Italian Espresso National InstituteEspresso is now one of the most successful symbols of "made in Italy" worldwide. It is also one of those that are copied the most, often with very poor results. It is not rare for the word espresso, coupled as it may be with other words or symbols evoking the spirit of Italy, to conceal all kinds of preparations, often in very bad taste.
Exercise Professionals Version 1 - November 2014 Recognised by Skills Active and endorsed by Exercise Association of NZ Table of Contents USING THIS PRESCREEN REPs PRE-SCREEN FORM PRE-SCREEN AND EXERCISE EXERCISE HABITS AND EXERCISE-RELATED COMPLICATIONS PURPOSE OF THE PRE-SCREEN ESTABLISHING PROGRAMME GOALS RISK FACTORS AND SIGNS/SYMPTOMS OF DISEASE CRITERIA FOR CARDIOVASCULAR DISEASE RISK FACTORS RISK STRATIFICATION EXERCISE-MEDICATION INTERACTIONS THE PRE-SCREEN TO EXERCISE PROGRAMME TRANSITION REPs PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q) REPs PRE-SCREENING HEALTH PROFESSIONAL REFERRAL LETTER 33 RESOURCES FOR THE EXERCISE PROFESSIONAL AND LIST OF ABBREVIATIONS Copyright and use of the NZ REPs Pre-Screening Form and GuideThe NZ Register of Exercise Professionals (NZ REPs) Pre-Screening Form and guide is exclusively for the use of REPs Registered Exercise Professionals. The NZ REPs Pre Screening Form and guide cannot be copied, replicated, altered, or shared without the express written permission of NZ REPs. 2014 New Zealand Register of Exercise Professionals Limited This guide has been produced by the NZ Register of Exercise Professionals, and authored by: Assistant Professor of Exercise & Sport Science Senior Lecturer, Exercise Science Western State Colorado University Auckland University of Technology United States of America Version 1 - November 2014 REPs New Zealand Pre-Screening Guide Part A.1 USING THIS PRE-SCREEN Many current pre-screen models tend to be exclusively focused on risk stratification alone. Unfortunately, these singularly-focused formats fail to provide Registered Exercise Professionals with all the necessary information required to formulate a safe and effective exercise programme. The New Zealand Register of Exercise Professionals Pre-Screen brings together four key sections to provide a template for complete exercise pre-screening. The Pre-Screen process is to ensure the safety of your client, and to determine key information to inform customised exercise prescription.
The intention is that this pre-screen form is used in a one-
This gives the client the chance to correct any to-one interview style setting, so the form is essentially a misconceptions that you may have and to add anything that template on which to compile answers given, for the most they have just remembered.
part verbally, by clients. At your discretion you may ask the What if you are not sure if exercising is safe for your client? client to complete certain sections independently, such as circling areas of injury on the figures in section 2, or It is appropriate to ask the client to return to their allied perhaps ticking relevant boxes in checklists such as medical health professional to ask for clearance to exercise. conditions. Such an approach can be more time efficient However it is important that you don't give the client the and avoid an ‘interrogation interview' feel to proceedings, but impression that you are ‘fobbing them off' or putting them in each Registered Exercise Professional will use the Pre-Screen the too hard basket. Make another appointment time within in a way fitting to their setting and their client. Although the the week so that they realise that you are keen to help but risk stratification (called Important Medical Information) is would prefer to consult with an appropriate professional the very first section, you may choose to alter the order of prior to commencing the structured programme.
the pre-screen process. For example, many Registered Keep in mind that privacy regulations prevent Registered Exercise Professionals would prefer to start with developing Exercise Professionals seeking direct information from a GP a rapport and ascertaining training goals prior to ‘launching' unless the client has first given permission. Please use the into an investigation on medical issues. However, it should be Health Professional Referral Letter which is in Part F of this recognised that the pre-screen process could also inform goal guide. This provides approval to speak with another health setting. For example, if during screening it is determined that professional, and provides clear questions which require an an individual has problems with glycemic control, improved answer so that you can provide the best programme.
glycemic control may be established as a training goal. One of the skills needed for an effective Pre-Screen is the • Do first make your client feel comfortable with the ability to follow through on a client's responses. For example, prescreen process. Explain why you are collecting if they have a knee injury, which knee is it? How did they do this information and what will be done with it.
it? How long ago was that? Did they see a doctor or physio? • Do break the Pre-Screen into sub topics. Some What did they suggest? What activities cause their knee pain? topics may be best asked verbally eg training What makes the knee feel good?…. Simply ticking the box goals, while others may be answered quicker in does not constitute sufficient information. Be an exercise writing eg the client ticking boxes for their injuries.
detective! It is important that you are sure that you understand • Don't talk to your client if you have asked them to exactly your client's situation. The client should feel that you fill out a section of the form – it's hard for them to are taking an interest in them and will therefore be able to concentrate on two things at once.
design a programme that is specific to them. Really get to the specifics of their goals and what they want to achieve. • Do look for non-verbal responses eg does the Sometimes as a Registered Exercise Professional you will client hesitate while deciding on an answer? have to dispel myths or help modify unrealistic goals as part • Do follow up all "yes" responses to medical or of the Pre-Screen process. injury questions ("Which leg? How did you do Complete the process by summing up all the important it? When? Did you get treatment? What did the points. Give your client the last say by asking something like doctor suggest? Do you still get pain? During "is that a fair summary of your health profile and the things what activities?) that you want to achieve from your training programme?" • Don't presume anything. Let the client tell you.
REPs New Zealand Pre-Screening Guide In summary, the imperative to ascertain key information prior to ensuing programme writing is reflected in the general order of proceedings: 1. Identify key risk factors
2. Identify other key medical / physical condition information
3. Determine information that informs programme design
4. Fitness assessment results (at your discretion) that may influence programming
(Called programme information in the Pre-Screening Form)
Section 1: Important Health Information (also known as Risk Stratification)
Clearly it is important to identify key risk factors prior to
included the option of using such results within the compiling a new structured exercise programme. The pre-screen. Follow strict and correct procedures if you are risk stratification section is based on an internationally using devices that extract blood in any way. You may also accepted model for assigning ‘risk factor points' to either choose to recommend that a client purchases a self-referred currently diagnosed conditions (for example, high blood test from a laboratory such as Labtests. Many common pressure) or from correctly conducted assessment (such as tests are fairly inexpensive and, in such facilities, are lipid profile testing) results. The total points assigned then conducted by trained professionals in laboratory settings. define risk. There are also ‘red flag' scenarios whereby You can actually walk in off the street and request blood known cardiovascular, pulmonary, and/or metabolic testing for many different measures. Results are typically diseases (or signs and symptoms of these diseases) will emailed directly to the client (often within a day) so there is automatically signal the need for a cautious approach to no breach if they choose to share them with you. The client exercise commencement, which needs to take place under can then choose to consult their GP if either recommended the consultation of a medical professional. Some current by you, or they perceive the need to pursue medical advice. international models use so-called ‘negative risk factors' Or, GP's may refer patients to testing at no extra cost whereby a positive factor is cancelled out when a negative (most common health measures by blood test are funded if risk factor is also present. For example, if one point is requested by a GP).
assigned owing to high blood pressure but HDL cholesterol Be very mindful of your scope of practice as a Registered (an example of a ‘negative risk factor') is in a good range, Exercise Professional. You do not diagnose, only screen. If the total points would be considered 0. We have chosen someone presents with an abnormal result your follow-up not to use such a model because it potentially places the would be to refer to a medical professional for clarification. Registered Exercise Professional in a scenario where they Don't tell them they have a condition, such as high may misguide a client by inadvertently negating a serious cholesterol, only that the result you acquired or observed, positive risk factor that needs medical attention. today, is outside the medically recommended range. No Currently known or measured by you? more. We believe that such screening can only serve to Many clients will come to you knowing about existing improve awareness of underlying metabolic disease and conditions. Many will also provide you with tests results increase client safety. It may be that your client was not from medical professionals such as GP's, particularly if they aware of a poor lipid profile or abnormal glucose control, in have been referred to you. In some cases, you may be in a which case you may well have done them and their GP a position to do a quick and easy screening test for some of good service. Discretion should be applied to results. the measures within your own facility. Fitness instructors, for For example, if a basic blood glucose test is performed example, often assess blood pressure. Height, weight, and and an abnormal result is noted, don't alarm the client, just waist circumference (done properly) are also quick and easy suggest a follow-up. Consider that in conjunction with other screening measures. You may also have access to some devices that need only a droplet of blood from a finger prick for lipid testing, blood glucose, or perhaps HbA1c. We have Screening tests are for screening, not diagnosing.
REPs New Zealand Pre-Screening Guide
Section 2: Other important conditions
This section is self-explanatory. No Registered Exercise
The order of the
Professional would design an exercise programme without Pre-Screen form usage
first gaining an understanding of the status of the client regarding the conditions within this section.
Although the risk stratification (section 1 titled "Important Health Information") is the very first section, you may choose to alter the order Section 3: Programming information
of the pre-screen process. In summary, the A key point of difference with the New Zealand REPs imperative is to ascertain key information prior Pre-Screen is that rather than focus on Section 1 Important to ensuing programme writing is reflected in the Medical Information alone, it also incorporates relevant general order of proceedings: information to ensure the design of a safe and effective exercise programme. Clearly, goals, exercise history, and 1. Identify key risk factors
availability are all critical to accomplishing this endeavor. Accordingly, we have designed a comprehensive pre-screen 2. Identify other key medical / physical
form that consists of these important features for your use. 3. Determine information that informs
Section 4: Monitoring Progression
4. Fitness assessment results
At your discretion you may also choose to conduct a range (programming information) that may
of assessments, appropriate to your client and your setting. Ideally, results from the assessments also inform design of your exercise programme. We have chosen some key components of fitness and common measures. Add your The intention is that the Pre-Screen form is own as you see fit. They may also be a useful tool to use in used in a one-to-one interview style setting, goal setting.
so the form is essentially a template on which to compile answers given by clients. You may ask the client to complete certain sections independently, such as circling areas of injury on the figures in section 2 of the pre-screen form.
REPs New Zealand Pre-Screening Guide APPROVED AND RECOMMENDED BY THE NZ REGISTER OF EXERCISE PROFESSIONALS (REPs). To be used in conjunction with the REPs New Zealand Pre-Screening Guide and associated risk stratification best practice. For use exclusively for REPs Registered Exercise Professionals only.
Medical Provider(s) Name and Contact: SECTION 1 : IMPORTANT MEDICAL INFORMATION
CARDIOVASCULAR AND PULMONARY CONDITIONS*:
Diagnosed heart condition or stroke, or unreasonable leg or chest pain during exercise? Blood pressure over 200/110mm/Hg (measured at time of this pre-screen)? Diagnosed pulmonary disease? (Exercise Professional - see note 1 below)IF YOU TICK YES TO THIS QUESTION PROCEED ONLY UNDER MEDICAL GUIDANCE IF YOU TICK YES TO 2 OR MORE OF THE FOLLOWING QUESTIONS, THEN PROCEED WITH CAUTION UNDER GUIDANCE Father or brother under 55 years with a history of heart disease or stroke? Mother or sister under 65 years with a history of heart disease or stroke? Male over 45 years? Female over 55 years? Over 140mm/Hg systolic or 90mm/Hg diastolic. Or, on blood pressure medication? Attack that required medical attention last 12 months? SMOKING:
Currently or quit within previous 6 months? GENERAL ACTIVITY LEVEL:
Currently sedentary? BODY COMPOSITION (INDICATIVE):
BMI ≥ 30 kg/m2 or Waist (cm) ÷ Height (cm) ratio above 0.6? BONE AND JOINT:
Known bone or joint problem that could be aggravated by exercise? Any other condition that may increase risk of adverse reaction to exercise? Identified blood lipids outside recommended range (Exercise professional see note 2 below): Diagnosed Type 1 or 2 diabetes (Exercise Professional - see note 3 below) NOTES FOR EXERCISE PROFESSIONAL
1) Cardiovascular / pulmonary disorder
2)) Dyslipidemia. Known result or
3) Glycemic control. Known result or
measured at time of pre-screen:
measured at time of pre-screen:
Shortness of breath with mild exertion or during sleep (Dyspnea) LDL ≥ 3.37 mmol/L Glucose ≥ 5.5 mmol/L over several readings Dizziness during exercise (Syncope) Total ≥ 5.18 mmol/L HbA1c ≥ 40 mmol/mol Ankle swelling (Edema) HDL < 1.04 mmol/L Triglycerides (TG) ≥ 1.7 mmol/L Unpleasant, rapid beating of heart (Palpitations / Tachycardia) TG/HDL ratio ≥ 4.0 Intermittent claudication (Cramping/pain in legs unexplained) Pulmonary disorder such as COPD, cystic fibrosis, emphysema, other REPs New Zealand Pre-Screening Guide
SECTION 2 : OTHER IMPORTANT CONDITIONS
Please circle any area that may be adversely affected by exercise: Any pain or major injury to:(Please tick any which apply) Feet / Ankles Calf / Shin Knees Hamstrings Hips / Groin Lower Back / Abs Upper back / Ribs Neck / Shoulders Arm / Elbow Wrists / Hands PREGNANT
now or in last 12 months EPILEPSY
Beta blockers ACE inhibitors Diuretic Statin Oral hypoglycemic Other Thank you for taking the time to answer the questions above. Your answers will help your REPs Registered Exercise Professional determine the best approach to help you reach your exercise goals.
I acknowledge that that information provided above regarding my health and personal information is, to the best of my knowledge, correct. I will inform my exercise professional immediately if there are any changes in my health status.
I understand that participating in physical activity and exercise can carry a risk, and I accept all responsibility for that risk.
I understand that due care will be undertaken by my REPs Registered Exercise Professional at all times. REPs New Zealand Pre-Screening Guide SECTION 3 : PROGRAMMING INFORMATION
Muscle mass increase Gain aerobic fitness Sport specific (speed etc) CURRENT OR VERY RECENT: Resistance/weight training Structured aerobic exercise Regular sport or recreation General activity Prior exercise facility membership(s)? Reason for stopping? List preferred timeslots (if any) and preferred maximum duration: What type of exercise(s) enjoyed previously? What type of exercise(s) disliked previously? REPs New Zealand Pre-Screening Guide SECTION 4 : MONITORING PROGRESSION
Waist / Height Ratio Blood pressure Systolic/Diastolic Estimated VO2 max Based on availability, assessment results and goals: Copyright and use of the NZ REPs Pre-Screening Form and Guide.The NZ Register of Exercise Professionals (NZ REPs) Pre-Screening Form and guide is exclusively for the use of REPs Registered Exercise Professionals. The NZ REPs Pre Screening Form and guide cannot be copied, replicated, altered, or shared without the express written permission of NZ REPs. 2014 New Zealand Register of Exercise Professionals Limited REPs New Zealand Pre-Screening Guide Part A.3 PRE-SCREEN AND EXERCISE Is the pre-screen and risk stratification
procedure a barrier to starting exercise?
Risk stratification flow chart.
No. The most important purpose of the risk stratification procedure is to identify those individuals who may benefit from first consulting with a GP prior to initiating exercise. It is critical to highlight that this step should not be perceived as • Complete REPs pre-screen•Acquire risk factor information a barrier to an individual starting an exercise programme. Research is quite clear that for most individuals the benefits of low-to-moderate intensity exercise substantially outweighs any risks. In fact, there is even greater risk of an individual remaining sedentary compared to starting low-to- Is there known cardiovascular, pulmonary, and/or metabolic disease? moderate intensity exercise. However, for a small segment (i.e. the high risk) of the population, the risk of exercise-related events such as a heart attack or sudden death, is substantial when performing unaccustomed exercise bouts, in particular vigorous intensity exercise. It is recommended that high risk individuals consult with their GPs in advance Are there major signs or symptoms of proceeding with an exercise programme. It may be suggestive of underlying cardiovascular, pulmonary, and/or metabolic disease? determined that these individuals would be better suited exercising in a medically supervised programme. You should use the REPs Pre-Screening Health Professional Referral Letter in Part F of this guide when referring clients on to other health professionals. This referral letter will ensure you obtain the relevant information and guidance Sum of positive CVD Risk factors • Family history from the other health professional to develop a safe and effective exercise programme.
• Sedentary lifestyle A risk stratification flow chart presented right can be used by Registered Exercise Professionals to guide them through the risk stratification procedures. Moderate-to-vigorous intensity exercise intensity exercise REPs New Zealand Pre-Screening Guide
Section A.4 EXERCISE HABITS AND EXERCISE-RELATED COMPLICATIONS What client exercise habits place them at increased risk for an adverse
Over the first few weeks of working with your client it is important to take note of their exercise habits. Do they have a
tendency to increase their resistance training weights markedly without first consulting with you? Or, do they exercise
vigorously on the treadmill and stop suddenly without cooling down?
These and other unhealthy exercise practices increase the risk of your client experiencing an adverse exercise-related event. Registered Exercise Professionals should correct clients in a firm but professional manner as soon as possible. This will ensure a more safe and effective exercise programme. In turn, this will promote a greater likelihood of lifetime physical activity. Exercise Training Habits disregard for appropriate warm-up & cool-down consistently exceeds prescribed training HR (intensity violator) consistently exceed prescribed training weights (intensity violator) disregard correct exercise form/technique REPs New Zealand Pre-Screening Guide
Part B Case studies If this scenario arises how should I proceed?
In this section we review common scenarios Registered Exercise Professionals will encounter during the pre-screen process.
Five separate case studies are presented. For each case study Registered Exercise Professionals should first carefully review
the client profile.
REGISTERED EXERCISE PROFESSIONALS should then perform the following: Identify the risk factors present Risk stratify the client Provide a recommended and suitable course-of-action REPs New Zealand Pre-Screening Guide Case Study #1 - SAMPLE PRE-SCREEN FORMS
SECTION 2 : OTHER IMPORTANT CONDITIONS
Please circle any area that may be adversely affected by exercise: APPROVED AND RECOMMENDED BY THE NZ REGISTER OF EXERCISE PROFESSIONALS (REPs). To be used in conjunction with the REPs New Zealand Any pain or major injury to: Pre-Screening Guide and associated risk stratifi cation best practice. For use exclusively for REPs Registered Exercise Professionals only.
(Please tick any which apply) Client Profi le 1 Example Medical Provider(s) Name and Contact: Dr Smith, ABC Medical Centre 37 Knees Hamstrings SECTION 1 : IMPORTANT MEDICAL INFORMATION
Hips / Groin Lower Back / Abs ✔ Upper back / Ribs CARDIOVASCULAR AND PULMONARY CONDITIONS*:
Neck / Shoulders Diagnosed heart condition or stroke, or unreasonable leg or chest pain during exercise? Blood pressure over 200/110mm/Hg (measured at time of this pre-screen)? Diagnosed pulmonary disease? (Exercise Professional - see note 1 below)IF YOU TICK YES TO THIS QUESTION PROCEED ONLY UNDER MEDICAL GUIDANCE PREGNANT
now or in last 12 months IF YOU TICK YES TO 2 OR MORE OF THE FOLLOWING QUESTIONS, THEN PROCEED WITH CAUTION UNDER GUIDANCE EPILEPSY
Father or brother under 55 years with a history of heart disease or stroke? ARTHRITIS
Mother or sister under 65 years with a history of heart disease or stroke? Male over 45 years? Female over 55 years? Over 140mm/Hg systolic or 90mm/Hg diastolic. Or, on blood pressure medication? Oral hypoglycemic Attack that required medical attention last 12 months? SMOKING:
Currently or quit within previous 6 months? Previous lower back pain (apparently lumbar spine and some sacro-illiac GENERAL ACTIVITY LEVEL:
Currently sedentary? joint by client general description) at times when gardening and lifting BODY COMPOSITION (INDICATIVE):
BMI ≥ 30 kg/m2 or Waist (cm) ÷ Height (cm) ratio above 0.6? for an extended period. Not currently sore. Not treated or diagnosed. BONE AND JOINT:
Known bone of joint problem that could be aggravated by exercise? Thank you for taking the time to answer the questions above. Your answers will help your REPs Registered Exercise Professional determine the best approach to help you reach your exercise goals.
Any other condition that may increase risk of adverse reaction to exercise? I acknowledge that that information provided above regarding my health and personal information is, to the best of my knowledge, correct. Identifi ed blood lipids outside recommended range (Exercise professional see note 2 below): I will inform my exercise professional immediately if there are any changes in my health status.
I understand that participating in physical activity and exercise can carry a risk, and I accept all responsibility for that risk.
Diagnosed Type 1 or 2 diabetes (Exercise Professional - see note 3 below) I understand that due care will be undertaken by my REPs Registered Exercise Professional at all times. NOTES FOR EXERCISE PROFESSIONAL
1) Cardiovascular / pulmonary disorder
2)) Dyslipidemia. Known result or
3) Glycemic control. Known result or
measured at time of pre-screen:
measured at time of pre-screen:
Shortness of breath with mild exertion or during sleep (Dyspnea) LDL ≥ 3.37 mmol/L Glucose ≥ 5.5 mmol/L over several readings Dizziness during exercise (Syncope) Total ≥ 5.18 mmol/L HbA1c ≥ 40 mmol/mol Ankle swelling (Edema) HDL < 1.04 mmol/L Triglycerides (TG) ≥ 1.7 mmol/L Unpleasant, rapid beating of heart (Palpitations / Tachycardia) TG/HDL ratio ≥ 4.0 Intermittent claudication (Cramping/pain in legs unexplained) Pulmonary disorder such as COPD, cystic fi brosis, emphysema, other REPs New Zealand Pre-Screening Guide REPs New Zealand Pre-Screening Guide SECTION 3 : PROGRAMMING INFORMATION
SECTION 4 : MONITORING PROGRESSION
Enjoys some gardening notices Muscle mass increase OK, some lumbar ﬂ exion and thoracic extension lifting capacity diminished Poor, hip hitch L noted Poor, heels up and lumbar ﬂ exion L knee medial deviation w hip lateral deviation Pretty good, some shoulder elevation Often feels lethargic Sport specifi c (speed etc) CURRENT OR VERY RECENT: Resistance/weight training ed aerobic exercise Previous gym 2 yrs ago, bike Regular sport or recreation ✔ General activity Occasional gardening Waist / Height Ratio Y, 2 yrs ago for 6 mths, at local Prior exercise facility membership(s)? fi tness Centre. Got bored, lacked Reason for stopping? motivation, winter Upper arm ﬂ exed: List preferred timeslots (if any) and preferred maximum duration: Blood pressure Systolic/Diastolic Estimated VO2 max 6.2kmh, 1.0% incl What type of exercise(s) enjoyed previously? Based on availability, assessment results and goals: Enjoyed biking on stationary bike in gym for a "few weeks" then got bored and did not seek new programme, membership dropped off. Several years ago played some social touch. Otherwise don't know but has heard weights are good for you and some friends have recommended it.
What type of exercise(s) disliked previously? Don't really know apart from some boredom with same cardio session repetitively.
Copyright and use of the NZ REPs Pre-Screening Form and Guide.The NZ Register of Exercise Professionals (NZ REPs) Pre-Screening Form and guide is exclusively for the use of REPs Registered Exercise Professionals. The NZ REPs Pre Screening Form and guide cannot be copied, replicated, altered, or shared without the express written permission of NZ REPs. 2014 New Zealand Register of Exercise Professionals Limited REPs New Zealand Pre-Screening Guide REPs New Zealand Pre-Screening Guide REPs New Zealand Pre-Screening Guide Case Study #1
A sedentary and non-smoking 37-yr old male comes to your facility hoping to start a moderate-intensity exercise programme. Part of the baseline assessments at your facility includes submaximal cardiorespiratory and muscular fitness testing. His health history questionnaire indicates he has no personal or family history of heart disease. You obtain a waist-to-height ratio and BP at your facility whilst sending him off to a test centre for blood work. Below are the measures obtained: TC = 5.09 mmol/L waist-to-height ratio = 0.48 LDL = 3.03 mmol/L HDL = 0.92 mmol/L FBG = 7.26 mmol/L TG = 4.39 mmol/L Risk factor(s) present: ✔ Sedentary✔ Dyslipidaemia (TG/HDL ratio ≥ 4.0)✔ Impaired fasting blood glucose (elevated FBG) – technically above the threshold for diabetes (a metabolic disease) Risk stratification: ✔ 2 points. Moderate, possibly high risk given FBG test but only on this one occasion. Needs follow-up to confirm result.
✔ Proceed with caution and the client should be referred to GP for exam given the metabolic profile. In particular, the FBG value is suggestive of possible diabetes – a known metabolic disease REPs New Zealand Pre-Screening Guide Case Study #2
An active and non-smoking 57-yr old female has entered your facility and would like to begin exercising more vigorously, including high intensity resistance training circuit classes. The only testing consists of height and weight. Her pre-screen paperwork reflects no personal or family history of heart disease. A copy of her most recent physical reveals the following information: TC = 4.53 mmol/L waist-to-height ratio = 0.42 LDL = 2.87 mmol/L HDL = 1.34 mmol/L HbA1c = 32 mmol/mol Risk factor(s) present: Risk stratification: REPs New Zealand Pre-Screening Guide Case Study #3
A sedentary and non-smoking female (46yrs) comes to your facility to start a moderate-intensity aerobics class. Her health history questionnaire indicates she has no personal history of heart; however, she reports some shortness of breath the last several months when climbing stairs. Additionally, her pre-screen reflects that both her father and mother died of heart attacks in their mid-forties. A copy of her most recent physical reveals the following information: TC = 4.68 mmol/L LDL = 2.53 mmol/L HDL = 1.45 mmol/L HbA1c = 24 mmol/mol Risk factor(s) present: Risk stratification: REPs New Zealand Pre-Screening Guide Case Study #4
A sedentary, non-smoking male (42yrs) comes to your facility to start an exercise programme. His pre-screen indicates he has no personal or family history of heart disease. You obtain the following assessment values at your facility during the pre-screen process: TC = 5.38 mmol/L BMI = 33.2 kg/m2 LDL = 3.47 mmol/L HDL = 1.42 mmol/L FBG = 5.35 mmol/L TG = 1.30 mmol/L Worksheet:
Risk factor(s) present: Risk stratification: REPs New Zealand Pre-Screening Guide MODEL RESPONSES for Each Client Case Study
Case Study #1
Risk factor(s) and/or, Signs & Symptoms and/or; ✔ Dyslipidaemia (TG/HDL ratio ≥ 4.0) Disease(s) present: ✔ Impaired fasting blood glucose (elevated FBG) – technically above the threshold for diabetes (a metabolic disease) Risk stratification ✔ Proceed with caution and the client should be referred to GP for exam given the metabolic profile. In particular, the FBG value is suggestive of possible diabetes – a known metabolic disease.
Case Study #2
Risk factor(s) and/or, ✔ Age (female ≥ 55 yr) Signs & Symptoms and/or; Disease(s) present:Risk stratification ✔ The client should be safe to progress with vigorous-intensity exercise. The only risk factor present is age. All other measures fall within normal ranges.
Case Study #3
Risk factor(s) and/or, Signs & Symptoms and/or; ✔ Hypertension (SBP ≥140 and/or DBP ≥ 90 mmHG) Disease(s) present: ✔ Family history of heart disease Shortness of breath with exertion Risk stratification ✔ The client should be referred to GP for exam. The individual has 3 risk factors, including a strong family history; and reports shortness of breath with exertion – this is a sign & symptom of underlying cardiovascular or pulmonary disease. Case Study #4
Risk factor(s) and/or, Signs & Symptoms and/or; ✔ Dyslipidaemia (elevated total cholesterol and LDL cholesterol) Disease(s) present: ✔ Obesity (BMI ≥ 30 kg/m2) Risk stratification ✔ Moderate risk ✔ The client can proceed with moderate-intensity exercise. If client wishes to participate in vigorous-intensity exercise it may be prudent to refer the individual to a GP prior.
REPs New Zealand Pre-Screening Guide Section C.1 PURPOSE OF THE PRE-SCREEN Why is pre-screening performed?
Exercise training will be relatively safe for the majority of
clients, even those with multiple chronic conditions, provided
that appropriate assessment and screening is performed
prior to beginning the programme (23). The likelihood of
an adverse event, although not entirely preventable, can
be markedly reduced with baseline assessments, risk
stratification, and patient education (1).
It is likely individuals with multiple chronic conditions will be stratified into a high-risk category and therefore require GP clearance and consent to participate in an exercise programme. Importantly, clients and Registered Exercise Professionals alike should inquire with their medical team about any specific limitations to be aware of when designing the exercise programme. The pre-screen process will also help identify central problems that can prove useful in designing the exercise programme and recognising limitations. For example, a hypertensive individual taking a medication may require a careful cool down after each and every exercise session or they may become lightheaded. What are the main goals of the
Prior to designing and implementing an exercise
programme, it is essential for Registered Exercise
Professionals to acquire as much information as possible
about the client. Accomplishing each of the following goals
will increase the likelihood of a safe and effective exercise
Identify goals of the exercise programme Identify those at increased risk for either disease and/or event based on the presence of risk factors Identify persons with significant existing disease Identify individuals with other special needs REPs New Zealand Pre-Screening Guide Section C.2 ESTABLISHING PROGRAMME GOALS How can Registered Exercise
factors! Research has reported that following three months of Professionals best assist clients
aerobic training the typical improvement in cardiorespiratory prioritise goals?
fitness can be expected to be between 10-30%. These changes pay big dividends in terms of long term health as An initial and considerable challenge facing Registered the literature suggests a 15% reduction in mortality for a 10% Exercise Professionals at the beginning of a partnership improvement in cardiorespiratory fitness (11).
with a new client is to assist them in successfully prioritizing the goals for the exercise programme. Simply put – what should the primary objectives of an exercise programme be Next to low cardiorespiratory fitness hypertension has for most clients? Undoubtedly every client will have different been implicated in the second highest number of overall outcomes in mind when desiring to become more active, deaths amongst American adults according to one study however; because CVD has been the most pressing health (5). Research has shown an inverse relationship between problem in New Zealand for the last 50 years it is logical exercise and blood pressure levels. Accordingly, it is to be that most adults engage in exercise programmes aimed at expected that engaging in a regular exercise programme reducing the risk of CVD development and CVD mortality. will confer benefits in terms of blood pressure reduction. If To accomplish this goal it is paramount to understand how truth be told, no other health outcome, compared to blood those risk factors that contribute to the process of CVD pressure, benefits nearly as quickly from performing exercise. development and mortality are positively modified with A single, acute bout of moderate intensity exercise can lower exercise training. systolic blood pressure by 5-7 mmHg for up to a remarkable 22 hours following the completion of the exercise session (3). Interestingly, the chronic benefits from exercise training in What are the major CVD risk factors
terms of blood pressure reduction are less pronounced with that can be positively modified with
the literature reporting a decrease of 3mmHg and 2 mmHg exercise?
in systolic and diastolic blood pressure, respectively after Major risk factors for CVD include low levels of anywhere between one to six months of aerobic training (12). cardiorespiratory fitness, dyslipidemia (for example, elevated Although these changes appear rather unassuming, it has low density lipoprotein – LDL cholesterol and low high been demonstrated that blood pressure decreases of as little density lipoprotein – HDL cholesterol), hypertension, Type as 2 mmHg are associated with a 6% decrease in stroke 2 diabetes mellitus (T2DM), and obesity (5). Registered mortality and a 4% decrease in coronary artery disease (7). Exercise Professionals should make every effort to acquire baseline measurements of all these parameters for each client. Subsequently, the obtained values can be evaluated The number one goal for many clients initiating an exercise for whether or not any of the risk factor numbers place programme is to lose weight. Given both the widespread the client in an elevated risk category. If so, positive prevalence of obesity and the fact that excessive fat mass changes to those specific risk factors should be a primary is associated with a myriad of unhealthy conditions this is exercise programme outcome. REGISTERED EXERCISE an admirable target. Regrettably, clients frequently establish PROFESSIONALS should also understand how much weight loss goals which are incongruent with what the improvement is expected for each parameter and how long scientific literature suggests are likely to occur with exercise training. Comprehensive reviews, focused on the topic of weight loss and exercise, report weight reductions of • Cardiorespiratory fitness approximately 0.5 to 1.4 kg with 4 months of training (22). Cardiorespiratory fitness has been coined the ultimate health Yet, for the Registered Exercise Professional, it is of absolute outcome (13), and for good reason; it has been shown importance that they clarify to their clients that these relatively that low cardiorespiratory fitness accounts for more deaths modest changes bestow important overall health benefits. in both men and women than any other CVD risk factor A number of studies have linked substantial improvements (5). The good news is that low cardiorespiratory fitness is to various chronic disease risk factors, including low exceptionally modifiable. In fact, improvements in fitness cardiorespiratory fitness, insulin resistance, and low HDL will likely be more pronounced when compared to other risk cholesterol, with weights loss reductions of only 2 to 3% (9). REPs New Zealand Pre-Screening Guide • Type 2 Diabetes T2DM is currently an epidemic that is projected to worsen; Dyslipidemia refers to abnormalities in the blood lipid and it has been estimated that 300,000 New Zealanders lipoprotein profile of which elevations in total cholesterol, LDL have T2DM (26). Heart disease death rates are two to cholesterol, and triglycerides, along with low HDL cholesterol, four times higher in those with T2DM compared to those are characteristic features. These parameters may be without the metabolic condition (14). The hallmark benefits modified with regular exercise. Three months of aerobic of regular exercise in those with T2DM include increased training has been linked to increases in HDL cholesterol insulin sensitivity, decreased HbA1C, and reduced insulin of 0.05 – 0.2 mmol/L (10). Likewise, regular exercise over requirements. Chronic aerobic training over two to 12 similar time periods results in LDL cholesterol reductions months has been reported to decrease HbA1C levels by between 3-10% (17, 30). Total cholesterol and triglycerides 0.6% (8). This reduction is clinical significant for T2DM can also be attenuated following several months of regular clientele and has been linked with a 22% reduction in exercise; typical decreases in total cholesterol are 4-20% microvascular complications and 8% reduction in rate of while triglycerides are lowered by 0.13 – 1.0 mmol/L (10). myocardial infarctions. In nondiabetics regular exercise also These positive modifications to the lipid profile yield important provides important benefits in terms of maintaining normal overall health benefits. It has been estimated that for every insulin sensitivity and blood glucose control. For example, 0.02 mmol/L increase in HDL cholesterol, the risk of a CHD it has been reported that two months of aerobic exercise event is reduced by 2 to 3% (27). Moreover, it has been training reduces fasting blood glucose levels by 0.15 purported that for every 1% decrease in LDL cholesterol there is a corresponding 1% reduced risk for significant heart disease events (24). Similarly, each 1% reduction in total cholesterol levels has been associated with a 2% decrease in CVD rate (25). Research has indicated that the above-mentioned modifications are most likely to be seen in HDL and triglycerides, while the adaptations in total cholesterol and LDL cholesterol are not as universal. The expected change, timeline, and meaningfulness for key health outcomes 10% VO2max = 15% risk of mortality Systolic blood pressure 2mmHg SBP = 6% stroke mortality and 4% CHD Diastolic blood pressure No data available 2-3% weight = improvements in other risk factors Fasting blood glucose No data available 0.6% HbA1c = 22% microvascular complications and 8% reduced rate of MI Total cholesterol 1% TC = 2% CVD rates 1% LDL = 1% risk of CHD event 0.02 mmol/L HDL = 2-3% risk of CHD event No data available It is paramount that Registered Exercise Professionals assist their clients with establishing attainable goals. Understanding the expected change in key health outcomes and the expected timeframe to achieve these adaptations will result in the most realistic and triumphant result. REPs New Zealand Pre-Screening Guide Section C.3 RISK FACTORS AND SIGNS/SYMPTOMS How can clients at increased risk
for either disease and/or event be
Clients with positive risk factors for cardiovascular disease
are at increased risk for ultimately developing cardiovascular
disease and/or experiencing an exercise-related cardiac
event. Positive risk factors are elements that contribute
towards disease profession. Similarly, clients with known
signs and/or symptoms of cardiovascular, pulmonary, and/
Common signs and symptoms
or metabolic disease are at increased risk of an exercise- of Cardiovascular, Pulmonary,
related cardiac event or other complication. and Metabolic Disease.
i. Positive risk factors for cardiovascular disease are Pain or discomfort in chest, arm, neck, jaw (ischemia) ii. Common signs and symptoms of cardiovascular, pulmonary, and metabolic disease. These individuals will SOB at rest or w/ mild exertion require medical referral and clearance before Dizziness or syncope commencing exercise. Orthopnea or paroxysmal nocturnal dyspnea Positive Risk Factors for Cardiovascular Disease Palpitations or tachycardia Known heart murmur Unusual fatigue or SOB with usual activities REPs New Zealand Pre-Screening Guide Section C.4 CRITERIA FOR CARDIOVASCULAR DISEASE What are the defining criteria for the positive cardiovascular disease risk factors?
The presence of positive cardiovascular disease risk factors (listed below) provides a framework for risk stratifying clients.
The overall number of positive risk factors should be totalled. In the event there is no available information for a specific positive
cardiovascular disease risk factor it has been recommended elsewhere (1) to assume the worst case scenario and count the
Defining criteria for positive cardiovascular disease risk factors.
• MI, coronary revascularization, or sudden death: ✔ before 55 yr in father or 1o male relative ✔ before 65 yr in mother or 1o female relative ✔ Men ≥ 45yr✔ Women ≥ 55yr • Current smoker or quit within previous 6 months • BP ≥ 140 mmHg SBP and/or ≥ 90 mmHg DBP ✔ on 2 occasions ✔ or on antihypertensive medication • HDL < 1.04 mmol/L (40 mg/dL) or• LDL ≥ 3.37 mmol/L (130 mg/dL) or • Triglycerides (TG) ≥ 1.7 mmol/L or • TG/HDL ratio ≥ 4.0 or • On lipid lowering meds • TC ≥ 5.18 mmol/L (200 mg/dL ) *only use if all that is available • Fasting BG ≥ 5.50 mmol/L (100 mg/dL) on 2 occasions• HbA1c ≥ 40 mmol/mol • BMI ≥ of 30 kg/m2 ✔ waist >102 cm for men, >88 cm for women ✔ waist-to-height ratio: ≥0.60 Sedentary lifestyle • no regular exercise programme ✔ do not meet minimal PA recommendations ✔ < 30 min mod-intensity; < 3 days/wk; < 3 months REPs New Zealand Pre-Screening Guide Section C.5 RISK STRATIFICATION How can healthy history and risk factor
information be used to risk
Upon obtaining a completed REPs pre-screen and
measures of positive cardiovascular disease risk factors
Registered Exercise Professionals are in a position to risk
stratify new clients into one of 3 classifications:
The criteria for each of these classifications is as follows: Low risk - individuals who are asymptomatic with no
diagnosed disease and have no more than one major
CVD risk factor
Moderate risk - Individuals who are asymptomatic
with no diagnosed disease and have two or more major
CVD risk factors
High risk - Those with known cardiovascular,
pulmonary, or metabolic disease or have one or more
signs/symptoms suggestive of cardiovascular or
REPs New Zealand Pre-Screening Guide Section D EXERCISE-MEDICATION INTERACTIONS My client is taking medication –
Common medication #1:
what do I need to know?
Mechanism of action: Thousands of New Zealanders currently take prescribed Beta blockers are commonly prescribed medications for medications in an effort to manage various chronic diseases. hypertension and heart disease. Beta blockers function by It is paramount for Registered Exercise Professionals to preventing the binding of epinephrine to receptors in the heart. gain a better understanding of the effects these common This results in both decreased resting and exercise HR and BP medications can have on the exercise response. This next values. Commonly prescribed beta blockers include atenolol section will provide a basic understanding of 5 common medications clients may be taking, how they affect exercise, and modifications required to the exercise programme. Interaction between medication and exercise response: The therapeutic effect provided by beta blockers also means an altered physiological response to exercise. Beta blocker treatment blunts the usual increases in HR and BP corresponding to higher exercise intensities/workloads. Beta The location of the targeted effect of blockers can also cause glucose intolerance in diabetics by common medications. masking the symptoms of hypoglycemia. Modifications required in the exercise programme: The fact that beta blockers reduce the HR response to exercise means traditional methods for establishing target HR (e.g., peak HR method or HR reserve method) are likely to be invalid. The most important modification required of the exercise programme for individuals taking a beta blocker is use of an alternative method for setting target intensity. The RPE scale is an excellent option. Registered Exercise Professionals should also strongly encourage diabetic patients whom are also prescribed beta blockers to regularly check blood glucose values with their glucometers prior to exercise to ensure levels are in a safe range. REPs New Zealand Pre-Screening Guide Common medication #2:
Common medication #3:
Mechanism of action: Mechanism of action: An ACE inhibitor is a medication primarily used for the Diuretics are another class of medications commonly used treatment of hypertension. Common ACE inhibitors include for the treatment of hypertension. One of the most common captopril, enalapril, and lisinopril. ACE inhibitors reduce types of diuretics is HCTZ. Diuretics act on the kidney and the activity of the complex renin-angiotensin-aldosterone lead to increased urine output. An up-regulation in urine system. Simply put, ACE inhibitors block the conversion excretion in turn leads to a lower plasma volume thereby of angiotensin I to angiotensin II primarily in the lungs. The lowering blood pressure. molecule angiotensin II is a potent vasoconstrictor of blood vessels. Therefore, reduced production of this molecule results in relaxation of the blood vessels and lower blood Interaction between medication and exercise response: pressure values.
In a similar manner to ACE inhibitors individuals on diuretics will have both lower resting and exercise blood pressure values. And, in a related manner, a principle concern for Interaction between medication and exercise response: individuals taking ACE inhibitors is that the combination of Individuals on ACE inhibitor medication have both lower the reduction in blood pressure from the diuretics coupled resting and exercise blood pressure values. However, with the natural-occurring postexercise hypotension can it is the interaction between ACE inhibitors and the result in excessive reductions in blood pressure. postexercise blood pressure response that requires added attention from Registered Exercise Professionals. An acute beneficial response to exercise is a phenomenon known as Modifications required in the exercise programme: postexercise hypotension whereby systolic blood pressure Clients on diuretics should be encouraged to perform a values can be reduced by 10-20 mmHg for up to 9 hours gradual cool down after all exercise sessions. Additionally, after the conclusion of exercise. The concern for individuals Registered Exercise Professionals should encourage taking ACE inhibitors is that the combination of the reduction clients taking a diuretic to perform a daily weight check. in blood pressure from the medication coupled with the This measure will ensure that the prescribed dosage of natural-occurring postexercise hypotension can result in diuretic is continuing to have its efficacious physiological excessive reductions in blood pressure. This can lead to benefits. A sudden change in weight of a few kilograms untoward events such dizziness and in rarer instances can help alert clients that something may be amiss and that syncope (i.e., temporary loss of consciousness). communication with their GP could be warranted. Modifications required in the exercise programme: Registered Exercise Professionals should strongly encourage a gradual cool down of 5-10 minutes of light aerobic activity that will assist the body to return to homeostasis and prevent excessive reductions in blood pressure. REPs New Zealand Pre-Screening Guide Common medication #4:
Common medication #5:
Mechanism of action: Mechanism of action: Statins are the most common medication prescribed for Oral hypoglycemics are a class of medications commonly high cholesterol. Statins function by inhibiting a key enzyme prescribed for individuals with T2DM. There are three major involved in the production of cholesterol in the liver. Common groups of oral hypoglycemics used to control blood glucose: statins include lipitor, zocor, and pravachol. 1) ß-Cell stimulants for insulin release, 2) drugs to improve insulin sensitivity, and 3) drugs that decrease intestinal absorption of carbohydrates. ß-Cell stimulants function by Interaction between medication and exercise response: inciting insulin release from the pancreas. These medications are taken with meals and help alleviate excessive increases Caution is advised when exercise is performed by individuals in post-meal blood glucose levels. The latter two oral taking statins. Although not common there are occasional hypoglycemic categories have little effect on the exercise instances where statins are associated with exertional response. A few common ß-Cell stimulants include glipizide rhabdomyolysis. Rhabdomyolysis is a condition in which and glyburide.
damaged muscle disuse breaks down and releases cellular content (e.g., protein myoglobin) into the blood. These products can be harmful to the kidney. The incidence Interaction between medication and exercise response: of exertional rhabdomyolysis is higher in de-conditioned individuals performing high-intensity exercise, most notably The transport of glucose from the blood into the muscle resistance training and eccentric exercises. The condition is cell is facilitated by the transporter protein GLUT-4. These also likely to be worsened if the high-intensity exercise is also transporter proteins respond to two signals – insulin and performed in hot and/or humid environments. exercise. Because of the insulin stimulation from ß-Cell stimulants, when combined with exercise, there is increased potential for hypoglycemia (i.e., low blood glucose). Modifications required in the exercise programme: There are several preventative measures Registered Exercise Modifications required in the exercise programme: Professionals can practice to avoid exertional rhabdomyolysis: The most important modification to the exercise programme 1. All exercise programming (aerobic and resistance for those clients' prescribed oral hypoglycemics is frequent training) should begin at low-intensity and progress monitoring of blood glucose values. It should be noted that it is not the responsibility of the exercise professional to 2. Registered Exercise Professionals should be vigilant to check blood glucose values. Rather, the client should bring the signs and symptoms of exertional rhabdomyolysis. their own glucometer and glucose strips which should have These may include muscle stiffness and/or pain, fatigue, been prescribed by a physician or endocrinologist. and dark coloured urine.
3. Clients should always be encouraged to remain hydrated and exercise at cooler ties of the day (if outside). Key take home message The combination of an aging New Zealand population along with the widespread prevalence of various chronic diseases heightens the chances that the next client coming to you for exercise guidance will also be taking a prescribed medication. This section highlighted how common medications influence the exercise response. Key modifications required of the exercise programme to accommodate interactions between medications and the exercise responses were also identified. REPs New Zealand Pre-Screening Guide Section E THE PRE-SCREEN TO EXERCISE PROGRAMME TRANSITION Will more of my clients be healthy or persons with multiple chronic diseases?
In 2011/2012 just over half (54%) of New Zealanders met national physical activity recommendations (31). Older New Zealanders are currently both the least physically active and the most rapidly growing of any age group. Physical inactivity is associated with numerous unhealthy conditions, including obesity, hypertension, T2DM, and CVD (4). Moreover, the presence of specific chronic conditions can lead to an even greater propensity of comorbidities. For instance, almost all clients with diabetes have at least one other chronic condition and nearly half have 3 or more comorbidities (32). The prevalence of common chronic and clinical populations is displayed in the table below. Collectively these factors make it increasingly likely that Registered Exercise Professionals will be interacting with clientele other than apparently healthy adults. Although there are exercise programming guidelines for older adult and various chronic-diseased populations, these recommendations exclusively address each group separately. This is unfortunate because rarely does a client possess only one chronic condition; rather it is much more likely that they will have multiple conditions (co-morbidities). This section will explain critical measures that can be taken to successfully break down complex cases into simple ones and ultimately lead to safer and more effective exercise programme outcomes. Prevalence of common chronic and clinical populations. 15% of adults (15 and older) Cardiac heart disease Metabolic Syndrome *modified from references (29, 31) REPs New Zealand Pre-Screening Guide How can exercise programming for complex clients be made more manageable?
Presently, both the New Zealand Heart Foundation (26) and Ministry of Health (31) list sedentary lifestyle as a controllable risk
factor for many chronic health conditions. Accordingly, exercise is a common therapeutic intervention strategy for clients with
comorbidities. Next, the complex scenario of designing an exercise programme for persons with multiple chronic conditions is
broken down into four simple and manageable steps.
To fully appreciate the arduous task of working with A critical shortcoming to our overall current healthcare individuals with multiple chronic conditions, it is paramount model for the management of chronic conditions is that the to recognise that the presence of these comorbidities may treatment has historically been approached in a singular serve as competing demands on client's self-management fashion. For example, an Endocrinologist might provide resources, thus reducing the time and energy an individual recommendations for a diabetic, while a Rheumatologist has remaining to devote to each and every condition (6). can provide guidance to an arthritic patient; yet it would Accordingly, these individuals will require additional guidance be rare for either medical professional to make note of the and resources to ensure that other conditions are managed concurrent chronic condition when devising a therapeutic effectively. An individual with a severe and symptomatic intervention. In fact, it has been noted that patients condition, such as heart failure, will likely have considerable infrequently receive guidance from medical professionals on difficulty managing other conditions (e.g., T2DM). In these prioritizing and managing multiple chronic conditions (18). It circumstances, a severe limitation should not preclude the is important to recognize that this philosophy also extends exercise professional from designing a routine that targets to current exercise guidelines for chronic conditions. As is each individual condition (18). summarized in Table 1, the exercise prescription guidelines for common chronic conditions are presented in a separate The exercise professional may need to be creative in and uniform manner (1). Given the strong likelihood that modifying the routine to sufficiently accommodate limiting your client will possess multiple chronic conditions, exercise factors, yet ensure thresholds for frequency, intensity, and professionals must be prepared to meet the challenge of time are also met to elicit positive training effects. Individuals developing a suitable comprehensive exercise programme with multiple comorbidities may possess conditions (e.g., that addresses each of the client's chronic conditions. low back pain, lupus, osteoarthritis, fibromyalgia) that fluctuate significantly from day-to-day in terms of severity. A requisite task is to initially create two separate lists, Exercise professionals must be prepared to accommodate which prioritise the chronic conditions of a client in terms an ever-changing chronic condition landscape with these of 1) long-term mortality risk and 2) symptom limiting. types of clients and constantly adjust the session to best The chronic condition topping the list in terms of mortality serve the client on any given day. Clients with comorbidities risk should ideally be the primary focus of the exercise will require a high degree of monitoring to ensure proper programme. For example, an individual with heart disease, adherence of the established exercise regimen and to osteoporosis, and arthritis should be most concerned about determine that the physiological responses to each session management of the heart disease. Epidemiological data are normal. Exercise professionals should be knowledgeable clearly shows an individual is more likely to die from heart of, and able to educate clients on, the potential signs that disease compared to the two other chronic conditions (21). would warrant the termination of exercise. Yet a primary focus on the management of the heart disease in this instance should not be misinterpreted to mean a The last point to understand concerning exercise singular and exclusive focus on only that condition. The programme design for clients with multiple conditions is vital. exercise programme similarly needs to also be formulated Although exercise can be applied as powerful therapeutic with the aim of positively modifying each of the other two intervention, there are certainly reasonable limitations to its conditions. Concurrent to designing an exercise programme overall effectiveness with each condition. There is powerful based upon the ‘long-term mortality risk' list, is also the evidence for a favourable relationship between exercise requirement for adjusting parameters of the training routine volume and numerous conditions, including risk of coronary in accordance with the ‘symptom limiting' list. As previously artery disease mortality, obesity, dyslipidemia, Type 2 mentioned, there will undoubtedly be occasions where diabetes, and colon cancer (1, 20, 28). On the other hand, an individual's unstable condition (e.g., arthritis) dictates conditions such chronic obstructive pulmonary disease, that the exercise session or programme revolves around Alzheimer's disease, and chronic low back pain, just to list a the limiting symptom(s). For instance, although specific few, may not see a marked improvement as a result of the weekly energy expenditure volume and exercise intensity REPs New Zealand Pre-Screening Guide thresholds must be surpassed to positively modify coronary with establishing the basic parameters of the exercise heart disease (1), these limits may be unattainable amid an prescription around the various conditions of an individual. arthritic flair-up. In view of these circumstances, the exercise Let's consider an individual who has arthritis, dyslipidemia, professional may elect to amend the routine in various hypertension, and T2DM. As highlighted in the previous manners, including decreasing the exercise volume and/or section there are different strategies to establishing the intensity, altering the exercise modality from land- to water- overall exercise programme. One guideline to employ when based, or rescheduling the exercise session to another day designing the programme is to follow the specific exercise when the symptoms are less restrictive. prescription for the chronic condition that poses the greatest risk of mortality for the individual. In this instance, Type 2 diabetes is generally considered to increase the risk for How important is it to improve muscular fitness? heart disease and all-cause mortality (33) more so than A balanced and comprehensive exercise programme the other conditions. Concomitantly, the other chronic should not consist of aerobic training exclusively, but also conditions and specific limiting symptoms must also be resistance training exercises. Importantly, over the past carefully considered when formulating the programme. In 10 years there has been a wealth of research highlighting this instance, the frequency and time parameters of the the various health benefits of regular resistance training to exercise prescription for each condition is comparable. Yet, improve muscular fitness, including enhanced functional there are some marked differences in the exercise intensity capacity, positive cardiometabolic profile, lowered risk of recommendations between conditions. While both moderate cardiac events, and reduced risk of mortality from all causes (64% to <77% HRmax) and vigorous (77% to <90% (2). The fact that resistance training can positively modify HRmax) exercise intensity are recommended in obesity body composition (i.e., improved muscle mass and reduced and T2DM populations, as can be noted from Table 5.2, fat mass) makes it an important strategy for the prevention vigorous intensity exercise is not recommended for either and treatment of metabolic syndrome. Further, regular hypertensive or arthritic populations. Therefore, it would be resistance training helps preserves bone mass as individual's prudent for the exercise professional to adopt the exercise age, thus reducing the risk of one developing osteoporosis prescription for T2DM in this scenario, provided the exercise later in life. Moreover, it is well recognised that one of the intensity was restricted to a moderate category. most important factors involved with good balance is An alternative strategy is to use the exercise prescription optimal muscle strength. As such, regular resistance training guidelines for a single chronic condition that proves to be that improves and/or maintains muscle strength will help the most limiting of the multiple conditions for each client. preserve balance, especially as one ages. This in turn will In particular this approach is warranted when the client play an important role in reducing the risk of falls. Overall, is symptomatic or the condition is not stable. Arthritis is there is strong scientific evidence to support the numerous characterized by periodic episodes of acute inflammation. health benefits of a structured and progressive resistance Pain and discomfort are common throughout these training programme. flares, and without sufficient caution, exercise can actually exacerbate the symptoms (1). Under these circumstances it would be ill-advised to pursue the exercise prescription guidelines for T2DM despite it topping our greatest risk In general, the exercise prescription for individuals with for mortality list. On the contrary, an exercise prescription comorbidities can follow the FITT framework. The table resembling the guidelines for arthritis recommended would below summarizes the basic evidence-based guidelines be more suitable.
for common clinical populations. This resource can assist The exercise prescription for common chronic and clinical populations 64% to <77% HRmax 64% to <90% HRmax 64% to <77% HRmax Metabolic Syndrome 64% to <77% HRmax 64% to <90% HRmax 64% to <90% HRmax * Modified from References (1, 16) REPs New Zealand Pre-Screening Guide Step #4
The final step in all evidence-based practice programmes
The considerable challenge of designing is the review of performance. Exercise professionals should exercise programs for clients with comorbidities regularly review the first 4 steps (Scenario, Understand, requires a simplified approach for Registered Prioritize, Exercise Programme Design) and seek ways to Exercise Professionals. This section conveyed improve in the future. Given the aforementioned complexity 4 basic steps to follow with each client to of exercise programme design for individuals with multiple accomplish the explicit goal of a safer and more chronic conditions, frequently reviewing all aspects of the effective exercise programme outcome. It is programme is mandatory. It is absolutely paramount for the important to note that the primary focus of this exercise professional to comprehend and fully appreciate section was to outline the procedures required the unstable nature of most chronic conditions (18, 28). to assist Registered Exercise Professionals with Quite simply put – the aims of your exercise programme are breaking down complex cases into more simple unpredictable and moving targets. You will be required to and manageable tasks. Additionally, it centred revise your mortality risk and symptom-limiting lists multiple on special considerations needing attention times. Likewise, the occasions where you will need to when interacting with and providing exercise modify the exercise routine to accommodate the sudden programming for clients with multiple chronic worsening of a symptom-limiting condition will be of irregular diseases. The intent of this section was not to frequency and duration. be exhaustive in its scope of addressing each and every chronic condition the Registered Exercise Professionals will encounter in their The review process also provides exercise professionals with career. Listed below the Registered Exercise the opportunity to provide clients with valuable feedback Professional will find a brief list of excellent on the effectiveness of the programme. Understanding the resources concerning the pathophysiology typical improvement (if any) for each chronic condition that and exercise guidelines for dozens of chronic can be expected through an exercise intervention, along conditions. It is highly recommended that these with the time course to achieve this modification, will help resources are utilised by Registered Exercise the exercise professional provide meaningful feedback to Professionals when implementing the steps clients. Remember an improvement for all chronic conditions outlined in this section with future clients.
is not always a feasible expectation (19). There will be scenarios where simply maintaining functional capacity or stabilizing the disease process can, and should, be viewed as a successful outcome.
REPs New Zealand Pre-Screening Guide REPs Physical Activity Readiness Questionnaire (PAR-Q) The REPs PAR-Q form is NOT INTENDED as an alternative to the main REPs Pre-Screening form, as it does not provide the
detail needed to develop personalised exercise assessment and prescription.
The PAR-Q is designed for quick, easy, and independent completion by the facility user. It is specifically and exclusively intended for the following situations: Unsupervised exercise facilities for users to sign prior to entry
Casual visitors to an exercise facility who will otherwise receive no further individual attention from a Registered Exercise
Professional. For example, a facility receptionist could request that a non-member visitor complete and sign the PAR-Q
prior to facility use.
NZ Register Of Exercise Professionals
Physical Activity Readiness Questionnaire (PAR-Q)
Medical Provider(s) Name and Contact: This form is used to identify if it is safe for you to commence unsupervised exercise.
Please read the questions carefully and answer each one to the best of your knowledge
Has your doctor ever said that you have a heart condition or have you ever suffered a stroke? Do you feel unexplained pain in your chest at rest or when you do physical activity? Do you ever lose your balance because of dizziness during physical activity? Have you had an asthma attack requiring medical attention at any time over the last 12 months? If you have diabetes, have you had trouble controlling your blood glucose at any time over the last 6 months? Do you have a bone or joint problem that could be made worse by participating in exercise? Do you have any other medical condition that may make it dangerous for you to participate in exercise? If you answer YES to any of the questions we* do not approve that you start exercising until you have first ! consulted your GP for clearance and advice.
If you answer NO to all of the questions we* consider that it is safe for you to commence some exercise, but it is highly preferable that you consult with a Registered Exercise Professional for personal advice first.
I acknowledge that the answers I have provided above regarding my health and personal information are, to the best of my knowledge correct. I understand that participating in physical activity and exercise can carry a risk, and I accept all responsibility for that risk.
I acknowledge that I will not be receiving any personalised exercise advice or support for this exercise session or visit. Customer Signature: _ Name of Facility: _ For use by REPs Registered Exercise Professionals Only NZ Register of Exercise Professionals 2014 REPs New Zealand Pre-Screening Guide Professional Referral Letter
Re: Client Name: Your client/patient has met with me with the goal of _ I am a Registered Exercise Professional with the New Zealand Register of Exercise Professionals (REPs). Before commencing a programme of exercise for your client/patient, I have carried out the REPs exercise pre-screening process. Information gathered during the screening process included the following: Sessions / week
Notes: (Exercise Professional: Include details of any:
Signs or Symptoms, Risk Factors, Known Conditions of Minutes / week
medical issues identified in pre-screen results). Intensity
Exercise professional to attach a copy of the REPs Pre-screening form, and any details of other practitioners treating the client.
In response to your client/patients pre exercise screening results, I request your guidance in relation to the following condition(s) to enable and ensure the delivery of a safe and effective exercise programme: Based on your client/patients goals, it is intended to have them commence an exercise programme consisting of the following: Describe the intended program focus in brief (1-2 sentences) – e.g. strength / cardio based programme group vs 1:1 REPs New Zealand Pre-Screening Guide Please indicate any recommendations you may have in relation to their exercise programme, including specific activities they cannot or should not be undertaking at this time, or other relevant notes.
Practitioner to include any notes for the exercise professional here: I will keep you informed of progress and any major changes in his/her condition. To acknowledge you have received this referral, please complete this section: Status of Referral: *please describe action required in notes Practitioner Name: Contact person for follow up: **please provide new contact details in notes Practitioner Title: Practitioner Signature: Please include in notes any instructions you may have regarding follow up or progress reporting. I welcome any advice you feel necessary and can be contacted by phone or by email anytime.
I give my permission for my exercise professional to communicate with the referring Practitioner and/or my GP regarding my health status and my progress relating to my exercise programme.
Client Signature: This letter is for use by REPs Registered Exercise Professionals Only NZ Register of Exercise Professionals 2014 REPs New Zealand Pre-Screening Guide Resources for the Exercise Professional designing exercise programmes for Clients with Comorbidities Will more of my clients be healthy or persons with multiple chronic diseases?
ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities, 3rd Ed ACSM's Guidelines for Exercise Testing and Prescription, 9th Ed ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription, 6th Ed American College of Sports Medicine (2014). ACSM's 10. Durstine JL, Grandjean PW, Davis PG, Ferguson MA, Guidelines for Exercise Testing and Prescription (9th ed.). Alderson NL, Dubose KD. Blood lipid and lipoprotein Baltimore: Lippincott Williams & Wilkins.
adaptations to exercise: A quantitative analysis. Sports Medicine. 2001;31:1033–1062.
American College of Sports Medicine position stand: Quantity and quality of exercise for developing and maintaining 11. Dunn AL, Marcus BH, Kamper JB, et al. Comparison of cardiorespiratory, musculoskeletal, and neuromotor fitness in lifestyle and structured interventions to increase physical apparently healthy adults: guidance for prescribing exercise. activity and cardiorespiratory fitness: a randomized trial. Medicine & Science in Sports & Exercise. 2011; 12. Fagard RH. Exercise is good for your blood pressure: effects American College of Sports Medicine position stand: exercise of endurance training and resistance training. Clinical and and hypertension. Medicine & Science in Sports & Exercise. Experimental Pharmacology and Physiology. 2006;33:853-6.
13. Franklin BA: Fitness: the ultimate marker for risk stratification Booth, F.W., Gordon, S.E., Carlson, C.J. and Hamilton, M.T. and health outcomes? Preventive Cardiology. 2007;10:42–6.
Waging war on modern chronic diseases: primary prevention through exercise biology. Journal of Applied Physiology. 14. Go AS, Mozaffarian D, Roger VL, et al; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke Blair SN. Physical inactivity: the biggest public health problem statistics—2013 update: a report from the American Heart of the 21st century. British Journal of Sports Medicine. Association. Circulation. 2013;127:e6–245.
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16. Haskell, W.L., Lee, I.M., Pate, R.R., et al. Physical activity and Chobanian AV, Bakris GL, Black HR, Cushman WC, Green public health: updated recommendation for adults from the LA, Izzo JL, et al. The Seventh Report of the Joint National American College of Sports Medicine and the American Heart Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-72.
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REPs New Zealand Pre-Screening Guide
Tom Rustom 25/09/2013 TYPE 2 DIABETES AND ITS MANAGEMENT (ALL THE BORING BITS THAT EVERYONE ALWAYS FORGETS, ESPECIALLY THE DRUGS) BLOOD GLUCOSE LOWERING THERAPY Metformin (Glucophage, Glumetza, Riomet) 1st line in treatment of T2DM (after lifestyle change) Suppresses appetite (useful in overweight patients) Does not cause hypoglycaemia S/Es – gastrointestinal, lactic acidosis