The
message from the nation's scientists is clear, unequivocal, and
unified: physical inactivity is a risk factor for
cardiovascular disease,1 2 and
its prevalence is an important public health issue. New scientific
knowledge based on epidemiological observational studies, cohort
studies, controlled trials, and basic research has led to an
unprecedented focus on physical activity and exercise. The promotion of
physical activity is at the top of our national public health agenda,
as seen in the publication of the 1996 report of the US Surgeon General
on physical activity and health.3
The attention now being given to physical activity supports the goals
of Healthy People 20004 and should lead to
increased levels of regular physical activity throughout the US
population, including the nearly one fourth of adult Americans who have
some form of cardiovascular
disease.5 Although regular exercise reduces
subsequent cardiovascular morbidity and
mortality,1 2 6 the incidence of a
cardiovascular event during exercise in patients with
cardiac disease is estimated to be 10 times that of otherwise healthy
persons.7 Adequate screening and evaluation are
important to identify and counsel persons with underlying
cardiovascular disease before they begin exercising at
moderate to vigorous levels.
Moderate (or higher) levels of physical activity and exercise are
achieved in a number of settings, including >15 000 health/fitness
facilities across the country. A recent survey of 110 health/fitness
facilities in Massachusetts found that efforts to screen new members at
enrollment were limited and
inconsistent.8 Nearly 40% of responding
facilities stated that they do not routinely use a screening interview
or questionnaire to evaluate new members for symptoms or history of
cardiovascular disease, and 10% stated that they
conducted no initial cardiovascular health history
screening at all.
This statement provides recommendations for
cardiovascular screening of all persons
(children, adolescents, and adults) before enrollment or participation
in activities at health/fitness facilities. Staff qualifications and
emergency policies related to cardiovascular safety are
also discussed. Health/fitness facilities are defined here as
organizations that offer health and fitness programs as their primary
or secondary service or that promote high-intensity recreational
physical activity (eg, basketball, tennis, racquetball, and swim
clubs). Ideally such facilities have a professional staff, but those
that provide space and equipment only (eg, unsupervised hotel exercise
rooms) are also included. A health/fitness facility user is defined as
a dues-paying member or a guest paying a regular daily fee to use the
facility specifically to exercise. These recommendations are intended
to assist health/fitness facility staff, healthcare providers, and
consumers in the promotion and performance of safe and
effective physical activity/exercise.
The writing group based these recommendations on a review of the
literature and the consensus of the group. Earlier statements from the
American Heart Association (AHA) and the American College of Sports
Medicine (ACSM) are highlighted and supplemented. These recommendations
were peer reviewed by selected authorities in the field
representing the AHA, the ACSM, the American College of
Cardiology, the International Health Racquet and Sports
Clubs Association (IHRSA), and the Young Men's Christian Association.
The recommendations are not mandatory or all-encompassing, nor do they
limit provision of individualized care by practitioners
exercising independent judgment. With this statement the AHA and the
ACSM assume no responsibility toward any individual for whom this
statement may be applied in the provision of individualized care.
Specific details about exercise testing and training of persons with
and without cardiovascular disease and those with other
health problems are provided elsewhere.7 9 10 11
The ACSM has published comprehensive guidelines for operating
health/fitness facilities.12 Although issues in
competitive sports are beyond the scope of this statement, the 26th
Bethesda Conference13 on sudden cardiac death in
competitive athletes and the AHA14 provide
specific recommendations for the screening and evaluation of athletes
for congenital heart disease, systemic hypertension, and other
cardiovascular diseases before participation in
competitive sports.
Cardiovascular Screening
Rationale
The Centers for Disease Control and Prevention,2
the ACSM,2 and the AHA11
recommend that every American participate in at least
moderate-intensity physical activity for
Efforts to promote physical activity will result in an increasing
number of persons with and without heart disease joining the >20
million persons who already exercise at health/fitness
facilities.15 Current market research indicates
that 50% of health/fitness facility members are older than 35 years,
and the fastest-growing segments of users are those older than 55 and
those aged 35 to 54.15 With increased physical
activity, more people with symptoms of or known
cardiovascular disease will face the
cardiovascular stress of physical activity and possible
risk of a cardiac event. More than one fourth of all Americans have
some form of cardiovascular
disease.5 The prevalence of coronary
heart disease for American adults aged 20 years and older is 7.2% in
the general population, 7.5% for non-Hispanic whites, 6.9% for
non-Hispanic blacks, and 5.6% for Mexican
Americans.5 The prevalence of myocardial
infarction in older Americans aged 65 to 69 is 18.0% and 9.7% for men
and women, respectively.5
Moderately strenuous physical exertion may trigger ischemic
cardiac events, particularly among persons not accustomed to regular
physical activity and exercise. Siscovick et al16
examined the incidence of primary cardiac arrest in men aged 25 to 75
years after excluding those with a history of clinically recognized
heart disease. Although the risk was significantly increased during
high-intensity exercise, the likelihood for primary cardiac arrest
during such activity in a clinically healthy population was estimated
at 0.55 events/10 000 men per year. Maron et
al17 studied causes of sudden death in
competitive athletes. In persons younger than 35 years, 48% of deaths
were due to hypertrophic cardiomyopathy.
Coronary artery anomalies, idiopathic left
ventricular hypertrophy, and coronary
heart disease each accounted for 10% to 20% of deaths. In those over
35, coronary artery disease accounted for approximately 80% of
all deaths. Overall, the absolute incidence of
death during exercise in the general population is
low.18 19 20 Each year approximately 0.75 and
0.13/100 000 young male and female athletes20
and 6/100 000 middle-aged men die during
exertion.19 No estimates are available for
middle-aged women or the elderly.
Cardiovascular events other than death during exercise
have also been studied. Data from the Framingham Heart Study indicate
that the baseline risk of myocardial infarction in a 50-year-old man
who is a nonsmoker and does not have diabetes is approximately 1% per
year, or approximately 1 chance per million per
hour.21 Heavy exertion (
Van Camp et al25 reported the incidence of major
cardiovascular complications in 167 randomly selected
cardiac rehabilitation programs that provided supervised exercise
training to 51 000 patients with known cardiovascular
disease. The incidence of myocardial infarction was 1/294 000
person-hours; the incidence of death was 1/784 000 person-hours.
Screening Prospective Members/Users
The cost-effectiveness of preparticipation screening is an important
consideration. Exercise testing is comparatively expensive.
The incidence of false-positive findings when testing
asymptomatic persons27 and the need
to follow up abnormal results can lead to subsequent and more costly
procedures. A thorough and mandatory screening process that might prove
optimally sensitive in detecting occult cardiovascular
disease might be so prohibitive to participation that fewer persons
would engage in a fitness program. Such a result would be
counterproductive to the goal of maximizing physical activity.
Because most of the health benefits of exercise accrue at moderate
levels of intensity,2 where the risks are
probably low, recommendations that would inhibit large numbers of
persons from participating in exercise programs are not justified.
Preparticipation screening should identify persons at high risk and
should be simple and easy to perform. Public health efforts should
focus on increasing the use of preparticipation screening.
Two practical tools for preparticipation screening are likely to have
an effect on identifying high-risk individuals without inhibiting their
participation in exercise programs. The PAR-Q28
(Table 1
Another simple, self-administered device that aims to identify
high-risk individuals without negatively impacting participation is a
questionnaire patterned after one developed by the Wisconsin Affiliate
of the American Heart Association29 (Table 2
Health appraisal questionnaires should preferably be interpreted by
qualified staff (see next section for criteria) who can limit the
number of unnecessary referrals for preparticipation medical
evaluation, avoiding undue expense and barriers to participation.
In view of the potential legal risk assumed by operators of
health/fitness facilities, it is recommended that all facilities
providing staff supervision document the results of screening.
Screening, particularly for participants for whom a medical evaluation
is recommended, requires time, personnel, and financial resources.
Individual facilities can determine the most cost-effective way to
conduct and document preparticipation screening.
Every effort should be made to educate all prospective new members
about the importance of obtaining a health appraisal and—if
indicated—medical evaluation/recommendation before beginning
exercise testing/training. The potential risks inherent in not
obtaining an appraisal should also be emphasized. Without an appraisal,
it is impossible to determine whether a person may be at significant
risk of severe bodily harm or death by participating in an exercise
program. The same is true of persons who undergo a health appraisal,
are identified as having symptoms of or known
cardiovascular disease, and refuse or neglect to obtain
the recommended medical evaluation yet seek admission to a
health/fitness facility program. Because of safety concerns,
persons with known cardiovascular disease who do not
obtain recommended medical evaluations and those who fail to complete
the health appraisal questionnaire upon request may be excluded from
participation in a health/fitness facility exercise program to the
extent permitted by law.
Persons without symptoms or a known history of
cardiovascular disease who do not obtain the
recommended medical evaluation after completing a health appraisal
should be required to sign an assumption of risk or release/waiver.
Both of these forms may be legally recognized in the jurisdiction where
the facility is located. When appropriate guidelines are followed, it
is likely that the potential benefits of physical activity will
outweigh the risks. Persons without symptoms or a known history
of cardiovascular disease who do not obtain
recommended medical evaluations or sign a release/waiver upon request
may be excluded from participation in a health/fitness facility
exercise program to the extent permitted by law. Persons who do not
obtain an evaluation but who sign a release/waiver may be permitted to
participate. However, they should be encouraged to participate in
only moderate- or lower-intensity physical activities and counseled
about warning symptoms and signs of an impending
cardiovascular event.
The major objectives of preparticipation cardiovascular
screening are to identify persons with known
cardiovascular disease, symptoms of
cardiovascular disease, and/or risk factors for disease
development who should receive a medical evaluation/recommendation
before starting an exercise program or undergoing exercise testing.
Screening also identifies persons with known
cardiovascular disease who should not participate in an
exercise program or who should participate at least initially in a
medically supervised program, as well as persons with other special
needs.7 12
Screening also serves another purpose. One of the trends in cardiac
rehabilitation is to "mainstream" low-risk, clinically stable
patients to community facilities rather than specialized, often costly
cardiac programs. Facility directors should expect that an increasing
percentage of their participants will have health histories that
warrant supervision of exercise programs by professional staff.
When a medical evaluation/recommendation is advised or required,
written and active communication with the individual's personal
physician (or healthcare provider) is strongly recommended. The sample
letter and medical release form in Tables 3A
Characteristics of Participants
Using Screening Results for Risk Stratification
Class A: Apparently healthy. There is no evidence of
increased cardiovascular risk for exercise. This
classification includes (1) "apparently healthy" younger persons
(Class A-1) and (2) irrespective of age, persons who are "apparently
healthy" or at "increased risk" (Classes A-2 and A-3) and who
have a normal diagnostic maximal exercise test. Submaximal
exercise tests are sometimes performed at health/fitness facilities
where permitted by law for nondiagnostic purposes,
including physical fitness assessment, exercise prescription, and
monitoring of progress.10 Such testing is also
useful for educating participants about exercise and for motivating
them. Nondiagnostic exercise testing should be conducted
only for persons in Class A and only by appropriately qualified,
well-trained personnel (see section on staffing below) who are
knowledgeable about indications and contraindications for exercise
testing, indications for test termination, and test interpretation. All
health/fitness facilities, including those where exercise testing is
performed, should have an emergency plan (see section on emergency
policies and procedures below) to ensure that emergencies
are handled safely, efficiently, and effectively. No restrictions other
than provision of basic guidelines are required for exercise training.
No special supervision is required during exercise training.
Class B: Presence of known, stable cardiovascular
disease with low risk for vigorous exercise but slightly greater than
for apparently healthy persons. This classification includes
clinically stable persons with (1) coronary artery disease
(myocardial infarction, coronary artery bypass surgery,
percutaneous transluminal coronary angioplasty,
angina pectoris, abnormal exercise test, or abnormal coronary
angiogram), (2) valvular heart disease; (3) congenital heart
disease (risk stratification for patients with congenital heart disease
should be guided by the 26th Bethesda Conference
recommendations13 ); (4)
cardiomyopathy (includes stable patients with heart
failure with characteristics as outlined below but not recent
myocarditis or hypertrophic cardiomyopathy); and
(5) exercise test abnormalities that do not meet the criteria outlined
in Class C below. The clinical characteristics of such persons are (1)
New York Heart Association (NYHA) Class I or II (Table 6
Class C: Those at moderate to high risk for cardiac
complications during exercise and/or who are unable to self-regulate
activity or understand the recommended activity level. This
classification includes persons with (1) coronary artery
disease with the clinical characteristics outlined below; (2) acquired
valvular heart disease; (3) congenital heart disease (risk
stratification for patients with congenital heart disease should be
guided by the 26th Bethesda Conference
recommendations13 ); (4)
cardiomyopathy (includes stable patients with heart
failure with characteristics as outlined below but not recent
myocarditis or hypertrophic cardiomyopathy); (5)
exercise test abnormalities not directly related to ischemia;
(6) a previous episode of ventricular fibrillation or
cardiac arrest that did not occur in the presence of an acute
ischemic event or cardiac procedure; (7) complex
ventricular arrhythmias that are uncontrolled at
mild to moderate work intensity with medication; (8) 3-vessel or left
main coronary artery disease; and (9) ejection fraction <30%.
One or more of the following clinical characteristics are also
present: (1)
Class D: Unstable conditions with activity
restriction. This classification includes those with (1) unstable
ischemia; (2) heart failure that is not compensated; (3)
uncontrolled arrhythmias; (4) severe and
symptomatic aortic stenosis; (5) hypertrophic
cardiomyopathy or
cardiomyopathy from recent myocarditis; (6) severe
pulmonary hypertension; or (7) other conditions that could be
aggravated by exercise (for example, resting systolic blood
pressure >200 mm Hg or resting diastolic blood
pressure >110 mm Hg; active or suspected myocarditis or
pericarditis; suspected or known dissecting aneurysm;
thrombophlebitis and recent systemic or pulmonary embolus).
In this population no physical activity is
recommended for conditioning purposes. Risk stratification for patients
with congenital heart disease should be guided by the 26th Bethesda
Conference recommendations.13
These classifications are presented as a means of
beginning exercise with the lowest possible risk. They do not consider
accompanying morbidities (for example, insulin-dependent diabetes
mellitus, morbid obesity, severe pulmonary disease, complicated
pregnancy, or debilitating neurological or orthopedic conditions) that
may constitute a contraindication to exercise or necessitate closer
supervision during exercise training.
Using Screening Results for Exercise Prescription
In the absence of atrial fibrillation, frequent atrial or
ventricular ectopy, a fixed-rate pacemaker, or similar
conditions, exercise intensity should be prescribed for persons with
cardiovascular disease (Class B or C) using target
heart rates and perceived exertion ratings in accordance with
previously published guidelines.7 10 For these
persons, target heart rates should be prescribed using data obtained
during exercise testing performed while the participant is taking his
or her usual cardioactive medications. In the absence of myocardial
ischemia or other significant exercise test abnormalities, a
target range of 50% to 90% of peak heart rate or 45% to 85% of peak
measured oxygen uptake or heart rate reserve is recommended. This
intensity level corresponds to 12 to 16 (moderate to hard) on the Borg
scale. In the presence of myocardial ischemia (ie,
ischemic ST-segment depression >1 mm, chest discomfort
believed to be angina pectoris, or other symptoms believed to be an
anginal equivalent), significant arrhythmia, or other
significant exercise test abnormalities (eg, a fall in systolic
blood pressure from baseline, systolic blood pressure
>240 mm Hg, or diastolic blood pressure
>110 mm Hg), the target training intensity is derived from
the heart rate associated with the abnormality. If this occurs at a
high level of exercise, the above target heart rate recommendations are
applicable, provided that the upper limit of the range is
Staffing
Health/fitness facility personnel involved in management or
delivery of exercise programs must meet academic and professional
standards and have the required experience as established by the
ACSM.10 12 Such personnel include the general
manager/executive director, medical liaison, fitness director, and
exercise leader. In general, health/fitness facility personnel should
have the formal training and experience needed to ensure that clients
are provided with safe, effective programs and services. The levels of
education and experience needed to ensure effectiveness and safety vary
with the health status of the client population. The kinds of personnel
who should be employed at health/fitness facilities serving various
types of clients are summarized in Table 5
The general manager/executive director is responsible for the
overall management of the facility and should have competencies in
business as well as design and delivery of exercise programs.
The medical liaison reviews medical emergency plans, witnesses
and critiques medical emergency drills, and reviews medical incident
reports. In Level 2 and 3 facilities (Table 5
The fitness director manages the facility's exercise and
activity programs and is responsible for program design and the
training and supervision of staff. He or she must have a degree in
exercise science, another health-related field, or equivalent
experience, and knowledge of exercise physiology, exercise programming,
and operation of exercise facilities. The fitness director must hold
professional certification at an advanced level by a nationally
recognized health/fitness organization. In Level 3 facilities this
certification should be comparable to ACSM health fitness instructor
certification. In Level 4 and 5 facilities the fitness director should
be certified at a level that correlates with ACSM exercise specialist
certification. The exercise specialist typically holds a master's
degree in exercise science or a related field and has extensive
experience in exercise testing and leadership in clinical populations.
He or she must be trained in cardiopulmonary resuscitation
(CPR) and should have
The exercise leader works directly with program participants and
provides instruction and leadership in specific modes of exercise. He
or she also helps program participants master the behavioral skills
needed to adhere to exercise programs. In Level 1, 2, and 3 facilities
the exercise leader as a minimum must have a high school diploma or
equivalent and entry-level or higher professional certification from a
nationally recognized health/fitness organization (comparable to ACSM
exercise leader certification). In Level 4 facilities the exercise
leader should have education and experience corresponding to that
required by ACSM health fitness instructor certification. In Level 5
facilities the exercise leader should be either an exercise specialist
or a health fitness instructor directly supervised by an exercise
specialist. In all cases the exercise leader must be trained in
CPR and should have prior supervised internship or work experience in
the health/fitness industry.
Some health/fitness facilities provide services in allied health
fields such as nutrition, stress management, and physical therapy.
Personnel providing such services should meet current accepted
professional standards in those fields and should be certified as
recommended by relevant professional organizations and licensed by or
registered with the state as required by law.
Emergency Policies and Procedures
All health/fitness facilities must have written emergency
policies and procedures that are reviewed and practiced regularly.
Such plans will correspond to the type of facility and risk level of
its membership outlined in Table 5
It is essential to acknowledge that emergency equipment alone
does not save lives. Equipment alone may offer a false sense
of security if it is not backed up with appropriate staffing. The
training and preparedness of an astute professional staff who can
readily handle emergencies is paramount. This issue is particularly
important if persons with certain medical conditions are recruited and
encouraged to exercise in a specific health/fitness facility. Such a
facility has the responsibility to offer appropriate coverage by
personnel as outlined above and in Table 5
The emergency plan must address transportation of victims to a
hospital emergency room and must include telephone access to 911 or the
local emergency unit access system. Health/fitness facility personnel
should be familiar with emergency transport teams in the area so that
access and location of the center are clearly identified. Staff should
greet the emergency response team at the entrance of the facility so
that they can be promptly guided to the site of the emergency. A staff
member should remain with the victim at all times. Prompt emergency
transport is optimized by free and ready access to the victim within
the health/fitness facility and assistance by designated staff.
General Considerations in Selecting a Health/Fitness
Facility
In selecting a health/fitness facility, an individual should first
consider his or her health status. Persons with a history of
cardiovascular disease should seek facilities that
provide or require a thorough medical evaluation of prospective
members/users. Personnel should include nurses, exercise specialists,
health/fitness instructors, and/or exercise leaders licensed or
certified by the appropriate agencies, organizations, or authorities.
They should be trained to recommend and supervise exercise in patients
with cardiovascular and other chronic diseases. Persons
at high risk for development of cardiovascular disease
should seek facilities that require appropriate medical evaluation of
clients and employ exercise leaders who are certified as competent to
design and deliver exercise programs for high-risk persons. Table 5
Persons seeking health/fitness facilities should select one that
meets professional and industry standards. Facilities should be clean,
well-maintained, and spacious enough to ensure the comfort and safety
of program participants. Indoor facilities should be climate
controlled, and changing rooms and showers should be provided. Flooring
in areas where exercise is to be carried out should be designed to
minimize risk of injury. Exercise equipment should be well-maintained.
The variety, amount, and availability of exercise equipment should
match individual needs and preferences, including time of day and
preferred mode of exercise. For example, if aerobic dance is the
preferred mode of exercise, individuals should seek a fitness center
that offers this program at a convenient time and that provides an
exercise leader who is competent in this activity and able to teach men
and women of various age and fitness levels.
The programs and services of a health/fitness center should
optimize participation. The location of the center should minimize time
spent traveling to it. The social environment should be attractive and
the staff competent in helping members/users master the behavioral
skills needed to adopt and maintain a physically active lifestyle.
Summary of Key Points
Footnotes
"Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness Facilities" was approved by the American Heart Association Science Advisory and Coordinating Committee in March 1998.
This statement is being published simultaneously in Medicine and Science in Sports and Exercise.
A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Avenue, Dallas, TX 75231-4596. Ask for reprint No. 71-0140. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 214-706-1466, fax 214-691-6342, or E-mail pubauth@amhrt.org. To make photocopies for personal or educational use, call the Copyright Clearance Center, 508-750-8400. (Circulation. 1998;97:2283-2293.)
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© 1998 American Heart Association, Inc.
AHA/ACSM Scientific Statement
Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness Facilities
Key Words: AHA Medical/Scientific Statements • exercise • risk factors • prevention
Regular exercise results in increased exercise capacity and
physical fitness, which can lead to many health benefits. Persons who
are physically active appear to have lower rates of all-cause
mortality, probably because of a decrease in occurrence of chronic
illnesses, including coronary heart disease. This benefit may
be the result of an improvement in cardiovascular risk
factors in addition to enhanced fibrinolysis, improved
endothelial function, decreased sympathetic tone, and
other as yet undetermined factors.1 Regular
endurance exercise leads to favorable alterations in the
cardiovascular, musculoskeletal, and neurohumoral
systems. The result is a training effect, which allows an individual to
do increasing amounts of work while lowering the heart rate and blood
pressure response to submaximal exercise. Such an effect is
particularly desirable in patients with coronary artery disease
because it allows increased activity with less
ischemia.1 
30 minutes on most, if not
all, days of the week. Unfortunately, many Americans are sedentary or
perform too little physical activity; only 22% of adult Americans
engage in regular exercise 5 times a week.3 The
prevalence of physical inactivity is higher among culturally diverse
segments of the US population, low-income groups, the elderly, and
women.3 It is important for healthcare providers
to educate the public about the benefits of physical activity and to
encourage more leisure-time exercise, particularly for those who are
underactive. Consumers should seek information about safe and effective
ways to increase physical activity and initiate and maintain a regular
program of exercise. 6 METs
[metabolic equivalents]) within 1 hour of
symptomatic onset of acute myocardial infarction has been
reported in 4.4% to 7.1% of patients.22 23 The
adjusted relative risk is significantly greater in persons who do not
participate in regular physical activity, with an approximate 3-fold
increase in risk during the morning hours. The relation of physical
activity to acute myocardial infarction in the
thrombolytic era was examined among 3339 patients in
the TIMI II trial,24 where moderate or marked
physical activity preceded myocardial infarction in 18.7% of
patients.
All facilities offering exercise equipment or services
should conduct cardiovascular screening of all new
members and/or prospective users. The primary purpose of
preparticipation screening is to identify both those not known to be at
risk and those known to be at risk for a cardiovascular
event during exercise. Recent evidence suggests that screening by
health/fitness facilities is done only
sporadically.8 In Canada, evidence from the
Canadian Home Fitness Test and its screening instrument, the Physical
Activity Readiness Questionnaire (PAR-Q), suggests that even simple
screening questionnaires can effectively identify many persons at high
risk and increase the safety of nonsupervised
exercise.26 Current knowledge of the relation
between identifiable risk factors, the incidence of
cardiovascular disease, and the triggering factors for
acute myocardial infarction suggests that screening is both reasonable
and prudent. 
) is a self-administered
questionnaire that focuses primarily on symptoms that might suggest
angina pectoris. Participants are directed to contact their personal
physician if they answer "yes" to 1 or more questions. The PAR-Q
also identifies musculoskeletal problems that should be evaluated
before participation since these might involve modification of the
exercise program. The questionnaire is designed to be completed when
the participant registers at a health/fitness facility. In unsupervised
fitness facilities (eg, hotel fitness centers), the PAR-Q can be
self-administered by means of signs prominently displayed at the main
entry into the facility. Although less satisfactory than documenting
the results of screening, use of signs and similar visual methods are a
minimal recommendation for encouraging prospective users to assess
their health risks while exercising at any facility.
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Table 1. Revised Physical Activity Readiness
Questionnaire
(PAR-Q) ). The 1-page form is slightly more
complex than the PAR-Q and uses history, symptoms, and risk factors
(including age) to direct prospective members to either participate in
an exercise program or contact their physician (or appropriate
healthcare provider) before participation. Persons at higher risk are
directed to seek facilities providing appropriate levels of staff
supervision. The questionnaire can be administered within a few minutes
on the same form participants use to join or register at the facility.
It identifies potentially high-risk participants, documents the results
of screening, educates the consumer, and encourages and fosters
appropriate use of the healthcare system. In addition, it can guide
staff qualifications and requirements. This instrument is also simple
enough to be adapted for use as self-screening signs posted in
nonstaffed facilities.
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Table 2. AHA/ACSM Health/Fitness Facility Preparticipation
Screening
Questionnaire and 3B can be used or
modified for such purposes.
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Table 3A. Sample Physician Referral
Form1
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Table 3B. Sample Authorization for Release of Medical
Information
Intensity of physical activity is measured through endurance- or
strength-type exercise as defined in Table 4. Health appraisal questionnaires should
be used before exercise testing and/or training to initially classify
participants by risk for triage and preliminary decision making (Table 5), namely, apparently healthy persons
(Class A-1); persons at increased risk (Classes A-2 and A-3); and
persons with known cardiovascular disease (Classes B,
C, and D). Apparently healthy persons of all ages and
asymptomatic persons at increased risk (Classes A-1 through
A-3) may participate in moderate-intensity
exercise without first undergoing a medical examination or a medically
supervised, symptom-limited exercise test. Apparently healthy younger
persons (Class A-1) may also participate in vigorous
exercise without first undergoing a medical examination and a medically
supervised exercise test. It is suggested that persons classified as
Class A-2 and particularly Class A-3 undergo a medical examination and
possibly a maximal exercise test before engaging in vigorous exercise.
All other persons (Classes B and C) should undergo a medical
examination and perform a maximal exercise test before participation in
moderate or vigorous exercise unless exercise is contraindicated (ie,
Class D). Data from a medical evaluation performed within 1 year are
acceptable unless clinical status has changed. Medically supervised
exercise tests should be conducted in accordance with previously
published guidelines.7
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Table 4. Classification of Physical Activity
Intensity3
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Table 5. Participant/Health-Fitness Facility Selection
Chart
With completion of the initial health appraisal and, if
indicated, medical consultation and supervised exercise test,
participants can be further classified for exercise training on the
basis of individual characteristics detailed below. The following
classifications have been modified using existing
AHA7 and ACSM10 guidelines
and are recommended (Table 5
): ); (2) exercise capacity >6 METs; (3)
no evidence of heart failure; (4) free of ischemia or angina at
rest or on the exercise test 
6 METs; (5) appropriate rise in
systolic blood pressure during exercise; (6) absence of
nonsustained or sustained ventricular
tachycardia; and (7) ability to satisfactorily self-monitor
intensity of activity. For these persons, activity should be
individualized with exercise prescription by qualified personnel.
Medical supervision is recommended during prescription sessions and
nonmedical supervision by appropriately qualified staff for other
exercise sessions until the participant understands how to monitor his
or her own activity. Subsequent exercise training may be performed
without special supervision.
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Table 6. New York Heart Association
Classification7 2 previous myocardial infarctions; (2) NYHA Class
III or greater; (3) exercise capacity <6 METs; (4) ischemic
horizontal or down-sloping ST depression 1 mm or angina at a
workload 6 METs; (5) a fall in systolic blood pressure with
exercise; (6) a medical problem that the physician believes may be
potentially life-threatening; (7) a previous episode of primary cardiac
arrest; and (8) ventricular tachycardia at a
workload <6 METs. Physical activity should be individualized, and
exercise should be prescribed by appropriately qualified medical
personnel. Medical supervision, monitoring for adverse signs and
symptoms, electrocardiographic monitoring of heart rate and rhythm, and
blood pressure monitoring are recommended during exercise sessions
until safety is established. Subsequent exercise training should be
supervised by appropriately qualified personnel.
For individuals considered to be in Class A, exercise training
intensity (Table 4) may be prescribed using the rating of perceived
exertion alone and/or specific target heart rates. A suggested rating
of perceived exertion for such persons is 12 to 16 (moderate to hard)
on the Borg scale of 6 to 20 and/or an intensity level that corresponds
to 50% to 90% of maximum heart rate or 45% to 85% of maximum oxygen
uptake or heart rate reserve. Heart rate reserve is defined as maximum
heart rate minus resting heart rate. For persons taking medications
that affect heart rate (eg, ß-adrenergic blockers), these heart rate
methods do not apply unless guided by an exercise tolerance test. 10 beats
per minute (bpm) below the level at which the abnormality appears.
Otherwise, the recommended upper limit of training heart rate is 10 bpm
less than that associated with the abnormality. . ), the medical liaison may
be a licensed physician, a registered nurse trained in advanced cardiac
life support, or an emergency medical technician. In Level 4 and 5
facilities (Table 5), the medical liaison must be a licensed
physician. 1 year of supervisory experience in the fitness
industry. . All fitness center staff who
directly supervise program participants should be trained in basic life
support. Health/fitness facilities must develop appropriate emergency
response plans and must train their staff in appropriate procedures to
provide during a life-threatening emergency. When an incident occurs,
each staff member must perform the necessary emergency support steps in
accordance with established procedures. It is important for everyone to
know the emergency plan. Emergency drills should be practiced once
every 3 months or more often with changes in staff; retraining and
rehearsal are especially important. When new staff are hired, new team
arrangements may be necessary. Because life-threatening
cardiovascular emergencies are rare, constant vigilance
by staff and familiarity with the plan and how to follow it are
important. . Acquisition of equipment
for evaluation and resuscitation will depend on the risk level of
participants, personnel, and medical coverage. All facilities must have
a telephone that is readily accessible and available when emergency
assistance is needed. It would be useful for all supervised facilities
to have a sphygmomanometer and stethoscope readily available. Level 4
and 5 facilities that recruit members with known
cardiovascular disease must have such equipment
available, and Level 5 facilities (supervised cardiac rehabilitation)
should be fully equipped according to the recommendations of the
AHA9 and the American Association of
Cardiovascular and Pulmonary
Rehabilitation.31 Such equipment includes a
defibrillator, oxygen, and fully stocked crash cart. Delineation of
specific equipment standards in such facilities is beyond the scope of
these guidelines; such information is detailed in the documents
above.9 31 Appropriately trained staff who are
medically and legally empowered must be available to operate such
devices during a facility's operational hours.
summarizes personnel and safety recommendations for health/fitness
facilities (Levels 1 through 5) serving clients in various health
categories (Classes A through C).
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