to investigate further the client’s condition then the client should discuss their health matter with their doctor before any exercise programme can be started.
Ensure clients do the following:
- the client could make an appointment with their doctor and ask the GP to write a letter with their recommendations.
- the client could take a medical approval form to the doctor, and a medical approval form could be posted to the doctor and returned.
The Adult Pre-exercise Screening System (APSS)
developed by Fitness Australia is composed of one compulsory and two optional stages. It provides fitness professionals with a simple system in which to screen clients for pre-existing medical conditions.
Stage 1
Stage 1 is compulsory involving administering the PARQ questionnaire. All fitness staff can administer a PARQ to a client or gym member. The outcome of the completed form is to direct the correct course of action. A person who answers ‘No’ to all questions can begin a physical activity programme with light to moderate intensity exercise Answering ‘Yes’ however, to any one or more questions needs additional attention before beginning a physical activity/exercise programme.
It is important to seek further clarification if the individual has answered ‘yes’ responses as it may not be necessary to refer on. For example, problems with a joint or joints can often be modified or avoided. Exercise during pregnancy can certainly continue if the woman is already exercising and there are no issues.
If you have any doubt or uncertainty about a person’s health status, then it’s best to seek further assistance from someone more experienced.
Stage 2
Stage 2 optional is an optional stage. The aim of this stage is to identify those individuals with risk factors or other conditions to assist appropriate exercise prescription. This stage is to be administered by a qualified exercise professional or level 4 exercise referral specialist.
Stage 3
Stage 3 involves professional quantifying the degree of risk associated with persons exercising even with light activity. The person is asked to answer a further 12 questions in order to identifying the level of risk
Risk Factors & Risk Stratification
Upon completion of the Health History Questionnaire & PAR-Q, individual clients can be evaluated based on their risk of experiencing an adverse cardiovascular event during exercise. According to the American College of Sports Medicine, instructors can stratify a client’s risk using variables such as age, risk factors & symptoms suggestive of disease. The “Initial ACSM Risk Stratification” screening defines 3 risk categories:
1: Low Risk: younger individuals who are asymptomatic and meet no more than 1 risk factor threshold.
2: Moderate Risk: Older individuals (men > 45 years of age; women > 55 years of age) or those who meet the threshold for 2 or more risk factors.
3: High Risk:Individuals with known cardiovascular or pulmonary disease; known metabolic disease, such as type 1 or type 2 diabetes; or 1 or more signs/symptoms suggestive of any of these diseases.
Once clients are stratified according to risk, trainers should use a standard such as the “ACSM Recommendations” to determine whether their clients should be referred to a physician for a thorough medical exam prior to beginning either a moderate or vigorous exercise program.
Informed Consent
The last step in the exercise screening process should provide an opportunity for all clients to give informed consent before beginning an exercise programme. Informed consent should be obtained prior to collecting data, especially physical data from health or fitness assessments.
Informed consent ensures your client knows and understands the purposes/ benefits and risks associated with an exercise programme or health fitness assessment. This enables your client to make an informed choice as to participate or not. You must obtain a written agreement to participate signed by the client. If the person is under 16, then consent must be sought from the parent or legal guardian.
The informed consent document can vary among facilities depending on clientele, staff, equipment, etc., but all informed consents should be written in an understandable manner & include certain basic information:
- purpose of the consent
- degree of exercise supervision (i.e., close monitoring, occasional monitoring)
- benefits & risks of exercise participation
- steps or procedures that will be followed in an emergency situation
- responsibilities of the client (i.e., reporting of symptoms, exercise program adherence)
- statement covering confidentiality & freedom of consent to participate in the program
- The fitness professional needs to explain to a new client at the outset that there are risks of injury associated with all aspects of a fitness programme.
Health Commitment Statement
The Health Commitment Statement sets the standards that health and fitness centres and facility users can reasonably expect from each other, concerning the health of the user.
The HCS is the evolution of the PAR-Q and was developed by Ukactive operator members, medico-legal professionals and health providers to support the evolving requirements of users and operators.
The HCS has been designed for users in a gym environment and with all operators in mind, allowing flexibility with its usage.
2.2
Describe risk stratification models
Risk stratification tools
In the UK, most exercise referral schemes have developed their own risk stratification tools and protocols for working with specific individuals and groups; these are based on risk factors and comorbidities: multiple chronic conditions affecting a client’s health and ability to exercise. In most instances these tools have been developed by working collaboratively with local medical practitioners (such as nurses, GPs and physiotherapists).
To date there has been no single model used and this has raised concerns in recent years because it was believed that a standardised approach should be adopted across schemes for both safety standards and monitoring and evaluation purposes.
There are a number of models available to stratify risk:
If the patient answers ‘yes’ to one or more questions, the instructor then uses the Irwin and Morgan assessment.
- Traffic light system
- Green = low risk (remain exercising, unsupervised)
- Amber = medium risk (individualised and supervised programmes for condition)
- Red = high risk (cardiac disease – referred back to healthcare professional)
Other risk stratification tools include: Logic model for the ACSM risk stratification scheme – Once the symptom(s) and risk factors are known, potential clients can be classified on the basis of the likelihood of events to occur during any exercise program participation.
Risk classification becomes progressively more important as disease prevalence increases in the population under consideration. Using health status, symptoms, and risk factor information, potential clients can be classified into one of three risk levels (low, moderate, or high) the risk level can be used to determine who should be cleared by their physician prior to participation.
2.3
Describe how to categorise client risk for exercise
Conducting a thorough health history will provide the instructor with valuable information for developing a client’s program. The purposes of a health history are to identify known disease and risk factors for disease, especially CVD, and to identify conditions that deserve special consideration when developing an exercise programme or require referral to a specialist professional.
The client’s physical activity level, lifestyle factors, relevant health history, medical conditions, current, past and present injuries, any disabilities or physical impairments, and current health status gathered as part of the initial consultation. may also be included in the initial client consultation to provide the most complete picture of the client’s health.
Physical activity readiness questionnaire (PARQ)
The Physical Activity Readiness Questionnaire (PAR-Q) is another assessment commonly used to assesses risk factors & overall readiness for someone who is about to begin an exercise program.
A person who answers ‘No’ to all questions can begin a physical activity program at light-moderate intensity. An individual who answers ‘Yes’ to any one or more needs additional attention before beginning a physical activity programme. This follow-up is usually going to involve either a medical check or another health professional to determine the balance of risk versus benefit for that individual.
Gaining medical clearance
If the client answers YES to one or more questions on the PAR-Q then it should initiate further investigation. Unless you have the correct qualifications or expertise to investigate further the client’s condition then the client should discuss their health matter with their doctor before any exercise programme can be started.
Once the symptom(s) and risk factors are known, potential clients can be categorised on the basis of the likelihood of events to occur during any exercise program participation. Risk classification becomes progressively more important as disease prevalence increases in the population under consideration.
Using health status, symptoms, and risk factor information, potential clients can be classified into one of three risk levels (low, moderate, or high), the risk level can be used to determine who should be cleared by their physician prior to participation.
Hypertension (high blood pressure) represents a unique risk factor in that it may be aggravated by short-term exercise, such as weight training. Therefore, although it appears within Table 11.1, special consideration should be given to clients with hypertension when screening for exercise testing or training.
Because hypertension is commonly grouped with several other risk factors associated with CVD (e.g., obesity, and diabetes), most hypertensive clients who want to start an exercise program fall into the moderate- or high-risk category.
However, in cases where hypertension is the only risk factor, cautious recommendations for preparticipation screening should be based on the severity of the hypertension and the desired intensity of exercise.
For low-risk clients with isolated stage 1 hypertension (140–159/90–99 mm Hg), exercise testing generally is not necessary for clearance to engage in up to moderate-intensity exercise. It is advisable for such clients to have physician clearance prior to participation.
On the other hand, if the client has documented stage 2 hypertension (>160/100 mm Hg) or if a client with stage 1 hypertension desires to engage in more intense exercise training, an exercise assessment is recommended to quantify blood pressure responses during exercise to aid in establishing prudent guidelines for exercise training.
2.4
Explain when to refer or signpost clients to medical professionals/exercise specialists
The primary responsibility of a Gym Instructor as previously discussed is to minimise the risks of exercise, whilst at the same time maximising the benefits. Through pre-exercise screening, the instructor may identify a health risk or condition that will impact the client’s exercise programme, and that is outside your scope of practice.
The gym instructor must refer the client to a more qualified health professional if they fall into one of four criteria:
1: Instant medical referral
- Any diagnosed metabolic, pulmonary or cardiovascular disease
- Signs or symptoms of a pulmonary or cardiovascular disease.
2: Several measurements require special attention and potential temporary deferral:
- High blood pressure, current smoker and positive family history of CHD
- Minor injuries such as sprains and strains
3: Doubt or uncertainty – Doubt or uncertainty regarding any aspect of the client’s health. As the instructor the best advice is to refer.
4: Client preference or doubt – If the client expresses a desire to be medically referred before starting an exercise programme, again the instructor should play safe and refer
5: A ‘yes’ response to a PAR Q (refer to GP) – Answering ‘yes’ to any questions on the PARQ requires the client to gain medical clearance prior to participation. As training demands that certain physiological systems are stressed at minimum thresholds to bring about adaptation, it would be unethical and potentially negligent to ignore the first level of screening. You must not step outside the fitness industry’s scope of practice for a fitness instructor, so therefore, ensure best practice and seek the guidance from the correct allied health professional.
Arteries
Our arteries function to transport blood away from the heart and are under high pressure. Arteries mainly carry oxygenated blood; however, there is an exception: the pulmonary artery transports deoxygenated blood from the heart’s right ventricle to the lungs.
Arteries have thick muscular walls (smooth muscle) which are elastic, allowing them to stretch when the heart contracts forcefully, pushing blood out from the left ventricle into the aorta. In this way, the pressure the blood exerts on the artery wall is not excessive. However, arterial pressure is critical because it maintains blood flow through the capillary beds.
[IMAGE 5]
Artery
Capillaries
Being only one cell thick, capillaries are the smallest type of blood vessel, so they’re incredibly thin. Blood pressure within the capillaries is very low (otherwise you would bleed to death), declining along their length from less than 35mmHg to about 18mmHg.
The thin walls allow oxygen, nutrients and carbon dioxide to exchange (via diffusion) between the capillaries and the body’s cells and from the body’s cells to the capillaries.
Veins
The role of veins is to carry mainly deoxygenated blood towards the heart. However, the pulmonary vein is the exception, carrying oxygenated blood from the lungs to the left atrium.
Venous pressure is low, only about 18mmHg from the venules to the right atrium. Due to the low pressure, veins have thin walls and a large lumen. The low pressure in veins means blood would struggle to return to the heart without a sufficient mechanism to aid return. Fortunately, several mechanisms assist venous return to the right atrium, which enable them to deal with low blood pressure flow. One striking feature is that veins below the heart level are lined with non-return valve structures. Once blood is pumped through the valve system, they shut, stopping any backflow of blood which would otherwise pool in the lower extremities.