6.4 Preparticipation Health Screening & Level of Monitoring (PAR-Q+, ACSM algorithm, ACC/AHA · GOLD · ADA · AACVPR)

ACSM Certified Clinical Exercise Physiologist ACSM-CEP

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1 Introduction & Exam Overview

1.1 The ACSM-CEP Role, Job Definition & Scope of Practice 1.2 Exam Format, Domain Weights & Scoring 1.3 Eligibility, Study Planning & Test-Day Strategy

2 Applied Exercise Physiology & Metabolic Calculations

Bioenergetics & Energy Systems (ATP-PC, glycolytic, oxidative) Acute Cardiorespiratory & Metabolic Responses to Aerobic Exercise Responses to Resistance Exercise & Chronic Training Adaptations ACSM Metabolic Equations, METs & Interpreting VO₂ / RER / Ventilatory Threshold

3 Pathophysiology of Clinical Populations

3.1 Coronary Artery Disease, Myocardial Infarction & Revascularization (PCI/CABG) 3.2 Heart Failure, Valvular Disease & Cardiac Rhythm Disorders 3.3 Hypertension, Dyslipidemia & Peripheral Artery Disease 3.4 Pulmonary Disease: COPD, Asthma & Restrictive/Interstitial Disorders 3.5 Diabetes, Metabolic Syndrome & Obesity 3.6 Renal Disease & Musculoskeletal/Orthopedic Conditions 3.7 Neuromuscular, Neurological & Cognitive Conditions (stroke, MS, Parkinson's, SCI) 3.8 Neoplastic, Immunologic & Hematologic Disorders (cancer, HIV/AIDS, anemia)

4 Clinical ECG Interpretation

4.1 ECG Leads, Waveforms, Rate & Rhythm Determination 4.2 Arrhythmias & Conduction Blocks 4.3 Ischemia, Injury & Infarction (ST changes, exercise-induced) 4.4 Drug & Electrolyte ECG Effects; Resting/Exercise Monitoring Setup & Lead Placement

5 Pharmacology for the Clinical Exercise Physiologist

5.1 Beta-Blockers, Calcium-Channel Blockers & Nitrates 5.2 RAAS Agents, Diuretics, Antiarrhythmics, Lipid-Lowering & Antithrombotic Drugs 5.3 Bronchodilators, Corticosteroids, Insulin & Oral Antidiabetic Agents 5.4 Medication Effects on HR/BP & Exercise Response; Dose/Meal/Dialysis Timing

6 Patient Assessment (Domain I, 18%)

6.1 Medical Records, HIPAA/HITRUST, Charting & Physician Referral 6.2 Patient Interview, Medical History & Medication Reconciliation 6.3 Resting Vital Signs, Body Composition & Resting ECG 6.4 Preparticipation Health Screening & Level of Monitoring (PAR-Q+, ACSM algorithm, ACC/AHA · GOLD · ADA · AACVPR) 6.5 Assessing Patient Goals, Readiness & Psychosocial Status

7 Clinical Exercise Testing (Domain II, 18%)

Submaximal Aerobic Tests (treadmill, cycle, step, 6-minute walk) Musculoskeletal Fitness, Mobility & Balance Testing Maximal Symptom-Limited GXT: Protocols, Contraindications & ECG Prep Test Termination: Relative & Absolute Indications Interpreting & Reporting Results (ECG response, RPP, claudication, Duke Treadmill Score, VO₂/RER/AT)

8 Exercise Prescription for Clinical Populations (Domain III, 22%)

FITT-VP Principles, Progression & Prescription Foundations Ex Rx for Cardiovascular Disease (CAD, HF, HTN, PAD, post-revascularization) Ex Rx for Pulmonary Disease (COPD, asthma; breathing techniques, supplemental O2) Ex Rx for Diabetes, Metabolic Syndrome & Obesity Ex Rx for Musculoskeletal, Neuromuscular, Neoplastic & Other Conditions Communicating Intensity (THR, RPE, talk test), Monitoring & Modifying the Prescription

9 Exercise Training & Leadership (Domain IV, 24%)

9.1 Discussing the Training Plan, Clinician & Patient Expectations/Goals 9.2 Instructing & Modifying Exercise Modes (cardiorespiratory, strength/endurance, flexibility, coordination, agility) 9.3 Patient Monitoring & Supervision During Exercise (telemetry, oximetry, glucometry, ECG) 9.4 Contraindications to Training & Modifying Recommendations 9.5 Documenting Clinical Status, Reporting Adverse Events & Interdisciplinary Coordination

10 Education & Behavior Change (Domain V, 13%)

10.1 Behavioral-Health Screening & Recognizing Distress (PHQ-9, Beck, SF-36; referral) 10.2 Patient Education, Health Literacy & Disease Self-Management 10.3 Motivational Interviewing & Behavior-Change Theories (Transtheoretical, HBM, Social Cognitive, Five-A's) 10.4 Promoting Adherence, Self-Efficacy, Relapse Prevention & Social Support

11 Legal, Professional & Emergency Management (Domain VI, 5%)

11.1 Emergency Equipment, Crash Cart Inspection & Emergency Procedures 11.2 CPR/AED/BLS/ACLS, Universal Precautions & EMS Activation 11.3 Scope of Practice, Legal/Ethical Standards, Liability/Negligence, Informed Consent & Professional Organizations (ACSM/AACVPR/AHA)

6.4 Preparticipation Health Screening & Level of Monitoring (PAR-Q+, ACSM algorithm, ACC/AHA · GOLD · ADA · AACVPR)

Key Takeaways Explain This Topic AI

ACSM's current preparticipation algorithm uses three factors — current activity status, signs/symptoms or known CV/metabolic/renal disease, and desired intensity — and deliberately does not count CVD risk factors.

"Regularly active" is defined as at least 30 minutes of moderate-intensity activity on at least 3 days per week for at least 3 months.

New signs or symptoms always override activity history: a regular exerciser who develops symptoms must discontinue exercise and seek clearance, just like a previously inactive symptomatic patient.

Disease-specific frameworks (ACC/AHA, GOLD, ADA, AACVPR) supplement the general algorithm for patients with an established cardiac, pulmonary, metabolic, or rehab-program diagnosis.

Clearance status and disease/risk information together determine the level of monitoring during sessions, from self-monitoring up to continuous ECG telemetry, oximetry, or glucometry.

Last updated: July 2026

Preparticipation Health Screening & Level of Monitoring (PAR-Q+, ACSM Algorithm, ACC/AHA · GOLD · ADA · AACVPR)

Quick Answer: Preparticipation screening answers one operational question: does this patient need medical clearance before starting or progressing an exercise program, and at what level of monitoring should sessions occur? ACSM's current algorithm answers that using three factors — current activity status, presence of signs/symptoms or known cardiovascular, metabolic, or renal disease, and desired exercise intensity — deliberately without counting cardiovascular risk factors, which is a separate tool covered in Section 6.2.

PAR-Q+: The Self-Guided Screening Tool

The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) is a brief, self-administered screening tool commonly used in general fitness and community settings. A "yes" answer to any of its core general-health questions triggers condition-specific follow-up pages or a recommendation to consult a qualified exercise professional or physician before proceeding. In the clinical CEP setting, PAR-Q+ typically serves as a first-pass filter; the more clinically detailed ACSM algorithm below is what actually governs the medical-clearance decision for patients already in, or being referred into, clinical exercise programs.

ACSM's Current Preparticipation Screening Algorithm

The algorithm evaluates three factors:

Current exercise participation — is the patient "regularly active," defined as performing at least 30 minutes of moderate-intensity physical activity on at least 3 days per week for at least 3 months ?

Signs/symptoms and/or known disease — does the patient have any signs or symptoms suggestive of cardiovascular, metabolic, or renal disease, or a known diagnosis of such disease?

Desired exercise intensity — is the patient planning light-to-moderate intensity, or vigorous intensity, activity?

A deliberate design choice distinguishes this algorithm from older screening tools: it does not ask about CVD risk-factor counts such as age or family history. ACSM removed risk-factor-based screening from the general clearance decision because it was shown to be overly conservative, referring large numbers of low-risk adults for unnecessary medical clearance and creating a barrier to exercise participation.

The Decision Logic

Currently regularly active? Disease/symptoms present? Recommendation

No No Medical clearance not necessary to begin light-to-moderate exercise; recommended before progressing to vigorous intensity

• No Yes — known disease and/or symptoms Medical clearance recommended before beginning any exercise program
• Yes No Continue current program; no clearance needed to progress intensity gradually

Yes Known disease, no symptoms May continue the current program without clearance; clearance recommended before progressing to vigorous intensity

Yes Symptoms present Discontinue exercise and seek medical clearance regardless of current activity level

Active signs or symptoms always override activity history — a regular exerciser who develops new symptoms is handled the same as anyone else with symptoms: stop and refer for clearance.

Disease-Specific Frameworks That Feed the Clearance Decision

For patients with an established diagnosis, the general algorithm above is supplemented by condition-specific guidance the CEP is expected to know exists and apply appropriately:

ACC/AHA cardiac guidelines inform risk assessment and exercise candidacy for patients with known coronary, valvular, or heart-failure disease (pathophysiology detailed in Chapter 3).

GOLD (Global Initiative for Chronic Obstructive Lung Disease) staging — based on spirometry (FEV₁ % predicted) and symptom/exacerbation history — informs exercise safety and intensity decisions for patients with COPD.

ADA (American Diabetes Association) glycemic guidance shapes exercise timing and intensity decisions for patients with diabetes: exercising with a pre-session glucose above roughly 250 mg/dL accompanied by ketones is avoided, a glucose above roughly 300 mg/dL even without ketones calls for caution with lighter intensity and rechecks, and a glucose below 70 mg/dL must be treated before exercise begins.

AACVPR (American Association of Cardiovascular and Pulmonary Rehabilitation) risk-stratification criteria (low/moderate/high risk) set formal program-entry criteria and supervision requirements specifically for cardiac and pulmonary rehabilitation programs.

Exam Tip: Don't Mix Up the Two Tools

A frequent point of confusion — and a favorite exam trap — is treating the ACSM CVD risk-factor count from Section 6.2 as the input to this algorithm. It is not. The current preparticipation algorithm uses only the three factors above (activity status, disease/symptoms, desired intensity). The eight-positive/one-negative risk-factor count is used elsewhere, specifically for stratifying supervision needs during maximal exercise testing (Chapter 7). A patient with five positive risk factors but no symptoms who already exercises regularly may still not need medical clearance under this algorithm — read each tool's actual inputs rather than assuming risk factors always drive the clearance decision.

From Clearance to Level of Monitoring

Once clearance status is resolved, the same intake information — disease history, risk stratification, and current signs/symptoms — determines the level of monitoring during sessions, ranging from unsupervised self-monitoring, to intermittent professional supervision, to continuous ECG telemetry, pulse oximetry, or glucometry during every session. This decision is revisited continuously, not just at intake; Chapter 9 covers how monitoring intensity is adjusted as a patient's clinical status changes over the course of a program.