Practicing Safety 1

Acknowledgment

• The instructor, Dr. Meaghan MacNutt, respectfully acknowledges the Syilx Okanagan Nation and their peoples, on whose traditional, ancestral, and unceded territory UBC Okanagan is situated.

Learning Outcomes

1. Safe Practice Approach

   • Describe the overall approach to safe practice.

   • Identify adverse events that are of greatest concern to Health Exercise Science (HES) professionals.

2. Physical Activity (PA) Behavior & Intensity

   • Describe how PA behavior and intensity influence the risk of adverse cardiovascular events.

3. Risk Influences

   • Recognize individual and environmental factors that affect the risk of adverse events during exercise.

   • Include both diagnosed and undiagnosed clinical conditions in these considerations.

4. Client Risk Assessment Process

   • Describe the process for client risk assessment.

   • Include how to appropriately collect and interpret relevant information.

Professional Practice Hazards

• The professional practice in HES is hazardous.

• The overarching goal is to keep everyone as safe as possible, which entails:

  1. PREVENT adverse events from occurring.

  2. PREPARE TO RESPOND in case an adverse event occurs.

  3. RESPOND effectively to adverse events.

  4. RECOVER, REPORT, AND REFLECT to improve safety practices.

Safety Concerns

Key Concerns for Safety

• Whose safety are we concerned with?

  • Focus on ensuring safety for clients and the public.

Prevention Knowledge

• Knowledge about risks is essential for prevention, including:

  • Understanding the specific adverse events to prevent.

  • Identifying risk factors linked to these events.

  • Assessing risk factors accurately.

  • Mitigating risks through appropriate practices.

  • Applying best practices to enhance safety.

  • Adjusting practice according to identified risks.

  • Determining the threshold for when the activity becomes too risky.

Adverse Events to Prevent in HES

• Medical events that are foreseeable with exercise include:

  • Sudden cardiac arrest

  • Heart attack

  • Stroke

  • Hypoglycemia

  • Heat illnesses

  • Falls

  • Other musculoskeletal (MSK) injuries

• Other foreseeable events not necessarily tied to PA:

  • Infectious diseases

  • Biohazard exposures

  • Chemical accidents

  • Sharps injuries

  • Fires

  • Natural disasters

• Focus on preventing events that are most common and most impactful.

Factors Influencing Risk

• Key factors influencing the risk of adverse medical events during exercise:

  • History of PA Behavior: Previous physical activity levels significantly affect risks.

  • Exercise Characteristics:

    • Intensity,

    • Duration, and

    • Mode of the exercise.

Understanding Acute Myocardial Infarction (AMI)

• Definition: Acute Myocardial Infarction (AMI), commonly known as a heart attack.

• Relative risk for heart attack based on activity level:

  • Compared to sedentary individuals, active individuals have a different baseline risk.

    • Options for Question:
      A. Twice as likely
      B. 10x more likely
      C. Half as likely
      D. 10x less likely

  • Key statistics show that active individuals face a significantly lower risk than sedentary ones and that risk increases in sedentary people during exercise.

Risk During Exercise

• During vigorous exercises, the risk of heart attack is influenced specifically by patterns of habitual physical activity.

• The risk for heart attack during vigorous exercise increases with:

  • Habitual PA levels:

  • As levels of regular exercise increase, the transient risk of heart attack during exercise decreases.

• For most individuals, the benefits of exercise outweigh the risks, including:

  • Even with increased immediate risks during exercise, active individuals maintain a decreased overall risk of heart attack when compared to sedentary peers.

Practitioner Takeaways

• Important takeaways for practitioners include:
  A. Emphasizing to clients that cardiovascular benefits of exercise typically outweigh risks.
  B. Understanding that all individuals are at increased risk of heart attack during vigorous exercise episodes.
  C. Acknowledging that sedentary individuals face the highest risk when starting new exercise regimens.
  D. Recognizing the risk increases with exercise intensity, particularly when moving clients to unaccustomed intensities.
  E. Remembering that other risk factors can increase the likelihood of exertional heart attack in both sedentary and active individuals.

Additional Factors Influencing Risk of Medical Events

• Further risk influencing factors include:

  • Health Status: Existing medical conditions.

  • Medications: The type and necessity of medications.

  • Sex: Gender-related risk differences.

  • Age: Age-related risk considerations.

  • Pregnancy: Unique considerations during pregnancy.

  • Environmental Factors:

    • Heat and cold exposure.

    • Humidity levels.

    • Air quality.

    • Equipment safety.

    • Facility layout and potential hazards (e.g., trip/slip hazards).

    • Lighting conditions.

    • Noise levels.

Clinical Conditions Affecting Risk

• Clinical conditions that may contribute to adverse event risk include:

  • Metabolic Diseases:

    • Type 1 Diabetes (T1D)

    • Type 2 Diabetes (T2D)

    • Chronic kidney disease

    • Renal failure

  • Cardiovascular Diseases:

    • Heart attacks

    • Hypertension

    • Strokes

    • Heart valve diseases

    • Heart transplant considerations

    • Heart failure

    • Congenital heart disease

  • Other conditions of concern:

    • Cancer

    • Osteoporosis

    • Concussion

    • Asthma

    • Movement and balance disorders

Risk Assessment Guidelines

Absolute Contraindications to Exercise

• Do Not Proceed with exercise if:

  • There is an acute myocardial infarction within 2 days.

  • Severe unstable angina is present.

  • Uncontrolled cardiac arrhythmias are diagnosed.

  • There is active endocarditis.

  • Severe symptomatic aortic stenosis is observed.

  • Acute pulmonary embolism or infarction is present.

  • Uncontrolled severe heart failure exists.

  • An acute non-cardiac situation that may worsen with exercise is identified, e.g., renal failure or active infection.

  • Acute myocarditis or pericarditis is diagnosed.

  • Any physical disability precluding safe PA participation is present.

  • Inability to provide informed consent.

Relative Contraindications to Exercise

• Proceed with Caution when:

  • There’s left main coronary artery stenosis or equivalent.

  • Moderate valvular heart disease exists.

  • Electrolyte abnormalities are noted.

  • Tachyarrhythmias or bradyarrhythmias are present.

  • Atrial fibrillation with uncontrolled ventricular rates occurs.

  • There is hypertrophic cardiomyopathy diagnosed.

  • Mental impairments may restrict cooperation.

  • High-degree atrioventricular (AV) block is present.

Identifying High-Risk Individuals

Risk Factor Identification

• Factors increasing cardiac events risk include:

  • Physical inactivity.

  • Male gender.

  • Older age.

  • Existing cardiovascular disease.

Quantifying Overall Cardiovascular Disease Risk

• Cardiovascular disease risk can be quantified by:

  • Counting the number of risk factors present, including:

    • Age: Men ≥ 45 years; women ≥ 55 years.

    • Family History: Incidents of myocardial infarction or coronary issues.

    • Cigarette Smoking: Active or recent smokers.

    • Physical Inactivity: Insufficient moderate PA (e.g., <30 min on 3 days/week).

    • Obesity: BMI ≥ 30 kg/m² or waist girth >102 cm for men and >88 cm for women.

    • Hypertension: BP ≥ 120/80 mmHg confirmed over separate occasions.

    • Dyslipidemia: LDL cholesterol ≥ 130 mg/dL or HDL cholesterol <40 mg/dL, requiring monitoring with lipid-lowering medications.

    • Diabetes: Fasting plasma glucose diagnostics ≥126 mg/dL or OGTT ≥200 mg/dL or HbA1c ≥6.5%.

  • Subtracting Protective Factors: High-density lipoprotein (HDL) cholesterol ≥60 mg/dL can afford some protection against cardiovascular disease risk.

Case Analysis of CVD Risk

Comparing Clients A and B

• Client A:

  • 52-year-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 observed

  • Family history of maternal heart attack at age 71

  • CVD Risk Count: 1

• Client B:

  • 35-year-old female

  • BMI = 24

  • Engages in <150 min MVPA/week

  • Non-smoker

  • Family history of paternal sudden cardiac death (SCD) at age 54

  • Takes medication (statin for cholesterol/ACE inhibitor for BP)

  • Fasting blood glucose = 140 mg/dL

  • CVD Risk Count: 5

CVD Risk Identification

• There is no universal magic number for determining CVD risk. However, calculating risk and utilizing this framework can aid in an informed risk assessment regarding exercise participation safety.

• Observations show that one cannot assume risk simply based on a person's appearance.

Individual Risk Utilization

• Risk assessment assists in:
  A. Excluding individuals for whom exercise isn’t safe.
  B. Identifying individuals requiring further medical evaluation pre-program initiation.
  C. Identifying individuals who can only exercise under qualified supervision.
  D. Recognizing individuals who should only exercise in clinical settings with an available rapid emergency response framework.
  E. Formulating exercise prescriptions, including modifications needed (e.g., modality, intensity, progression).

Pre-participation Screening Process

Client Interview (Questionnaires)

• Critical information to ascertain during a client interview includes:

  • Family history of cardiovascular, metabolic, or renal disease.

  • Personal history regarding cardiovascular, metabolic, or renal diseases, including:

    • Surgical history.

    • Current medications (prescription/non-prescription).

    • Identifying symptoms of various diseases: angina, palpitations, dyspnea, intermittent claudication, excessive fatigue, dizziness, etc.

    • Smoking History: Collect insights into the client’s past and present smoking status.

    • Reflect upon the client’s physical activity history, ensuring to ask follow-up questions as appropriate.

Clinical Assessment

• Important measurements to collect during clinical assessments include:

  • Heart rate (HR).

  • Blood pressure (BP).

  • Relevant ECG, SpO2, blood glucose metrics, and other necessary biomarkers.

  • Subjective signs of disease: wheezing or coughing, ankle edema, confusion, syncope, unusual behavior or appearance, sweating patterns, and skin temperature (pallor/flushing).

Risk Assessment Tools

• The CSEP GAQ (Get Active Questionnaire) is designed for assessing the risk of adverse events during physical activity.

• The GAQ:
  A. Asks about clinical diagnoses.
  B. Inquires about family medical history.
  C. Queries recent signs and symptoms of disease.
  D. Asks about physical activity behavior.
  E. Provides guidance on how to gradually engage in more activity.

• The GAQ identifies and advises individuals at higher risk due to:
  i) Diagnosed medical conditions.
  ii) Undiagnosed medical conditions.
  iii) Patterns of physical activity behavior.

Case Study Example of Client Guidance

Client Background

• A 48-year-old man desires to begin playing pick-up hockey.

• He answers “NO” to all the initial GAQ questions.

• His current physical activity is at or above the guideline of 150 minutes MVPA per week.

  • Recommended:

    • Answer: A (He is considered to be okay to start and gradually increase vigorous PA).

• If he were not currently meeting the PA guideline, the recommendation would vary to:

  • Seek medical clearance before engaging in PA.

Follow-Up Interactions with Clients Regarding Symptoms

Client’s Reported Symptoms

• The client highlighted dizziness/lightheadedness in previous exercise bouts as an experienced symptom.

  • Advice:

    • Recommend consulting a health care provider to identify potential causes and minimize risks.

    • Advise against increasing exercise intensity until evaluated.

Certification and Liability

CSEP Certified Personal Trainer (CSEP-CPT) Guidelines

• As a CSEP-CPT, you are qualified to work with:
  A. Anyone without limitations.
  B. Only apparently healthy individuals.
  C. Any individual if they have received medical clearance.
  D. Apparently healthy clients and those with a single diagnosed condition that is stable.

Management of Medical Conditions

• If a client (like the 48-year-old man) discloses a condition such as Type 2 diabetes:

  • It is the Qualified Exercise Professional's (QEP) responsibility to assess whether the condition is managed and stable.

Definition of Medical Condition Stability

• A medical condition is deemed stable when:
  i) It is medically managed and the client remains asymptomatic.
  ii) There’s no change in the treatment plan or medications for six months.
  iii) Any prescribed medications are being followed accordingly.

Conclusion & Practical Applications

• Certification material emphasizes the importance of understanding risk assessment and appropriate responses in the professional practice of Health Exercise Science.

• Practitioners should implement these guidelines and tools to ensure the safety and well-being of clients.