ACSM Risk Stratification

ACSM Risk Stratification

Why is it important to screen clients?
Exercise can increase the risk of sudden cardiac death and heart attack Cardiovascular events usually only occur in clients with preexisting conditions Many clients are unaware of their risk

Why is it important to screen clients?
Exercise usually only provokes cardiovascular events only in clients with pre-existing heart disease. Exercise typically does not provoke cardiac events in clients with normal cardiovascular systems.

Cardiovascular Disease
What Risk Factors and/Or symptoms should personal trainers consider screening for? Cardiovascular Disease Hypertension, High Cholesterol, Past Heart Attack, Stroke etc. Metabolic Disease Diabetes, Kidney Diseases etc. Pulmonary Disease Asthma, COPD (common in smokers) etc. Conditions aggravated by exercise Exercise Induced Asthma, Arthritis etc.

What should a screening identify?
Clients with medical contraindications to exercise At-risk clients who need a medical exam first Clients who need a medically supervised exercise program Clients with other special needs Identify the personal trainer best suited for the client

Three Phases of the Screening Process
Risk Classification Determine if client is at risk for a cardiovascular, metabolic or pulmonary condition Health-History Evaluation and Related Assessments Complete resting measurements – heart rate, blood pressure etc. Medical Clearance or Referral Determine if doctor must be seen before starting an exercise program

Eight Steps of the Screening Process
1. Determine the number of risk factors and number of signs and symptoms (based on tables 11.1 and 11.2) 2. Determine whether the client is at low, moderate or high risk (based on figure ) 3. Determine whether a medical evaluation or exercise testing is necessary (based on figure 11.6) 4. Conduct a health-history evaluation 5. Obtain a medical clearance if necessary 6. Complete an informed consent 7. Conduct appropriate assessments 8. Refer the client to a physician or other health care provider if necessary

ACSM Risk Classification
The ACSM risk classification process is used to identify clients who should undergo a medical examination and exercise testing before beginning a moderate or vigorous exercise program. Medical clearances (if necessary) should be obtained after the personal trainer has conducted both the risk classification and a thorough health-history interview with the client.

What are the two self-guided questionnaires that can be used with clients?
Physical Activity Readiness Questionnaire (PAR-Q) Figure AHA/ACSM Health/Fitness Facility Pre-Participation Screening Questionnaire Figure 11.2

Medical Clearance When working with clients transitioning out of cardiopulmonary rehabilitation, physical therapy or another medically supervised program, a written medical clearance is recommended, even if the physician referred them to a personal trainer.

Explain the difference between a positive and negative risk factor for atherosclerotic cardiovascular disease: A positive risk factor is linked to increased likelihood of cardiovascular disease. The more positive risk factors present the greater the chances of cardiovascular disease. The presence of 2 or more risk factors warrants medical clearance prior to exercise. A negative risk factor helps prevent the risk of cardiovascular disease and subtracts 1 risk factor from the sum of the risk factors.

Positive Risk Factors for Cardiovascular Disease – See Table 11
Positive Risk Factors for Cardiovascular Disease – See Table 11.1 for more in-Depth information Age Family History Cigarette Smoking Sedentary Lifestyle Obesity Hypertension Dyslipidemia Pre-Diabetes

What is a Negative Risk Factor for Cardiovascular Disease?
High Density Lipoprotein Cholesterol greater than 60 mg/dL

Matching- answers Given at end of PPT
13 Low density lipoprotein cholesterol >130 mg*dL or high density lipoprotein cholesterol <40 mg*dL or on lipid-lowering medication. If total serum cholesterol is all that is available use >200 mg*dL Age 14 >60mg*dL Negative risk factors, removes 1 risk factor. B. Cigarette Smoking 15 Impaired fasting glucose >100mg*dL and <125 mg*dL; or impaired glucose tolerance >140 mg*dL and <199 mg*dL confirmed by measurements on at least 2 separate occasions C. Dyslipidemia 16 Men > 45 years; women >55 years D. Family History 17 Body mass index >30 kg/m2 or waist girth 120 cm (40 in) for men and >88 cm (35 in for women E. High Density Lipoprotein Cholesterol 18 Myocardial infarction, coronary revascularization or sudden death before 55 years in father or other male first-degree relative, or before 65 years in mother or other female first-degree relative F. Hypertension 19 Not participating in at least 30 minutes of moderate intensity physical activity on at least 3 days a week for at least 3 months G. Obesity 20 Current cigarette smoker or those who quite within the previous 6 months or exposure to environmental tobacco smoke H. Prediabetes 21 Systolic blood pressure >140 mmHg and/or diastolic >90mmHg, confirmed by measurements on at least 2 separate occasions, or on anti-hypertensive medication I. Sedentary Lifestyle

22 Temporary or short lived symptoms Acute 23 Any condition that renders some particular movement, activity or treatment improper or undesirable B. AHA/ACSM Health/Fitness Facility Pre-Participation Screening Questionnaire 24 Programs that are recommended for patients with major cardiac impairment or adverse signs or symptoms (i.e., those at increased risk for future cardiovascular events). C. Asymptomatic 25 An episode in which some of the hearts blood supply is severely cut off or restricted, causing the heart muscle to suffer and die from a lack of oxygen. Commonly known as a heart attack D. Cardiovascular Disease 26 A person showing no signs or symptoms Contraindication 27 A general term for any disease of the heart, blood vessels or circulation F. Medically supervised exercise program 28 An unexpected death due to cardiac causes that occurs in a short time period (generally within 1 hour of symptom onset) in a person with known or unknown cardiac disease. G. Metabolic Disease 29 Self-administered health questionnaire. Focuses in the symptoms of heart disease and potential musculoskeletal problems that should be evaluated prior to participation in an exercise program. If a client checks yes then refer to physician. H. Myocardial Infarction 30 Any disease or disorder that disrupts normal metabolism – the process of converting food to energy on the cellular level I . Physical Activity Readiness Questionnaire (PAR-Q) 31 Any condition that affects the blood vessels along the route between the heart and lungs. J. Pulmonary Disease 32 Sudden onset of disease K. Sudden Cardiac Death 33 Includes history, symptoms and risk factor to direct clients to either participate in an exercise program or contact their health care provider before participation. L. Transient

Identify the major Signs or Symptoms suggestive of Cardiovascular, pulmonary or Metabolic Disease
Pain discomfort in the chest, neck, jaw or arms or other areas that may result from ischemia Shortness of breath at rest or with mild exertion Dizziness or syncope (passing out) Orthopnea or paroxysmal nocturnal dyspnea Ankle edema Palpitations or tachycardia Intermittent Claudication Known heart murmur Unusual fatigue or shortness of breath with usual activities

What does ischemic mean?
What happens when your heart doesn’t get enough oxygen. Usually happens because of a shortage of blood and oxygen to the heart muscle. It is usually caused by a narrowing or blockage of one or more coronary arteries.

When chest pain and discomfort occurs, what key features indicate an ischemic origin?
Characterized by a constricting, squeezing, burning heaviness or heavy feeling Located in sub sternal, across mid-thorax, anteriorly in one or both arms, shoulders, neck, cheeks, teeth, forearms, fingers and interscapular region Provoked by exercise or exertion, excitement or other forms of stress, cold weather and occurrence after meals

When chest pain and discomfort occurs, what key features indicate That it is Not an ischemic origin?
Characterized by a dull ache, knifelike, sharp stabbing and jabs aggravated by respiration Located in left sub mammary area; in the left hemithorax Provoked by completion of exercise and provoked by a specific body motion

38 An extra or unusual sound heard during a heartbeat. May indicate valvular or other cardiovascular disease. A. Angina Pectoris 39 Disease of the heart valves in which the opening of the aortic valve is narrowed. B. Ankle edema 40 Chest pain caused by an inadequate supply of oxygen and decreased blood flow to the heart muscle. Symptoms may include pain or discomfort, heaviness, tightness, pressure or burning, numbness, aching and tingling in the chest, back, neck, throat, jaw or arms C. Aortic Stenosis 41 Condition where the heart muscle become thick, common cause of sudden cardiac arrest in young people. D. Dyspnea 42 An abnormally uncomfortable awareness of breathing, can be a sign on chronic obstructive pulmonary disease E. Heart murmur 43 Swelling of the ankles. Bilateral edema is a sign of heart failure. Unilateral ankle edema is usually caused by a blood clot in a vein. F. Hypertrophic Cardiomyopathy

44 Dyspnea that begins 2 to 5 hours after the onset of sleep, relieved by sitting on the edge of the bed or getting out of bed. A. Intermittent Claudication 45 Unpleasant awareness of the forceful or rapid beating of the heart. Often result from anxiety. B. Ischemia 46 Obstruction of blood vessels which causes inadequate blood flow and leads to insufficient oxygen supply to an organ, tissue or body part C. Orthopnea 47 A heart rate that exceeds the normal range. Resting heart rate >100 bpm. D. Palpitations 48 Dyspnea that occurs at rest in a reclined position that is relieved by sitting upright or standing. E. Paroxysmal nocturnal dyspnea 49 Painful cramping in the leg or hip that occurs when walking or exercising and typically disappears when the person stops the activity. F. Syncope 50 Loss of consciousness, caused by reduced blood flow to the brain. G. Tachycardia

Identify and define known cardiovascular, pulmonary and metabolic diseases: Cardiovascular
Coronary artery disease: Major form of cardiovascular disease; results when the coronary arteries are narrowed by deposits of fibrous and fatty tissue

Peripheral Vascular disease: Affects 20% of Americans over 65. Caused by atherosclerosis (hardening of the arteries) that cause decreased blood flow to the legs.

Cerebrovascular disease: Group of brain dysfunctions related to disease of the blood vessels supplying the brain. Hypertension is the most common cause as it damages blood vessel linings making them more narrow and stiff. Can lead to stroke.

Identify and define known cardiovascular, pulmonary and metabolic diseases: Pulmonary
Chronic Obstructive Pulmonary Disease (COPD): Condition of chronically poor airflow to the lungs that worsens over time. Cigarette smoking is the leading cause of COPD.

Asthma: Chronic lung disease that inflames and narrows the airways. Causes recurring periods of wheezing, chest tightness, shortness of breath and coughing.

Interstitial lung disease: Thickening of the interstitium of the lungs which affects the ability to breathe and get oxygen into the blood stream. Can be caused by inflammation, scarring or extra fluid within the lungs. Fluid that is pressing on the lung. Notice the difference in size between the two lungs

Cystic Fibrosis: Inherited disease characterized by the buildup of thick, sticky mucus that can damage many of the body’s organs. The average life expectancy for someone with cystic fibrosis is only 37 years.

Born with the condition Type 2- Develops over time
Identify and define known cardiovascular, pulmonary and metabolic diseases: Metabolic Diabetes Mellitus: Disease where a person has high blood sugar either because the pancreas does not produce enough insulin (Type 1) or because cells do not respond to the insulin that is produced (Type 2) Born with the condition Type 2- Develops over time

Identify and define known cardiovascular, pulmonary and metabolic diseases: Metabolic
Renal Disease: Occurs when the kidneys fail to adequately filter waste products from the blood

Risk Levels Risk classification becomes progressively more important as disease prevalence increases. Clients can be classified into low, moderate or high risk levels. The risk level is used to determine who should be cleared by their physician prior to participation.

What determines is a client is Low, Moderate or High Risk? Low
No known cardiovascular, pulmonary, metabolic disease, no major signs or symptoms of suggestive of cardiovascular, pulmonary or metabolic disease, less than 2 cardiovascular disease risk factors.

What determines is a client is Low, Moderate or High Risk? Moderate
No known cardiovascular, pulmonary, metabolic disease, no major signs or symptoms of suggestive of cardiovascular, pulmonary or metabolic disease, 2 or more cardiovascular disease risk factors.

What determines is a client is Low, Moderate or High Risk? High
Known cardiovascular, pulmonary, metabolic disease, OR major signs or symptoms of suggestive of cardiovascular, pulmonary or metabolic disease, cardiovascular disease risk factors.

44 No known cardiovascular, pulmonary, metabolic disease, no major signs or symptoms of suggestive of cardiovascular, pulmonary or metabolic disease, less than 2 cardiovascular disease risk factors. A. Low Risk 45 Known cardiovascular, pulmonary, metabolic disease, OR major signs or symptoms of suggestive of cardiovascular, pulmonary or metabolic disease, cardiovascular disease risk factors. B. Moderate Risk 46 No known cardiovascular, pulmonary, metabolic disease, no major signs or symptoms of suggestive of cardiovascular, pulmonary or metabolic disease, 2 or more cardiovascular disease risk factors. C. High Risk

Question 57 The personal trainer must remember that no set guidelines for exercise testing and participation can cover all situations. Exercise testing recommendations reflect the notion that the risk of cardiovascular events increase as a function of increasing physical activity intensity. What this means- whenever you participate in some form of exercise there is always the risk of having a heart attack. As a Personal Trainer it is your responsibility to reduce the likelihood of a heart attack occurring. This is a form of Risk Management.

Question 58 Exercise testing can be submaximal or maximal. Submaximal exercise testing does not require all-out effort, gives an estimated maximal oxygen uptake. Maximal testing tests how hard the heart works during exercise and helps find the upper limits of the cardiovascular system. Most personal trainers will need to refer clients for maximal testing due to the cost of equipment. The fitness assessments we perform in class (1 mile walk, mile run, Queens College) are all submaximal tests.

Question 59 Medical supervision of exercise tests varies from physician- supervised tests to situations in which no physician may be present. The degree of physician supervision may differ, depending on local policies and circumstances, the client’s health status and the experience of the staff conducting the test. In all situations in which exercise testing is being performed site personnel should at least be certified at a level of basic life support. Medically supervised exercise tests typically occur in cardiac rehabilitation facilities.

What is the difference between moderate and vigorous exercise?
Moderate exercise intensity is any exercise that is 40 to 60% of VO2R 3-6 METs and defined as an intensity that causes noticeable increases in heart rate and breathing. Vigorous exercise intensity is any exercise that is > 60% of VO2R, >6 METs and defined as an intensity that causes substantial increases in heart rate and breathing.

Use this table to complete question 60
Low Risk Medical exam recommended before exercise? _____ Moderate _____ Vigorous Exercise Test recommended before exercise? Medically supervised exercise test recommended before exercise? _____ Submax _____ Max

Moderate Risk Medical exam recommended before exercise? _____ Moderate _____ Vigorous Exercise Test recommended before exercise? Medically supervised exercise test recommended before exercise? _____ Submax _____ Max

High Risk Medical exam recommended before exercise? _____ Moderate _____ Vigorous Exercise Test recommended before exercise? Medically supervised exercise test recommended before exercise? _____ Submax _____ Max

Explain why the following is recommended to be included in a health-history evaluation: Medical History Includes current and previous medical conditions, injuries, surgical procedures and therapies can all influence an exercise plan. Include dates and thoroughly discuss all conditions listed.

Explain why the following is recommended to be included in a health-history evaluation: Medications
Some medications will affect heart rate and blood pressure response to exercise. Client’s need to report any changes in medication. Beta blockers, diuretics and calcium channel blockers are medications to particularly be aware of.

Explain why the following is recommended to be included in a health-history evaluation: Exercise History A client’s experience with exercise is important to allow the trainer to know if an advanced protocol is appropriate, attitude towards working out is important to know as it may alter the type of exercises selected.

Explain why the following is recommended to be included in a health-history evaluation: Nutrition
Dietary intake is directly related to weight and body composition. It will also affect potential for disease, mood and energy level.

Documentation Documentation is an important part of risk management. Personal trainers should keep accurate records of client responses to testing and training, changes in reported health status and how these changes are communicated to appropriate health care providers. Client health information should be updated regularly. Records may be maintained either in paper or electronic form and should be stored in a safe place to maintain client confidentiality. No rule for amount of time files must be kept, usually years.

Explain the difference between obtaining medical clearances to exercise and obtaining physician input: When seeking medical clearance the personal trainer will not allow the client to exercise until the physician approves to do so. When seeking physician input the personal trainer typically proceeds with training, but may make modifications and incorporates recommendations provided by the physician

When a client should be referred for medical clearance:
Per ACSM risk stratification process When client has significant or recent health status change not evaluated by physician

What is HIPAA? Health Insurance Portability and Accountability Act of Requires the US department of health and human services to establish national standards for electronic health care information to facilitate efficient and secure exchange of private health data. Provides federal protection and gives patient’s rights with respect to personal health information.

Question 67 It is the responsibility of the personal trainer to refer clients to other members of the team when problems or potential problems arise or are identified that are beyond the personal trainers scope of practice. Referral may take place at any time – during the physical assessment process, once exercise training has begun or even several months into training.

Question 68 Potential problems may be discovered while conducting physical assessments. The Personal Trainer must DECIDE whether or not to refer the client to a health care provider for a more IN-DEPTH assessment. Personal trainers should err on the side of caution. If in DOUBT the Personal Trainer should REFER the client to an appropriate physician or specialist.

Question 69 Personal trainers are responsible to continually reevaluate the health status of their clients through either formal (direct questions, written or physical assessments) or informal (casual conversation or observation) means.

Question 69 Cont. The onset of NEW signs and symptoms, AGGRAVATION of existing medical conditions, or occurrences of INJURY may warrant stopping or MODIFYING exercise training until after further consultation with the physician. Recognizing these situations and communicating EFFECTIVELY with the health care team will maximize the SAFETY of clients, increase their probability of successfully REACHING established health and fitness goals, and raise the STATURE of the Personal Trainer in the eyes of the medical community. This is why it is important to have a list of professionals to refer your client to.

Question 70 Serious joint injuries or those that do not resolve quickly should at a minimum prompt a recommendation to follow up with a health care professional and modification of training techniques to protect or minimize strain on the joint. Clients reporting a muscle or joint problem that has been either brought on or aggravated by exercise should be referred to a health care professional. Personal trainers should be careful not to move beyond their appropriate scope of practice.

Question 71 Personal trainers should encouraged injured clients to use the RICE method until their client can get an appointment with their physician.

What does RICE stand for? You should know this 

When referring a client for consultation what information should be sent to the physician?
Heart Rate Blood pressure Observed signs and symptoms Was the client sweating, short of breath etc. Accurate description of the situation

What can a personal trainer do to make communication with health care providers more efficient
Always include information that clearly identifies the client, including his or her full name, age, sex, and date of birth Be clear and to the point as to the purpose of the communication Set a response date

If something needs to be turned around quickly, write “URGENT” in big letters at the top of the form Provide options that can be checked off easily Allow room for additional comments

Faxing or ing is typically more effective and quicker than the mail system Call the office staff and notify them that a fax or that needs attention is on the way If requesting a release or personal medical information, then automatically include a Release of Medical Information form signed by your client Doctors offices will not release information unless they are given permision by your client

Informed Consent Generally written document that conveys health/fitness information to the client to achieve an understanding regarding his/her participation options.

Informed consent for the fitness assessment ensures that the client:
Has full knowledge of the tests to be performed Understands the relevant risks associated with those test Know about alternative procedures Understands the benefits associated with the assessments

Informed consent for the fitness assessment ensures that the client:
Has been provided an opportunity for inquiry Gives consent voluntarily, not under any duress or fact inaccuracy Is of legal age and mentally competent

Explain why written consent is preferred over verbal or implied consent:
Written consent is an effective risk management practice. Having the consent in writing could be used in court as documentation that the client was made aware of activities to be performed and possible side effects (i.e. injury, even death) of participating in the activity.

13 C Low density lipoprotein cholesterol >130 mg*dL or high density lipoprotein cholesterol <40 mg*dL or on lipid-lowering medication. If total serum cholesterol is all that is available use >200 mg*dL Age 14 E >60mg*dL Negative risk factors, removes 1 risk factor. B. Cigarette Smoking 15 H Impaired fasting glucose >100mg*dL and <125 mg*dL; or impaired glucose tolerance >140 mg*dL and <199 mg*dL confirmed by measurements on at least 2 separate occasions C. Dyslipidemia 16 A Men > 45 years; women >55 years D. Family History 17 G Body mass index >30 kg/m2 or waist girth 120 cm (40 in) for men and >88 cm (35 in for women E. High Density Lipoprotein Cholesterol 18 D Myocardial infarction, coronary revascularization or sudden death before 55 years in father or other male first-degree relative, or before 65 years in mother or other female first-degree relative F. Hypertension 19 I Not participating in at least 30 minutes of moderate intensity physical activity on at least 3 days a week for at least 3 months G. Obesity 20 B Current cigarette smoker or those who quite within the previous 6 months or exposure to environmental tobacco smoke H. Prediabetes 21 f Systolic blood pressure >140 mmHg and/or diastolic >90mmHg, confirmed by measurements on at least 2 separate occasions, or on anti-hypertensive medication I. Sedentary Lifestyle

22 L Temporary or short lived symptoms Acute 23 E Any condition that renders some particular movement, activity or treatment improper or undesirable B. AHA/ACSM Health/Fitness Facility Pre-Participation Screening Questionnaire 24 F Programs that are recommended for patients with major cardiac impairment or adverse signs or symptoms (i.e., those at increased risk for future cardiovascular events). C. Asymptomatic 25 H An episode in which some of the hearts blood supply is severely cut off or restricted, causing the heart muscle to suffer and die from a lack of oxygen. Commonly known as a heart attack D. Cardiovascular Disease 26 C A person showing no signs or symptoms Contraindication 27 D A general term for any disease of the heart, blood vessels or circulation F. Medically supervised exercise program 28 K An unexpected death due to cardiac causes that occurs in a short time period (generally within 1 hour of symptom onset) in a person with known or unknown cardiac disease. G. Metabolic Disease 29 I Self-administered health questionnaire. Focuses in the symptoms of heart disease and potential musculoskeletal problems that should be evaluated prior to participation in an exercise program. If a client checks yes then refer to physician. H. Myocardial Infarction 30 G Any disease or disorder that disrupts normal metabolism – the process of converting food to energy on the cellular level I . Physical Activity Readiness Questionnaire (PAR-Q) 31 J Any condition that affects the blood vessels along the route between the heart and lungs. J. Pulmonary Disease 32 A Sudden onset of disease K. Sudden Cardiac Death 33 B Includes history, symptoms and risk factor to direct clients to either participate in an exercise program or contact their health care provider before participation. L. Transient

38 E An extra or unusual sound heard during a heartbeat. May indicate valvular or other cardiovascular disease. A. Angina Pectoris 39 C Disease of the heart valves in which the opening of the aortic valve is narrowed. B. Ankle edema 40 A Chest pain caused by an inadequate supply of oxygen and decreased blood flow to the heart muscle. Symptoms may include pain or discomfort, heaviness, tightness, pressure or burning, numbness, aching and tingling in the chest, back, neck, throat, jaw or arms C. Aortic Stenosis 41 F Condition where the heart muscle become thick, common cause of sudden cardiac arrest in young people. D. Dyspnea 42 D An abnormally uncomfortable awareness of breathing, can be a sign on chronic obstructive pulmonary disease E. Heart murmur 43 B Swelling of the ankles. Bilateral edema is a sign of heart failure. Unilateral ankle edema is usually caused by a blood clot in a vein. F. Hypertrophic Cardiomyopathy

44 E Dyspnea that begins 2 to 5 hours after the onset of sleep, relieved by sitting on the edge of the bed or getting out of bed. A. Intermittent Claudication 45 D Unpleasant awareness of the forceful or rapid beating of the heart. Often result from anxiety. B. Ischemia 46 B Obstruction of blood vessels which causes inadequate blood flow and leads to insufficient oxygen supply to an organ, tissue or body part C. Orthopnea 47 G A heart rate that exceeds the normal range. Resting heart rate >100 bpm. D. Palpitations 48 C Dyspnea that occurs at rest in a reclined position that is relieved by sitting upright or standing. E. Paroxysmal nocturnal dyspnea 49 A Painful cramping in the leg or hip that occurs when walking or exercising and typically disappears when the person stops the activity. F. Syncope 50 F Loss of consciousness, caused by reduced blood flow to the brain. G. Tachycardia

44 A No known cardiovascular, pulmonary, metabolic disease, no major signs or symptoms of suggestive of cardiovascular, pulmonary or metabolic disease, less than 2 cardiovascular disease risk factors. A. Low Risk 45 C Known cardiovascular, pulmonary, metabolic disease, OR major signs or symptoms of suggestive of cardiovascular, pulmonary or metabolic disease, cardiovascular disease risk factors. B. Moderate Risk 46 B No known cardiovascular, pulmonary, metabolic disease, no major signs or symptoms of suggestive of cardiovascular, pulmonary or metabolic disease, 2 or more cardiovascular disease risk factors. C. High Risk

Low Risk Medical exam recommended before exercise? No Moderate No Vigorous Exercise Test recommended before exercise? Medically supervised exercise test recommended before exercise? No Submax No Max

Moderate Risk Medical exam recommended before exercise? No Moderate Yes Vigorous Exercise Test recommended before exercise? No Moderate No Vigorous Medically supervised exercise test recommended before exercise? No Submax No Max

High Risk Medical exam recommended before exercise? Yes Moderate Yes Vigorous Exercise Test recommended before exercise? Medically supervised exercise test recommended before exercise? Yes Submax Yes Max

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