1. ACE Personal Trainer Manual 5th Edition
Chapter 6: Building Rapport and the Initial Investigation Stage
Lesson 6

2. FACILITATING CHANGE AND MOTIVATIONAL INTERVIEWING
Once a trainer has developed __________________________________, the next step is identifying the client’s readiness to change behavior and stage of change.
Motivational interviewing helps:
Determine the client’s level of readiness, or current stage of change
The client learn more about the reasons for change
The client participate in the behavioral change process
Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. In other words, it is an interviewing technique to get clients “off the fence” about exercise. Motivational interviewing is not about simply questioning; it involves careful listening and strategic questioning.

3. READINESS TO CHANGE QUESTIONNAIRE

4. THE HEALTH-RISK APPRAISAL
While moderate levels of physical activity promote numerous benefits, there is an increased risk for those individuals who are:
Unhealthy
Have an existing disease
At risk for disease
Pre-participation screening includes identifying:
The presence or absence of __________
Signs or symptoms suggestive of _________
Medical ____________________________
At-risk individuals who should first undergo _______________evaluation
Those with medical conditions who should participate in ____________________________programs
Disease refers to cardiovascular, pulmonary, and/or metabolic disease.
Further consideration should be given when assessing an individual’s risk as to whether the exercise program is self-directed or being conducted under the consultation and supervision of a qualified fitness professional. With self-directed exercise, a standard questionnaire is completed by the individual with little to no feedback from the fitness professional. These questionnaires are designed to provide information regarding existing risks for participation in activity and the need for medical clearance beforehand. A pre-participation screening must be performed on all new participants, regardless of age, upon entering a facility that offers exercise equipment or services. The screening procedure should be valid, simple, cost- and time-efficient, and appropriate for the target population. Additionally, there should be a written policy on referral procedures for at-risk individuals.

5. THE HEALTH-RISK APPRAISAL
The Physical Activity Readiness Questionnaire (PAR-Q) is a minimal, safe pre-exercise screening measure for low-to-moderate training:
A minimal __________________________ prerequisite
Quick, easy, and non-invasive to administer
Limited by its lack of detail and may overlook important health conditions, medications, and past injuries
The process for health-risk appraisal:
Review the client’s health information, medical history, and lifestyle habits
Risk stratification
Need for medical examination/clearance or supervision
Recommendations for lifestyle modification
Strategies for exercise testing and programming

6. RISK STRATIFICATION
Risk-stratification determines the presence or absence of:
Known cardiovascular, pulmonary, and/or metabolic disease
Cardiovascular risk factors
Signs or symptoms suggestive of cardiovascular, pulmonary, and/or metabolic disease
Risk-stratification is categorized as:
Low
Medium
High
Risk stratification is important because someone with only one positive risk factor will be treated differently than someone with several positive risk factors. Recommendations for physical activity/exercise, medical examinations or exercise testing, and medically supervised exercise are based on the number of associated risks; risk stratification is categorized as low, moderate, or high.
Signs or symptoms of medical conditions are included in risk stratification, but given the need for specialized training to make a diagnosis, and the importance of staying within the defined scope of practice of personal trainers, these signs and symptoms must only be interpreted by a qualified licensed professional within the clinical context in which they appear.
These signs and symptoms include the following (ACSM, 2014):
Pain (tightness) or discomfort (or other angina equivalent) in the chest, neck, jaw, arms, or other areas that may result from ischemia
Shortness of breath or difficulty breathing at rest or with mild exertion (dyspnea)
Orthopnea (dyspnea in a reclined position) or paroxysmal nocturnal dyspnea (onset is usually two to five hours after the beginning of sleep)
Ankle edema
Palpitations or tachycardia
Intermittent claudication (pain sensations or cramping in the lower extremities associated with inadequate blood supply)
Known heart murmur
Unusual fatigue or difficulty breathing with usual activities
Dizziness or syncope, most commonly caused by reduced perfusion to the brain

7. ACSM RISK-FACTOR STRATIFICATION

8. EVALUATION FORMS Informed consent: Agreement and release of liability:
The client acknowledges having been informed about the risks associated with activity
Discloses the purposes, procedures, risks, and benefits associated with the assessments
Agreement and release of liability:
Releases a personal trainer from liability for injuries resulting from a supervised exercise program
Represents a client’s voluntary abandonment of the right to file suit
Does not necessarily protect the trainer from being sued for negligence
It is recommended that personal trainers consult a legal professional familiar with local and regional laws prior to utilizing the informed consent and agreement and release of liability forms.
Visit to download a free PDF of a health-history questionnaire, exercise history and attitude questionnaire, and medical release form, as well as other forms and tools that you can use throughout your career as a personal trainer.

9. Health-history questionnaire:
EVALUATION FORMS
Health-history questionnaire:
Past and present exercise and physical-activity information
Medications and supplements
Recent or current illnesses or injuries, and chronic or acute pain
Surgery and injury history
Family medical history
Lifestyle information (related to nutrition, stress, work, sleep, etc.)
It is recommended that personal trainers consult a legal professional familiar with local and regional laws prior to utilizing the informed consent and agreement and release of liability forms.
Visit to download a free PDF of a health-history questionnaire, exercise history and attitude questionnaire, and medical release form, as well as other forms and tools that you can use throughout your career as a personal trainer.

10. EVALUATION FORMS Exercise history and attitude questionnaire:
The client’s previous exercise history and behavioral and adherence experience
Medical release:
The client’s medical information
Explains physical-activity limitations and/or guidelines as outlined by the physician
Deviation from these guidelines must be approved by the physician
Testing forms:
Used for recording testing and measurement data during the fitness assessment
It is recommended that personal trainers consult a legal professional familiar with local and regional laws prior to utilizing the informed consent and agreement and release of liability forms.
Visit to download a free PDF of a health-history questionnaire, exercise history and attitude questionnaire, and medical release form, as well as other forms and tools that you can use throughout your career as a personal trainer.

11. HEALTH CONDITIONS THAT AFFECT PHYSICAL ACTIVITY
Injuries related to physical activity usually come from:
Aggravating an existing condition (either known or unknown by the client)
Precipitating a new condition
After ______________ muscles surrounding an injured joint begin to ________________

12. CARDIOVASCULAR DISEASE
Atherosclerosis:
Accumulation of fatty cholesterol and calcium deposits on artery walls causing hardening, thickening, and loss of elasticity
When this process affects the arteries that supply the heart, it is called coronary artery disease (CAD).
Positive risk factor:
Myocardial infarction or heart attack:
May result from atherosclerosis when the blood supply is limited and the increased oxygen demand cannot be met
Angina:
May also result from atherosclerosis
Described as pressure or tightness in the chest, arm, shoulder, or jaw
May be accompanied by shortness of breath, sweating, nausea, and palpitations
Coronary artery disease:
A history of CAD or chest pain should have a physician’s release
Many people with CAD have no known symptoms.
Hypertension:
Prevalent among elderly and African-American individuals
The risk of CAD, stroke, and kidney disease increases with higher levels of systolic and diastolic blood pressure.

13. RESPIRATORY SYSTEM DISORDERS
Respiratory system disorders will interfere with the body’s ability to provide enough oxygen for the increasing demand that occurs during aerobic exercise:
Bronchitis
Asthma
Chronic obstructive pulmonary disease (COPD)
Any client with a respiratory disorder should have physician’s clearance:
These conditions may result in dyspnea.
Regular exercise may aggravate the condition for some people.
Conversely, exercise may improve it.

14. MUSCULOSKELETAL DISORDERS
Clients should be referred to an appropriate healthcare professional and have a physician’s clearance to exercise if they suffer from issues such as:
Minor sprains and/or strains
Runner’s knee/swimmer’s shoulder/tennis elbow
Iliotibial band syndrome (ITBS) or shin splints
Spine disorders, such as herniated discs
Bursitis
Tendinitis
Arthritis
Significant muscle weakness or joint laxity
Recent orthopedic surgery, and any disuse atrophy
The musculoskeletal system consists of the muscles, bones, tendons, and ligaments that support and move the body. This is the system most commonly injured during exercise. Aside from the pain and discouragement of an injury, there are other factors with which to contend. Client motivation and the trainer’s scope of practice create concerns when working with a client with previous or current musculoskeletal injuries. Changes or modifications in the exercise program are necessary to accommodate the injury. For these reasons, it is important to be cognizant of potentially hazardous situations before they occur.

15. METABOLIC DISORDERS Diabetes: Thyroid disorders:
A client’s situation and exercise program should be discussed with his or her physician before working with a personal trainer.
Requires physician approval before starting an exercise program, especially if receiving insulin
Thyroid disorders:
Hyperthyroid individuals have an increased level of thyroid hormones and a higher metabolic rate.
Those with hypothyroidism have a reduced level of hormones and require thyroid medication to regulate their metabolism.
Require physician approval before starting an exercise program

16. OTHER CONDITIONS Hernia: Pregnancy: Illness or infection:
A protrusion of the abdominal contents into the groin or through the abdominal wall
May be further aggravated by the Valsalva maneuver
Is a relative contraindication for resistance training unless cleared by a physician
Pregnancy:
Important to maintain a good fitness level, instead of maximum fitness goals
A client should have physician’s approval until three months after delivery.
Illness or infection:
A recent history may impair a client’s ability to exercise.
Moderate exercise may be appropriate during a mild illness.
Generally not advisable to start a new exercise program during an illness

17. MEDICATIONS
Medications alter the biochemistry of the body and may affect a client’s ability to perform or respond to exercise.
Any client taking a prescription medication that could potentially have an effect on exercise should have a physician’s clearance for physical activity.
The most common categories of medications:
Antihypertensives
Bronchodilators
Cold medicines
Refer to Table 6-2: Effects of Medication on Heart-rate Response

18. ANTIHYPERTENSIVES
Antihypertensives primarily affect one of four different sites:
Heart: to reduce its force of contraction
Peripheral blood vessels: to open or dilate them to allow more room for the blood
Brain: to reduce the sympathetic nerve outflow
Kidneys: to reduce blood volume by excreting more fluid
The most common antihypertensives:
Beta blockers
Calcium channel blockers
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin-II receptor antagonists
Diuretics
It is important for personal trainers to have a strong understanding of how medications affect resting, exercise, and maximal heart rate (see Table 6-2). Depending on the medication and its effects, a trainer may over- or underestimate training intensity, potentially causing harm or creating program ineffectiveness.

19. ADDITIONAL MEDICATIONS
Bronchodilators (medications for asthma)
Relax or open the air passages in the lungs
Stimulate sympathetic nervous system
Increase exercise capacity when limited by bronchospasm
Cold medicine
Decongestants
Stimulate vasoconstriction, which reduces the volume of swollen tissues
Vasoconstriction may raise blood pressure and increase heart rate both at rest and possibly during exercise.
Antihistamines
Produce a drying effect in the upper airways and may cause drowsiness

20. CHOOSING THE RIGHT ASSESSMENTS
Not all clients need or desire a complete assessment; consider the following:
Goals of the assessment
Fitness and training goals are different; testing should also be unique
Physical limitations of the participant
Choose tests that will provide valid results without causing undue stress
Testing environment
Equipment calibration or proper surface
Adequate lighting
Proper emergency response protocol
Appropriate temperature
Availability of equipment
Participant age
An older, deconditioned client will not perform the same test as a younger client

21. HEART-RATE MEASUREMENT
Radial artery–the ventral aspect of the wrist on the thumb side
Carotid artery–located in the neck, lateral to the trachea
Other sites can also provide a pulse location:
Brachial artery
Femoral artery
Posterior tibial artery
Popliteal artery
Abdominal aorta
When using the carotid artery for pulse detection, instruct the client not to push too hard, as this may evoke a vagal response and actually slow down the heart rate.
It is also possible to auscultate the actual beat of the heart using a stethoscope placed over the chest. If when palpating the client’s pulse, the trainer feels any irregularity in the rate or rhythm of the pulse, it is recommended that the client contact his or her personal physician.

22. HEART-RATE MEASUREMENT
Heart rate is a valid indicator of work intensity or stress on the body:
Lower resting and submaximal heart rates indicate higher fitness levels.
Higher resting and submaximal heart rates indicate poor physical fitness.
Resting heart rate (RHR) is influenced by:
Fatigue
Body composition
Drugs and medication
Alcohol
Caffeine
Stress
Average RHR is 70–72 bpm
Males 60–70
Females 72–80 bpm
A traditional classification system exists to categorize RHRs:
Sinus bradycardia, or slow HR: RHR <60 bpm
Normal sinus rhythm: RHR 60 to 100 bpm
Sinus tachycardia, or fast HR: RHR >100 bpm
The higher values found in the female RHR are attributed in part to:
Smaller heart chamber size
Lower blood volume circulating less oxygen throughout the body
Lower hemoglobin levels in women

23. RHR MEASUREMENT PROCEDURE
Allow the client to rest comfortably for several minutes.
Palpate a pulse site or listen using a stethoscope (auscultation).
Place the tips of the index and middle fingers over the artery and lightly apply pressure.
Avoid using your thumb, which has a pulse of its own.
Place the bell of the stethoscope to the left of the client’s sternum just above or below the nipple line.
Count the number of beats for 30 or 60 seconds.
True RHR is measured just before rising from bed in the morning.
The client may also measure his or her own resting HR and report back.
Several methods are used to measure heart rate, both at rest and during exercise:
12-lead electrocardiogram (ECG or EKG)
Telemetry (often two-lead, including commercial heart-rate monitors)
Palpation
Auscultation with stethoscope
Palpation and auscultation are each accurate within 95% of a heart-rate monitor.
Additional key notes about heart rate:
A client’s HR provides insight into overtraining, as any elevation in RHR >5 bpm over the client’s normal RHR that remains over a period of days is good reason to offload or taper training intensities.
Certain drugs, medications, and supplements can directly affect RHR. Individuals should abstain from consuming non-prescription stimulants or depressants for a minimum of 12 hours prior to measuring RHR.
Body position affects RHR. Standing or sitting positions elevate HR more so than supine or prone positions due to the involvement of postural muscles and the effects of gravity.
Digestion increases RHR, as the processes of absorption and digestion require energy, necessitating the delivery of nutrients and oxygen to the gastrointestinal tract.
Environmental factors can affect RHR, as it is believed that noise, temperature, and sharing of personal information can place additional stress on the body, increasing HR as the body attempts to tolerate the stressors.

24. EXERCISE HEART RATE MEASUREMENT PROCEDURE
Measuring for 30 to 60 seconds is generally difficult during exercise.
A 10- to 15-second count is recommended.
Count the first pulse beat at the start of the time interval.
Multiply the counted score by either six (for a 10-second count) or four (for a 15-second count).
Start counting at “one” instead of “zero” to accurately estimate HR.
A 10- to 15-second count is recommended over a six-second count given the larger potential for error with the shorter count.
Conventional wisdom has long held that one should begin at “zero” when counting a client’s pulse rate in order to accurately estimate the number of cardiac cycles. In fact, counting the first beat as zero will consistently underestimate exercise heart rate. If the pulse is counted for 10 seconds, the magnitude of the underestimation will be 6 bpm, since the 10-second count is multiplied by six. Starting at zero is only appropriate if the clock is started on a specific beat, but this method is very difficult in a fitness setting. Starting at “one” is particularly important in group settings, where exercisers will begin their counts at different points in the cardiac cycle.

25. MEASURING BLOOD PRESSURE
________________________blood pressure (SBP):
The pressure created by the heart as it pumps blood into circulation via ventricular contraction
Greatest pressure during one cardiac cycle
________________________blood pressure (DBP):
The ______________exerted on the ______________walls as blood remains in the arteries during the filling phase of the cardiac cycle, or between beats when the heart relaxes
Minimum pressure that exists within one cardiac cycle
The brachial artery is the standard site of measurement.
Korotkoff sounds are sounds made from vibrations as blood moves along the walls of the vessel.
Blood pressure is measured indirectly by listening to the Korotkoff sounds, which are sounds made from vibrations as blood moves along the walls of the vessel. These sounds are only present when some degree of wall deformation exists. If the vessel has unimpeded blood flow, no vibrations are heard. However, under pressure of a blood pressure cuff, vessel deformity facilitates hearing these sounds. This deformity is created as the air bladder within the cuff is inflated, restricting the flow of blood.

26. MEASURING BLOOD PRESSURE
When inflated to pressures greater than the highest pressure that exists within a cardiac cycle, the brachial artery collapses, preventing blood flow. As the air is slowly released from the bladder, blood begins to flow past the compressed area, creating turbulent flow and vibration along the vascular wall. The first BP phase, signified by the onset of tapping Korotkoff sounds, corresponds with SBP. DBP is indicated by the fourth (significant muffling of sound) and fifth (disappearance of sound) phases (Figure 6-9). As the cuff is continuously released, blood pressure within the vessel increases and eventually will exceed the pressure within the cuff. At this point, the blood pressure completely distends the vessel wall back to its original shape and the Korotkoff sounds will fade (fourth phase) and then disappear (fifth phase). Typically, in adults with normal blood pressure, the fifth phase is recorded as DBP. However, in children and adults with a fifth phase below 40 mmHg, yet who appear healthy, the fourth phase may be used.

27. BLOOD PRESSURE ASSESSMENT EQUIPMENT AND PROCEDURES
Equipment needed:
Sphygmomanometer (BP monitor cuff)
Stethoscope
Chair
Procedure set up:
Client is seated with both feet flat for two full minutes
Proper cuff placement and cuff size
Client’s arm supported by an armchair or by the trainer
Proper cuff placement instructions:
While the right arm is considered standard, many individuals favor placing the cuff on the left arm due to the increased proximity to the heart, which amplifies the heart sounds.
Smoothly and firmly wrap the blood pressure cuff around the arm with its lower margin about 1 inch (2 cm) above the antecubital space (i.e., the front of the elbow)
The tubes should cross the antecubital space
Since BP cuffs come in a variety of sizes, it is important to ensure the correct size is used, as obese or muscular clients may have falsely elevated BP readings, while thin, small-framed individuals may have falsely low BP readings with a standard-sized cuff
The client’s arm should be supported either on an armchair or by the trainer at an angle of 0 to 45 degrees

28. BLOOD PRESSURE CLASSIFICATION
Common causes for mistakes in measuring blood pressure include:
Cuff deflation that is too rapid
Inexperience of the test administrator or inability of the test administrator to read pressure correctly
Improper stethoscope placement and pressure
Improper cuff size or an inaccurate/uncalibrated sphygmomanometer
Auditory acuity of the test administrator or excessive background noise
During exercise:
Blood pressure is very difficult to obtain during exercise due to the excessive amount of movement and noise, unless the person is riding a stationary bicycle.
Traditionally, when exercise blood pressure measurements are justified, they are usually measured before and following exercise (to monitor against excessive hypotension).
A sphygmomanometer with a stand and a hand-held gauge are better choices for measuring BP during exercise.
If SBP drops during exercise, it should immediately be re-measured prior to terminating the session, just to ensure accuracy in measurement. If the client was anxious prior to the cardiorespiratory assessment, it is likely that the initial exercise SBP reading will drop.

29. RATINGS OF PERCEIVED EXERTION (RPE)
RPE is used to subjectively quantify a client’s overall feelings and sensations during the stress of physical activity.
Borg Scale:
6 to 20 point scale
Each value corresponds to a heart rate:
6 = heart rate of 60 bpm
12 = heart rate of 120 bpm
20 = heart rate of 200 bpm
Modified Borg Scale:
0 to 10 point scale
Can be used to gauge intensity when a trainer does not need to measure HR via the RPE
Subjective measures of exertion are useful since they can be compared and have been validated against the physiological measure of heart rate. They can be used to complement or replace heart rates (when the client is taking certain drugs that may alter the heart-rate response to exercise such as beta blockers) in providing feedback on exercise intensity.
Common trends:
Men tend to underestimate exertion, while women tend to overestimate exertion.
The use of RPE has a significant learning curve that demonstrates deviation toward the mean as the client becomes more familiar with the scale.
Initially, very sedentary individuals may find it difficult to use RPE charts, as they often find any level of exercise fairly hard.
Conditioned individuals may under-rate their exercise intensity if they focus on the muscular tension requirement of the exercise rather than cardiorespiratory effort.
Recommendations for usage:
The 6 to 20 scale is difficult to use and should only be utilized if HR equivalents are needed and the actual exercise HR is not a reliable indicator of exertion (e.g., when a client is taking medications that affect HR responses, such as beta blockers).
The 0 to 10 scale should always be used to gauge intensity when the trainer does not need to measure HR via the RPE.

30. RATINGS OF PERCEIVED EXERTION