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

Physical Activity and the Physical Fitness Components: Basics of Fitness

            When people decide to take the first step and become fit, most would usually ask a friend who already works out and some would consult a fitness professional. When we actually decide to take that plunge and exercise, how and what do we train? That would ultimately depend on your goals in. Some will prefer to lose weight and have more endurance and while others would like to gain weight through an increase in muscle size. Some would like to have both. What your goals are would dictate on how and what to train. However, what exactly are the terms and definitions related to fitness and health? What do we train when we want to get fit?

The terms health, wellness, and physical fitness are often interchanged. When people decide to take the plunge and become more fit, are the definitions really the same?

            Simply put, health can be defined simply as being alive with no major health problems. Another definition can be the overall condition of the body or mind and then presence or absence of illness or injury ². Alternatively, it can be, as defined by Corbin and Welk, “Health is a state of optimal well-being that contributes to one’s quality of life. It is more than freedom from disease and illness. It includes high-level mental, social, emotional, spiritual, and physical wellness with in one’s heredity and personal limits ¹.

            Wellness, on the other hand, is a “state of healthy living achieved by practicing of a healthy lifestyle which includes regular physical activity, proper nutrition, maintaining good emotional and spiritual health, and eliminating unhealthy behaviours” ⁶. Technically all facets of one’s life should be healthy, other words. With physical activity being one part of the total wellness scheme.

Moreover, what is the definition of fitness? There are two kinds of fitness that we should be aware of: physical and metabolic. Metabolic fitness is actually a measure of non-performance parameters. It measures the blood lipid profile, blood pressure, and blood sugar and insulin levels. These measures are used to assess risk of diabetes and cardiovascular disease ^{1, 3}.  These parameters are used for risk assessment for those wishing to start a physical fitness program.

Physical fitness on the other hand, is the body’s ability to meet the ordinary as well the unusual demands of daily life safely and effectively, without undue fatigue. And still have energy left over for leisure and recreational activities ³. It is the body’s ability to function efficiently and effectively. It is based on the five (5) physical fitness components. In this case, it is also called health-related fitness. In which the goal is help reduce the risk of hypo-kinetic disease and improve physical fitness, and daily tasks are carried out with less effort and fatigue ⁶.  

If performance of a motor skill is part of the equation, which certain jobs may require such as fire-fighter, the six (6) skill components are also used as basis ¹. The fitness programs here are designed to achieve high levels of performance in motor skills, or successful performance in sport ^{1, 3}.

The first step in becoming fit is an increase in physical activity. Physical activity is actually defined as ”a general broad term that is used to describe all forms of large muscle movements including sports, dance, games, work, lifestyle activities, and exercise”¹. It is bodily movements produced by the skeletal muscles that require energy expenditure³. An increase in physical activity requiring energy expenditure are therefore one of the requirements of becoming physically fit. Physical activity is any activity other than exercise that requires light to vigorous effort. Therefore, from washing the car, to walking two to three blocks from the house to the grocery store, to performing Olympic lifts for sports performance can be considered physical activity. However, for the purpose of people starting out, light to moderate physical activity is recommended. A good guide to physical activity would the physical activity pyramid. One can follow two pyramids. The first is taken form the Health Fitness Instructor’s Handbook in fig. 1.

Fig.1 the Activity Pyramid ⁴

For Asians, and specifically for Filipinos, another type of physical activity pyramid is also available as shown in fig. 2. This is from the Philippine Association for the study of Overweight and Obesity.

Fig. 2 the Filipino Pyramid Activity Guide ⁵

 

To use the pyramids as a guide is a simple matter. The bottom of both pyramids is the day-to-day activities and should be done as often as possible. These are considered light physical activities. Recreational and aerobic activities dominate the second level. The recommendation is that one should do these activities three (3) to five (5) times a week. The third level is leisure activities and exercises for strength and flexibility. These should be done two (2) to three (3) times a week. The top tier should be done minimally at best. Energy expenditure through physical activity helps in controlling weight together with a sound diet.

            Exercise, which is found on the second tier of both pyramids, is form of physical activity that is planned, structured and repetitive bodily movements whose purpose is to improve, or maintain one or more of the components of physical fitness ³.

             There are certain norms and standards that are supposed to tell us that we are fit. Or that we have reached our goal. Each of these norms pertains to a component of physical fitness.  Moreover, what are those components that determine physical fitness? As mentioned earlier there are five fitness components, or areas, that comprise physical fitness: Cardiovascular endurance, muscular strength, muscular endurance, flexibility, and body composition. Let us define each one.

1.      Cardiovascular endurance - Also called aerobic fitness or cardio respiratory fitness. This is the ability of the heart, blood vessels, blood, and respiratory system to supply the nutrients and oxygen to the working muscle and their ability to utilize this fuel to allow sustained exercise. ^{1, 3}

2.      Muscular strength – This is the ability of the muscle to exert an external force to lift a heavy object. Alternatively, it may also be defined as the amount of force a muscle can produce with a single maximal effort. ^{1, 2}

3.      Muscular endurance – This is muscles’ ability to generate submaximal force repeatedly over a period time ^{1, 6}, or the ability of the muscle to resist fatigue and sustain a given level of contraction, holding a particular contraction ².

4.      Flexibility – This is the range of motion around a given joint, or the ability of the joint to move through its full range of motion ^{1, 2}.

5.      Body Composition – The only non-performance measure among the fitness components. This component refers to the proportion of fat and fat free mass in the body ².

Each of the components can affect our daily activities. For example, cardiovascular fitness is needed when walking a certain distance, climbing stairs, doing yard work (a.k.a. gardening, for those of us who have a garden), cleaning your room (or apartment or house, depending on where you live). In addition, leisure and social activities, such as a weekend bike, or hike, or sports, or a night out dancing, can become more enjoyable with good cardiorespiratory fitness ⁵. In addition, there is a reduced risk of hypokinetic disease. Hypokinetic diseases are those diseases that stem from lack of physical activity. Such diseases include hypertension, heart diseases, chronic low back pain, and obesity ³.

Muscular strength and endurance are usually termed together by the ACSM (American College of Sports Medicine) as muscular fitness. Muscular fitness are basic components that are required in daily activities such as sitting, walking, running, lifting and carrying various objects ³.  In addition, some amount of strength and endurance are required for housework and recreational activities 3. Several benefits of these two components are the following: Improved performance of physical activities, injury prevention, improved body composition, improved muscle and bone health during aging, improved body composition, improved posture and reduced risk chronic low back pain, and an improved quality of life ^1,2.

Flexibility is not the province of athletes alone. Even mere mortals such as us need flexibility on our daily activities. Simple activities such scratching a part of our back, bending down to tie our shoes or putting on a shirt require flexibility ⁶. Good flexibility makes daily activities such as lifting, turning, and bending much easier ³. Benefits of adequate flexibility include good joint health, maintain optimal posture and prevent excessive muscle strain such as chronic low back pain, relief of muscle cramps, improving impaired mobility, and relaxation.

Body composition is the only non-performance measure among the fitness components. This is affected by the diet and the amount of physical activity we do. According to most exercise physiologists, the human body can be divided into fat-free mass and body fat. Fat-free mass is made up of all the body’s non-fat tissue. This includes bone, water, muscles, connective tissues, organs and teeth. However, a small percentage of fat is required by the body to function properly. This called essential fat. In men, it makes up about 3% to 5% of total body weight. For the women, it is about 8% to 12%. The other fat in the body is stored as fat cells or adipose tissue. It is located under the skin and around the viscera (major organs) ².

When the body stores too much fat, overweight and obesity can result. Overweight is defined by Hoeger and Hoeger as “the excess amount weight against a given standard such as height or recommended percentage body fat” ³. Obesity, on the other hand, is an excessive amount of fat in the body, which is typically 25% for men and 30% for women ⁶.

Either too much fat or too little fat can affect health. Diseases such as the metabolic syndrome, diabetes and premature death can result from too much fat in the body. Metabolic syndrome is a group of symptoms that include the following: insulin resistance, high blood pressure, high blood glucose levels, abnormal blood lipid levels, and, of course, high body fat deposits in the abdominal region. By far the biggest impact of overweight and obesity is on self-image. This can lead to depression, anxiety, and low self-esteem ².

At the other end of the spectrum, extremely low levels of body fat can also be a hazard to health. Although it is not as big a problem as overweight and obesity. Extreme leanness on the other hand can affect normal body functioning. This can affect the reproductive, respiratory, and immune system.

There are the five fitness components one should be aware of when one decides to take that first step to becoming fit. The next step is to make sure that you are cleared to safely do physical activity.

Bibliography:

1.   Corbin, Charles B., Gregory J. Welk, William R. Corbin, Karen A. Welk, and Cara L. Sidman “Concepts of Fitness and Wellness 9^th edition” 2011

2.    Fahey, Thomas D., Paul M. Insel, and Walton T. Roth “Fit and Well: Core Concepts and Labs in Physical Fitness and Wellness 9^th edition” 2011

3.    Hoeger, Werner W. K. and Sharon A. Hoeger “Lifetime Physical Fitness and Wellness 11^th edition” 2011

4.      Howley, Edward T. and B. Don Franks “Health Fitness Instructor’s Handbook” 1997

5.      Philippine Association for the Study of Overweight and Obesity, 2000

6.   Powers, Scott K. and Stephen L. Dodd ”Total Fitness and Wellness 5^th edition” 2009