Preparticipation Screening Notes

Evaluating Health Status

• Fitness professionals routinely encounter indiPreparticipation viduals with low cardiorespiratory fitness (CRF) and a variety of health and medical conditions. Exercise is safe for most people, but professionals must identify those at increased risk of sudden cardiac death (SCD) and acute myocardial infarction (MI).

• Preactivity screening determines the current health status and whether medical clearance is recommended before fitness testing or the onset of regular physical activity.

• Risk of exercise is not zero: vigorous exercise carries a small risk of acute cardiovascular events, and risk is higher for those who are unaccustomed to such activity or who have hidden cardiovascular disease.

• ACSM summarizes this risk: “The risk of an exercise related event such as cardiac arrest or acute MI is greater in those individuals performing unaccustomed physical activity, and is greatest with vigorous intensity, physical activity.”

• Real-world triggers can precipitate events (e.g., snow shoveling): such activities can act as acute stressors in susceptible individuals. See referenced cases and discussions illustrating how exertion may unmask underlying disease.

Informed Consent

• Informed consent is the first step prior to preparticipation screening.

• The consent documents communication about purpose and procedures, risks and discomfort, potential benefits, participant responsibilities, treatment of data, participant questions, and the participant’s right to withdraw at any time.

Screening Forms and Process

• Screening consists of three main forms:

  • Preparticipation physical activity questionnaire (PAR-Q+)

  • Pre-Activity Screening Questionnaire (PASQ)

  • Health screening questionnaire

• Ensure that all material is kept private, confidential, and secure.

• The screening process determines risk level and whether medical clearance is recommended, while gathering broader medical history information.

• A key point: a large proportion of adults over 40 may be advised to consult a physician before exercise under prior risk-factor–based screening, which could deter physical activity. Contemporary PAR-Q+ approaches aim to identify those at higher risk without creating unnecessary barriers.

Purpose of Screening

• The screening serves to determine level of risk and indicate whether medical clearance is needed before exercising.

• It gathers broader information about medical history beyond prior risk factors.

• A notable statistic: a recent study found that 95% of adults over 40 would have been advised to consult a physician under older risk-factor–based screening. This may act as a barrier to physical activity.

• Screening helps identify individuals who are not regularly active and may be at higher risk when they start exercising.

Review Medical History

• Review for diagnoses of cardiovascular, metabolic, or renal disease.

  • Cardiovascular disease includes heart disease, peripheral vascular disease, and cerebrovascular disease.

  • Metabolic disease includes type 1 or type 2 diabetes.

  • Renal disease is considered.

• Be aware of major signs and symptoms of cardiovascular, metabolic, or renal disease (see Table 2.1).

• A person is symptomatic if any major signs/symptoms are present; such individuals should obtain medical clearance prior to activity. If already active, they should discontinue exercise and seek medical clearance.

Determine Desired Level of Activity

• Aerobic exercise intensity is classified as:

  • Light: $ext{Light} <br>ightarrow ext{≥}0 ext{ to } 40\%\ VO<em>2R$ (Note: transcription shows $\leq 40\%\ VO</em>2R$)

  • Moderate: $40\%\ VO<em>2R \le ext{Intensity} < 60\%\ VO</em>2R$

  • Vigorous: $\ge 60\%\ VO_2R$

• Exercise intensities can be expressed in multiple units (VO2R, % VO2R, METs, RPE) as shown in the table below.

Exercise Intensities: HHR/VO2R, METS, and RPE

• Light: $ext{VO}_{2R} = 0\% ext{ to } 40\% \, ext{(roughly)}$; $2 \le ext{MET} < 3$; $ext{RPE} = 9-11$

• Moderate: $40\% \, \le \text{VO}_{2R} < 60\%$; $3 \le ext{MET} < 6$; $\text{RPE} = 12-13$

• Vigorous: $\text{VO}_{2R} \ge 60\%$; $6 \le ext{MET} < 8$; $\text{RPE} = 14-17$

• Qualitative descriptions:

  • Light: slight increases in heart rate and breathing

  • Moderate: noticeable increases in heart rate and breathing

  • Vigorous: substantial increases in heart rate and breathing

• The values above are aligned with commonly used ranges: VO2R, METs, and RPE anchors.

Rating of Perceived Exertion (RPE)

• Borg original scale (1982):

  • 6–20 scale with qualitative anchors (e.g., 9–11 = light, 12–13 = somewhat hard, 14–16 = hard, 17–20 = very hard).

• Modified Borg scale:

  • 0 to 10 scale serves as an alternative, with 0 = rest and 4 = somewhat hard, 6–8 = hard to very hard, 10 = very, very hard.

The New Method (Preparticipation Screening Approach)

• The method considers three factors:
  1) The individual’s current level of structured physical activity;
  2) The presence of major signs or symptoms suggestive of cardiovascular, metabolic, or renal disease; and
  3) The desired exercise intensity.

• Note: Pulmonary involvement is no longer listed as a standalone risk factor for cardiovascular risk in the decision process.

Warning Signs and Safe Progression

• Exercise-related cardiovascular events are often preceded by warning signs or symptoms.

• A safer approach is to “start slow and go slow,” allowing 2–3 months for progression to avoid sudden high-intensity or maximal effort.

• Educate individuals about warning signs and symptoms of cardiovascular events and ensure they know how to respond.

PAR-Q+ and Form 2.1 (Continued)

• 2023 PAR-Q+ instructions:

  • If you answer NO to all follow-up questions about medical conditions, you are ready to become more physically active. Sign the PARTICIPANT DECLARATION.

  • Start with 20–60 minutes of low to moderate intensity exercise, 3–5 days per week, including aerobic and muscle-strengthening components.

  • Progress to accumulate ≥150 minutes of moderate-intensity activity per week as you advance.

  • If you are >45 years old and not accustomed to regular vigorous-to-maximal effort, consult a qualified exercise professional before engaging in this intensity.

  • If you answer YES to any follow-up questions, complete the online ePARmed-X+ screening and/or consult a qualified exercise professional to work through ePARmed-X+ and obtain further information.

  • Delays for temporary illness (e.g., cold or fever), pregnancy (discuss with health care practitioner or use ePARmed-X+), or health changes; wait until better before continuing.

  • You may photocopy the PAR-Q+. The full questionnaire must be used without changes. The PAR-Q+ collaborators and assisting organizations disclaim liability for activity undertaken.

• PARTICIPANT DECLARATION (sample content):

  • The signer acknowledges understanding and completion of the questionnaire, acknowledges that clearance is valid for up to 12 months unless conditions change, and acknowledges that the center may retain a copy while safeguarding confidentiality.

  • Requires participant name, signature, date, and if underage, a parent/guardian signature and witness.

• Additional notes:

  • PAR-Q+ was created using evidence-based AGREE processes by the PAR-Q+ Collaboration and collaborators.

  • The document and its versions are supported by public health and health service organizations; references to those bodies are included for context.

Table 2.1: Major Signs or Symptoms of Cardiovascular, Metabolic, and Renal Diseases

• Angina (chest, neck, jaw, arms, etc.), with possible nausea in women; indicates ischemia and insufficient myocardial blood supply.

• Palpitations or tachycardia (RHR > 100 bpm): may indicate an arrhythmia; can be caused by caffeine, fever, anemia, high cardiac output, etc.

• Shortness of breath at rest or with mild exertion: dyspnea; may be normal in trained individuals at high CRF or abnormal in untrained individuals.

• Dizziness or syncope: loss of consciousness; can occur during or after exercise and may indicate cardiac output disorders; potentially life-threatening.

• Ankle edema: edema around the ankles; may indicate congestive heart failure (CHF) or venous/lymphatic issues.

• Intermittent claudication: cramping pain in legs with exertion due to insufficient blood supply from atherosclerosis; resolves within 1–2 minutes after stopping and is more common with CHD and diabetes.

• Orthopnea or paroxysmal nocturnal dyspnea (PND): dyspnea when lying down or during sleep; reflects left ventricular dysfunction; PND may accompany COPD.

• Known heart murmur: can be benign or indicate cardiovascular disease; certain exertion-related sudden deaths require ruling out specific conditions like hypertrophic cardiomyopathy and aortic stenosis.

• Unusual fatigue or shortness of breath with usual activities: may indicate onset or progression of cardiovascular or metabolic disease.

• Adapted content reflects guidance from ACSM’s guidelines and emphasizes the importance of medical clearance when signs/symptoms are present.

Table 2.2: Atherosclerotic Cardiovascular Disease Risk-Factor Thresholds

• Positive risk factors (defining criteria):

  • Age: Men ≥ 45 years; Women ≥ 55 years

  • Family history: MI, revascularization, or sudden death before age 55 in father or male first-degree relative; before age 65 in mother or female relative

  • Cigarette smoking: Current smoker, quit within previous 6 months, or exposure to environmental tobacco smoke

  • Physical inactivity: Not meeting minimum thresholds of MET-min per week or minutes of moderate/vigorous activity

  • BMI/waist: BMI ≥ 30 kg/m² or waist circumference > 102 cm for men or > 88 cm for women

  • Blood pressure: SBP ≥ 130 mmHg and/or DBP ≥ 80 mmHg on average across ≥2 occasions or on antihypertensive meds

  • Lipids: LDL-C ≥ 130 mg/dL or HDL-C < 40 mg/dL in men or < 50 mg/dL in women or non-HDL-C ≥ 160 mg/dL or on lipid-lowering meds; if only total cholesterol is available, use ≥ 200 mg/dL

  • Fasting glucose: ≥ 100 mg/dL; or 2-hour plasma glucose ≥ 140 mg/dL in an OGTT; or HbA1c ≥ 5.7%

  • Obesity: See BMI/waist above (these criteria are mutually reinforcing in risk assessment).

• Negative risk factor: HDL-C is protective; if HDL-C is high, subtract one risk factor from the sum of positive risk factors.

• Note: If a risk factor’s presence/absence cannot be disclosed, treat it as a positive risk factor for clinical judgment purposes.

• Thresholds are drawn from the ACSM risk-factor framework and are summarized for practical use in preparticipation screening.

• Adapted from ACSM guidelines (11th edition) and updated references; consult the most current edition for precise wording.

ACSM Risk Stratification: Counting Risk Factors

• The following four items are counted as risk factors in the risk-stratification framework:
  1) Age: Men > 45; Women > 55
  2) Family history: MI, coronary revascularization, or sudden death before 55 in a father or male first-degree relative, or before 65 in a mother or female first-degree relative
  3) Cigarette smoking: Current smoker or quit within the previous 6 months
  4) Hypertension: Blood pressure > 130/80 mmHg on separate occasions or on antihypertensive medications

• Additional factors (Dislipidemia, Pre-diabetes, Obesity, Sedentary lifestyle) are incorporated in broader risk assessments in subsequent tables and figures.

• For the full scoring system, see the ACSM Kapos/11th edition guidance and figure/table references (e.g., Table 2.2, Table 2.2a, and Figure 2.1 in the source material).

Table 2.2a and Table 2.2 (Expanded Risk-Factor Thresholds)

• No-participation vs. Participation states: The decision matrix considers whether the individual participates in regular exercise or not, and whether they have known disease or signs/symptoms.

• No regular exercise + no disease + no signs/symptoms → Medical clearance not required; continue with light-to-moderate activity and progress as tolerated after ACSM guidelines.

• No regular exercise + disease present OR signs/symptoms present → Medical clearance recommended or necessary depending on the disease status and symptoms; progression follows after clearance.

• Regular exerciser with known disease but asymptomatic → Medical clearance for moderate exercise may not be necessary; for vigorous exercise, clearance may still be recommended within 12 months if no changes in signs/symptoms.

• Presence of signs/symptoms at any disease status → Discontinue exercise and seek medical clearance before resuming.

• The table emphasizes gradual progression, monitoring, and the need for medical clearance based on disease status and symptom presence.

• These decision rules align with the ACSM preparticipation screening algorithm (Figure 2.1) and should be used in conjunction with current ACSM guidelines.

Figure 2.1 ACSM Preparticipation Screening Algorithm (Summary)

• A flowchart guiding aerobic exercise participation based on disease status and symptoms:

  • No cardiovascular, metabolic, or renal disease and no signs/symptoms → Proceed with moderate-to-vigorous exercise following ACSM guidelines.

  • Known cardiovascular, metabolic, or renal disease but asymptomatic → Medical clearance for vigorous activity may be considered; continue with moderate activity after clearance.

  • Signs or symptoms suggestive of disease present → Discontinue exercise and seek medical clearance; return to exercise only after clearance and following ACSM guidelines.

• The figure highlights the need to tailor activity based on health status and symptoms, incorporating the most current recommendations.

Following the Screening Process: Administer Tests and Evaluate Results

• Resting data: Resting heart rate (RHR), blood pressure (BP), percent body fat, waist circumference, flexibility.

• Submaximal graded exercise test: Monitoring heart rate (HR), BP, and rating of perceived exertion (RPE).

• Muscular strength and endurance, flexibility, and functional fitness assessments.

• Compare test results to normative data or track changes over time to chart progress.

Develop an Individualized Exercise Prescription

• Key considerations:

  • Health status determined by screening and medical clearance (if needed)

  • Personal goals of the client

  • Fitness test results and clinical guidelines

• Chapters 13–16 provide prescribing guidelines for generally healthy adults; chapters 17–21 cover special populations.

• The prescription should be tailored to the individual’s baseline fitness, health status, goals, and risk factors, with progression aligned to ACSM guidelines.

Evaluate Progress with Follow-Up Tests

• Periodically repeat fitness tests and health screening questionnaires.

• Use results to modify exercise prescription or supervision level as needed.

• Follow-up fitness testing cadence:

  • After 3 months of regular exercise for beginners

  • Then every 6 months

  • Annual testing may be sufficient for established exercisers

Fitness Program Decisions and Referrals

• Clients may be referred to a physician for consent or consultation when indicated by screening results.

• Recommendations may include:

  • A clinical or other supervised program

  • Vigorous-intensity exercise (with clearance or supervision as appropriate)

  • Unsupervised physical activity (if deemed safe by risk stratification)

• Reviews of risk factors and education about risk should be conducted (reference Table 2.2 in the textbook).

Additional Context and Examples from the Transcript

• Snow shoveling is cited as a trigger for acute MI and sudden coronary death, illustrating how unexpected, vigorous exertion in a high-risk context can provoke adverse events.

• A clinical example (Figure 1) shows serial ambulatory ECG recordings of nonsustained ventricular tachycardia in a high-BMI individual with known CAD during filming activities, contrasted with ventricular events during graded exercise testing (GXT). This underscores the variability of risk with activity type and baseline condition.

• The PAR-Q+ process emphasizes safety, documentation, confidentiality, and the need to adapt activity plans based on the individual’s health status and risk profile.

• The framework integrates major signs/symptoms, risk-factor thresholds, and smooth progression to minimize adverse events while maximizing health benefits.

Formulas, Thresholds, and Key Variables (Summary)

• Exercise intensity classifications (as % VO2R):

  • Light: $ext{VO2R} \le 40\%$

  • Moderate: $40\% \le \text{VO2R} < 60\%$

  • Vigorous: $\text{VO2R} \ge 60\%$

• Corresponding METs and RPE are aligned with these categories:

  • Light: $2 \le \text{MET} < 3; \text{RPE} \approx 9-11$

  • Moderate: $3 \le \text{MET} < 6; \text{RPE} \approx 12-13$

  • Vigorous: $\text{MET} \ge 6; \text{RPE} \approx 14-17$

• RPE scales (Original Borg and Modified Borg) provide practical anchors for exertion monitoring during exercise sessions.

• ASCMD/ACSM risk-factor thresholds include:

  • Age, family history, smoking, inactivity, adiposity (BMI/waist), blood pressure, lipids (LDL, HDL, non-HDL), fasting glucose/HbA1c.

  • Negative risk factor: HDL-C as a protective factor; high HDL-C can reduce the risk factor tally by one.

• Clear guidance on medical clearance depends on the combination of disease status, symptom presence, and exercise intensity planned.

Practical Takeaways for Preparticipation Screening

• Use PAR-Q+ and follow-up questions to determine the need for medical clearance prior to initiating or advancing an exercise program.

• Identify and classify risk using the ACSM framework, and tailor recommendations accordingly (no clearance needed vs. clearance required before moderate or vigorous activity).

• Monitor signs and symptoms, progression plans, and test results to adjust prescriptions safely and effectively.

• Maintain confidentiality and proper documentation throughout the screening and exercise programming process.

• Educate clients about warning signs of cardiovascular events and promote gradual progression to minimize risk while maximizing benefits.