Practicing Safety 1
Acknowledgment of Traditional Territory
Dr. Meaghan MacNutt respectfully acknowledges the Syilx Okanagan Nation and their peoples, emphasizing the importance of recognizing the traditional, ancestral, and unceded territory of UBC Okanagan.
Today's Learning Outcomes
Describe the overall approach to safe practice and identify the adverse events of greatest concern to HES (Human Exercise Science) professionals.
Explain how physical activity (PA) behavior and PA intensity influence the risk of adverse cardiovascular events.
Recognize other individual and environmental factors that affect the risk of adverse events during exercise, including both diagnosed and undiagnosed clinical conditions.
Describe the client risk assessment process, including the appropriate collection and interpretation of information.
Importance of Safety in Professional Practice
Practicing in HES is fraught with hazards.
Goal: Ensure safety for all participants.
PREVENT adverse events from occurring.
PREPARE TO RESPOND should an adverse event occur.
RESPOND effectively to adverse events.
RECOVER, REPORT, and REFLECT to enhance safety in practice.
Whose Safety Is a Concern?
All stakeholders involved in physical activity, including clients and the broader community.
Knowledge for Prevention
To prevent adverse events, professionals must have knowledge regarding:
Types of adverse events targeted for prevention
Risk factors associated with these events
Assessment methods for these risk factors
Strategies to mitigate risk
Best practices in the field
Adjustments necessary to accommodate risk
Understanding when the risk may be too high.
Adverse Events Targeted for Prevention in HES
Medical Events Associated with Exercise:
Foreseeable medical complications include:
Sudden cardiac arrest
Heart attack
Stroke
Hypoglycemia
Heat illness
Falls
Other musculoskeletal (MSK) injuries.
Other Foreseeable Events:
Events not necessarily tied to physical activity include:
Infectious diseases
Biohazard exposure
Chemical accidents
Sharps injuries
Fires
Natural disasters.
The focus of preventive measures will be on events that are the MOST COMMON and MOST IMPACTFUL.
Factors Influencing Risk of Adverse Events During Exercise
Risks are influenced by multiple factors:
History of physical activity behavior
Exercise characteristics, including:
Intensity
Duration
Mode of exercise.
Understanding Acute Myocardial Infarction (AMI)
Definition:
AMI is defined as an acute myocardial infarction, commonly known as a heart attack.
Statistics Related to Risk:
Relative to sedentary individuals, the likelihood of a heart attack:
Correct Answer: D. 10x less likely for active individuals.
Risk During Exercise:
Exercise can increase heart attack risk; awareness of who is at risk is crucial:
Risk during vigorous activity is notably higher for sedentary people and all individuals participating in vigorous exercise.
Intensity of Exercise and Risk Association:
The risk of heart attack during vigorous exercise _ with habitual PA, suggesting that:
Correct Answer: B. decreases with increased levels of habitual physical activity.
Risk-Benefit Analysis of Exercise
For the majority, exercise benefits will outweigh risks:
Despite slight increases in transient risk during exercise, active individuals have a decreased overall risk of myocardial infarction compared to sedentary individuals.
Critical Takeaways for Practitioners
Inform clients that cardiovascular benefits from exercise typically outweigh risks.
Acknowledge all individuals face increased heart attack risks during vigorous exercise.
Remember that risk is highest for sedentary individuals beginning an exercise regimen.
Recognize that risk increases with exercise intensity and significantly when transitioning clients to new intensities.
Be aware that additional risk factors can elevate the likelihood of exertional heart attacks in both sedentary and active clients.
Additional Risk Influencing Factors During Exercise
The following factors can compound risk during exercise:
Health status
Medications
Sex
Age
Pregnancy
Environmental conditions, including:
Heat/cold
Humidity
Air quality
Equipment quality and layout
Facility arrangement
Trip/slip hazards
Lighting
Noise.
Clinical Conditions that Heighten Risk
Metabolic Diseases:
Type 1 and Type 2 Diabetes
Renal Diseases:
Chronic kidney disease
Kidney failure
Cardiovascular Diseases:
Heart attack
Hypertension
Stroke
Heart valve disease
Heart transplant
Heart failure
Congenital heart disease.
Also includes conditions like:
Cancer
Osteoporosis
Concussion
Asthma
Movement/balance disorders.
Practice Guidelines for Clinical Risk Factors
Absolute Contraindications to Exercise (DO NOT PROCEED)
Acute myocardial infarction (within 2 days)
High-risk unstable angina
Uncontrolled cardiac arrhythmias
Active endocarditis
Severe symptomatic aortic stenosis
Decompensated symptomatic heart failure
Acute pulmonary embolism or infarction
Acute noncardiac disorders worsened by exercise (e.g., infection, renal failure)
Acute myocarditis or pericarditis
Physical impairment preventing safe physical activity
Inability to secure consent.
Relative Contraindications to Exercise (PROCEED WITH CAUTION)
Left main coronary stenosis or equivalent conditions
Moderate valvular heart disease
Electrolyte abnormalities
Tachyarrhythmias or bradyarrhythmias
Uncontrolled atrial fibrillation
Hypertrophic cardiomyopathy
Mental impairment reducing cooperation ability
High-degree AV block.
Identifying Higher-Risk Individuals During Exercise
Factors that increase likelihood of cardiac events include:
Physical inactivity
Male sex
Older age
Existing cardiovascular disease (CVD).
Cardiovascular Disease Risk Assessment
Overall cardiovascular disease risk is quantified through counting risk factors:
Age:
Men ≥45 years; women ≥55 years
Family History:
Heart attack, coronary revascularization, or sudden death before age 55 in male first-degree relatives or before age 65 in female first-degree relatives.
Cigarette Smoking:
Current smokers or those who quit within the last 6 months, plus exposure to environmental tobacco smoke.
Physical Inactivity:
Not engaging in at least 30 minutes of moderate intensity exercise on at least 3 days a week for a minimum of 3 months.
Obesity:
BMI ≥30 kg·m−2 or waist circumference >102 cm (40 in) for men, >88 cm (35 in) for women.
Hypertension:
Systolic BP ≥120 mm Hg, and/or diastolic BP ≥80 mm Hg confirmed on at least two occasions or on antihypertensive medication.
Dyslipidemia:
LDL cholesterol ≥130 mg/dL (3.37 mmol·L−1) or HDL cholesterol <40 mg/dL (1.04 mmol·L−1), or on lipid-lowering medication. Total cholesterol threshold is ≥200 mg/dL (5.18 mmol·L−1).
Diabetes:
Fasting plasma glucose ≥126 mg/dL (7.0 mmol·L−1), OGTT values ≥200 mg/dL (11.1 mmol·L−1), or HbA1c ≥6.5%.
Subtracting Protective Factors:
High-density lipoprotein (HDL) cholesterol ≥60 mg/dL (1.55 mmol·L−1).
Case Studies in CVD Risk Assessment
Client Comparative Analysis
Client A
52 years old, male
BMI = 34
Engages in >150 min MVPA/week
Non-smoker
LDL = 120 mg/dL
HDL = 65 mg/dL
BP = 115/75
No diabetes
Family history: mother had heart attack at age 71 Risk Calculation:
Risk = 1 (age) + 1 (obesity) - 1 (active) + 1 (LDL) + 1 (HDL) + 2 (family history) = 5.
Client B
35 years old, female
BMI = 24
Engages in <150 min MVPA/week
Non-smoker
Family history: father died from SCD (sudden cardiac death) at age 54
Takes statin to manage cholesterol and ACE inhibitor for BP
Fasting blood glucose = 140 mg/dL Risk Calculation:
Risk = 1 (age) - 1 (active) + 1 (high glucose) + 1 (dyslipidemia) + 2 (family history) = 5.
CVD Risk Assessment Implications
There's no singular number for CVD risk; assessing risk provides insight for risk evaluation without making assumptions based on appearances.
Applications of Individual Risk Information
Risk information can guide:
A. Excluding individuals for whom exercise isn't safe.
B. Identifying individuals needing medical evaluation before starting an exercise regimen.
C. Suggesting individuals who should only engage in supervised exercise by a qualified professional.
D. Noting individuals who need to exercise in clinical environments with rapid emergency response available.
E. Tailoring exercise prescriptions, including modality, intensity, progression, and adjustments as required.
Pre-Participation Screening and Risk Assessment
Client Interview
Information to Collect:
Family history of cardiovascular, metabolic, and renal (CMR) diseases.
Personal history, including:
Surgical history
Current prescription/non-prescription drugs
Symptoms of diseases:
Angina (chest pain)
Palpitations
Dyspnea (shortness of breath)
Intermittent claudication (lower extremity pain during PA)
Headaches
Fatigue or weakness
Dizziness or lightheadedness
Visual disturbances
Smoking history
Physical activity history.
Important to ask follow-up questions as appropriate.
Clinical Assessment
Measurements Required:
Heart Rate (HR)
Blood Pressure (BP)
As necessary: ECG, SpO2, blood glucose levels, other lab tests.
Signs of diseases:
Wheezing or coughing
Ankle edema
Confusion or disorientation
Syncope (fainting) and pre-syncope
Abnormal sweating
Skin color changes (pallor/flushing)
Skin temperature (cool/clamminess)
Trembling.
Guidance from CSEP GAQ
The CSEP Get Active Questionnaire (GAQ) is a self-assessment tool for evaluating risks of adverse events during physical activity.
It aids qualified exercise professionals (QEPs) in client risk assessments by asking questions about:
Clinical diagnoses
Family medical history
Recent signs and symptoms of disease
Physical activity behavior
Guidance for increasing physical activity.
Identifies individuals at higher risks due to:
Diagnosed medical conditions
Undiagnosed medical conditions
Past physical activity behavior.
Recommendations for Client Engagement
Case Study - 48-Year-Old Male
Scenario:
A 48-year-old man wishes to start playing pick-up hockey and answers “NO” to all initial GAQ questions.
Guidance:
According to CSEP, he should be fine to start and gradually increase to vigorous physical activity.
Scenario - Not Meeting PA Guidelines
If the same man reported not meeting the guideline of 150 min of MVPA per week, recommendations would be:
Seek medical clearance before starting any physical activity.
Scenario - Visit with QEP
If the client follows up and meets with a QEP after answering “NO” to all questions and expresses no concerning symptoms:
Guidance to start moderate activity and progress in intensity and duration gradually.
Dizziness During PA Response
If the client reports experiencing dizziness/lightheadedness during physical activity in the past 6 months (indicated by answering “YES” to relevant GAQ question):
Advise consulting a healthcare provider to investigate causes and minimize risk before upping physical activity intensity.
Responsibilities of a CSEP Certified Personal Trainer (CSEP-CPT)
CSEP-CPTs are permitted to work with:
Apparently healthy individuals
Individuals with one medically diagnosed stable condition.
Determining Stability of a Condition
A medical condition is “stable” when:
i) It is being managed with medication and the client shows no symptoms.
ii) There have been no changes to medication or treatment in the last 6 months.
iii) All prescribed medication is being followed as directed.
CSEP-CPT Health Screening Tool for Medical Conditions
Clients with a medical condition should complete the following screening:
Indicate if any of the following are true:
Presence of diabetic complications affecting eyes, kidneys, or feet.
Symptoms of hypoglycemia (e.g., shakiness, confusion) during activity.
Client's interest in vigorous exercise.
If any statements are true, refer the client to a healthcare provider for clearance before increasing physical activity.
Practical Applications of Tools in Varied Situations
Practitioners should practice using risk assessment tools in diverse scenarios to ensure readiness and effectiveness in real-world applications.