Pre-participation Screening

            Before beginning any structured physical activity and/or exercise program, it is prudent to have one’s self checked first. Most especially if you were previously sedentary and have never done any form of physical activity for a few years, and/or above 45, for a male, and 55, for a female, years of age. If you are getting a personal trainer to help you with your fitness regimen, then he or she should start with checking your physical readiness to exercise.  This called the pre-participation screening. It can range from questionnaires to a medical check-up, which check certain metabolic parameters and clinical exercise testing.

            Do deaths occur during exercise? Yes, they do. However, sudden cardiac death in younger individuals below the 30 to 40 age group is low. This is also due to the low prevalence of cardiovascular disease. At least for the US. As per the American College of Sports Medicine (ACSM), the absolute risk of exercise-related death among high school and college athletes is one per 133,000 for men, and one per 769,000 for the women. While deaths do occur in this age group, the cause is usually congenital and hereditary.⁵  

            For the adults, the risk is, of course, higher. This is due do the higher prevalence of cardiovascular disease. However, it has also been estimated that one per year for every 15,000 to 18,000 people. Another study presents it in another way, the risk for sudden death during vigorous physical activity at 0.3 to 2.7 events and 0.6 to 6.0 events per 10,000 person hours, for men and women respectively.⁵

            The easiest to administer would be the questionnaires. One of the easiest to administer, and widely accepted is the PAR-Q, Physical Activity Readiness Questionnaire (fig.1)^1,2,3,4,5.

Fig. 1 Physical Activity Readiness Questionnaire (PAR-Q)

(Courtesy of the Canadian Society for Exercise Physiology²)

            The American College of Sports Medicine (ACSM), the Canadian Society for Exercise Physiology (CSEP), and the National Strength and Conditioning Association (NSCA) are some of the associations that recommend the use of the PAR-Q.

The PAR-Q has instructions on it’s use at the top of the first page. It was designed to assess people between the ages of 15 and 69. The PAR-Q consists of seven questions, which can be answered in less than five minutes. Five of the questions pertain to cardiac function and one to orthopaedic. The last question being a catchall, which the previous six did not cover.

If the respondent answered yes to one or more of the questions in the PAR-Q, he/she is advised to consult a doctor before becoming more physically active. If the answer is no, then it is safe to assume that one may begin to become physically  more active. Start slowly and gradually build up. As per the instructions on the PAR-Q itself, the questionnaire is valid for 12 months. If during those 12 months, one’s health deteriorates and ends up answering “yes” to any of the questions, then one should consult a doctor.

If you have answered “yes” to one or more questions in the PAR-Q, the next step would be to answer the PARmed-X, the Physical Activity Readiness Examination (fig.2) ². This is a four-page form that a physician may use to evaluate the client. It includes a checklist of medical conditions that may require special consideration and management. A conveyance/referral form is also included, in which the physician may allow unrestricted physical activity. Alternatively, that the physical activity be under medical supervision.

Fig. 2 Physical Activity Medical Examination (PARmed-X)

(Courtesy of the Canadian Society for Exercise Physiology²)

For pregnant women wishing to be more active, there is a PARmed-X for Pregnancy available as well (fig. 3)². It is also meant to be answered by the physician with the client present It contains a checklist which include the general health status, status of current pregnancy, activity during the last month, and physical activity intentions. It also contains a list of absolute and relative contraindications to exercise, prescription for aerobic and muscular conditioning, a health evaluation form, advice for active living during pregnancy, and some safety considerations.

Fig. 3 Physical Activity Medical Examination for Pregnancy (PARmed-X for Pregnancy)

(Courtesy of the Canadian Society for Exercise Physiology²)

There are other self-guided questionnaires available. The ACSM has the “AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire”⁵. It is also a one pager and assesses medical history, symptoms, and cardiovascular risk factors.

Vivian Heyward recommends the “Medical History Questionnaire”⁴. It provides information on the client’s personal illnesses, surgeries and hospitalizations. The client’s family history concerning diabetes, heart disease, hypertension, and stroke is also taken into account. Finally, an assessment of previous medical diagnoses, signs and symptoms of disease that has occurred in the past year, or that are currently present.

The NSCA also recommends the Health/Medical Questionnaire as a tool to assess the positive coronary risk factors  associated with coronary artery disease, orthopaedic concerns, recent operations, and a history of the client has suggested signs and symptoms of disease, any medications taken, existing diagnosed pathologies, and lifestyle management.¹

         If the client wishes to have a personal trainer, he/she can use the above-suggested questionnaire to assess the appropriateness of moderate to vigorous activity. If the trainer is more knowledgeable and/or possesses an ACSM certification, he/she can assess the risk stratification of the client.

           

ACSM risk stratification is based on the  following citeria:⁵

• The presence or absence of known cardiovascular, pulmonary, and/or metabolic disease
• The presence or absence of signs or symptoms suggestive of cardiovascular, pulmonary, and/or metabolic disease.
• The presence or absence of CVD risk factors 

The appropriate recommendations for medical examinations, exercise testing, physical activity/exercise prescription, and physician supervision are based on where the client’s risk stratification is. The client is classified into one of three classifications:⁵

• Low Risk – Asymptomatic men and women who have one or no risk factor listed
• Moderate Risk – Asymptomatic men and women who have two or more risk factors listed
• High Risk – Those who have known cardiovascular, pulmonary, or metabolic disease or one or more of  signs and symptoms listed. 

For the High Risk stratification, listed below are the major signs and symptoms, which are suggestive of cardiovascular, pulmonary, or metabolic disease:⁵

• Discomfort or pain (or other anginal equivalent) in the chest, neck, jaw, arms, and other areas that may result from ischemia
• Shortness of breath at rest or with mild exertion
• Dizziness or Syncope 
• Orthopnea or paroxysmal nocturnal dyspnea
• Ankle edema
• Palpitations or tachycardia 
• Intermittent claudication
• Known heart murmur
• Unusual fatigue or shortness of breath with usual activities.

The risk factors for use with the risk stratification are listed below. These are atherosclerotic cardiovascular disease thresholds.⁵

• Age – positive risk factor if: Men ≥ 45, and Women ≥55 years old
• Family history – myocardial infarction, coronary revascularization, or sudden death before 55 years of age for father or other male first degree relative, or before 65 years of age in mother or other female first-degree relative.
• Cigarette smoking – current cigarette smokers, or those who quit within the last 6 months, or are exposed to environmental tobacco smoke. 
• Sedentary lifestyle – Not participating in at least 30 minutes a day of moderate intensity  (40% - 60% VO₂R) physical activity on at least three days a week for at least three months. 
• Obesity – a body mass index of ≥ 30 kg∙m², or a waist girth of >102cm (40 inches) for men and; 88cm (35 inches) for women. 
• Hypertension – systolic blood pressure of ≥140mm Hg, and/or a diastolic ≥90mm Hg on at least two separate occasions, or on anti-hypertensive medication 
• Dyslipidemia – Low-density lipoprotein Cholesterol (LDL-C) ≥130 mg∙dL^-1 (3.37 mmol∙L^-1); or high-density lipoprotein cholesterol (HDL-C) < 40 mg∙dL-1 (1.04 mmol∙L-1); or on lipid-lowering medication. If total serum cholesterol (TC) is all that is available, ≥ 200 mg∙dL-1 (5.18 mmol∙L-1) 
• Prediabetes – Impaired fasting glucose (IFG) = fasting plasma glucose ≥ 100 mg∙dL^-1 (5.50 mmol∙L^-1), but < 126 mg∙dL-1 (6.93 mmol∙L^-1), or impaired glucose tolerance (IGT) = 2 hour values in oral glucose tolerance test (OGTT) ≥ 140 mg∙dL^-1 (7.70 mmol∙L^-1) but < 200mg∙dL^-1 (11.00 mmol∙L^-1) confirmed by measurements on least two separate occasions. 

A negative risk factor that can be considered is the High-serum HDL Cholesterol. It can negate the dyslipidemia if the HDL-C is ≥ 60 mg∙dL^-1 (1.55 mmol∙L^-1)

            These are the common pre-participation screening tools used by personal trainers and by people who wish to be more physically active. Which to use will ultimately depend upon which is more accessible to the end-user. The self-guided questionnaires, such as the PAR-Q, PARmed-X, and PARmedX for Pregnancy are available online from the Canadian Society for Exercise Physiology.           

Bibliography:

1.      Baechle, Thomas and Roger Earle “Essentials of Personal Training” 2004

2.      Canadian Society for Exercise Physiology, www.csep.org

3.      Corbin, Charles B., William R. Corbin, Gregory J. Welk, and Karen A. Welk “Concepts of Fitness and Wellness 9^th ed.” 2011

4.      Heyward, Vivian H. “Advanced Fitness Assessment and Exercise Prescription 4^th ed.” 2002

5.      Thompson Walter R. “ACSM’s Guidelines for Exercise Testing and Prescription 8^th ed.” 2010