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CURRENT OPINION / OPINION COURANTE

Revised clearance for participation in physical activity: greater screening responsibility for qualified university-educated fitness professionals
Veronica K. Jamnik, Norman Gledhill, and Roy J. Shephard

Abstract: For many individuals, pre-participation clearance using the PAR-Q and the PARmed-X has become a barrier to adopting a physically active lifestyle. An extensive project is therefore planned to reduce the number of medical referrals from the PAR-Q and to revise the PARmed-X so that it becomes more effective, user friendly, and evidence based. The entire process will likely require 3 years to complete; therefore, as an interim solution, we propose giving greater preparticipation screening responsibility to qualified university-educated fitness professionals. The highest level of professional fitness qualification in Canada is the Canadian Society for Exercise Physiology Certified Exercise Physiologist; the requirements for this certification are such that it could serve as a model allowing other countries that use the PAR-Q to develop similarly qualified university-educated fitness professionals who could also be entrusted with greater pre-participation screening responsibility. Key words: barriers, exercise adoption, PAR-Q, PARmed-X, risk stratification, certified exercise physiologist. Resume : Le fait de devoir remplir le Q-AAP et le X-AAP afin dobtenir lautorisation de pratiquer des activites physi` ` ques est pour plusieurs une barriere a ladoption dun mode de vie sain. De facon a diminuer le nombre de consultations ` ` ` medicales a la suite de la passation du Q-AAP et a rendre le X-AAP plus efficace, plus convivial et solidement etaye, les ` ` autorites competentes preparent un projet exhaustif. Il faut prevoir a tout le moins 3 ans pour rendre le projet a terme : en attendant, nous avons lintention de donner aux professionnels possedant une formation universitaire en activite physique ` plus de responsabilite concernant le depistage relatif a la pratique de lactivite physique. Le plus haut niveau dattestation de formation professionnelle en activite physique est donne par la Societe canadienne de physiologie de lexercice ; les ` exigences de cette formation sont elevees et pourraient inciter dautres pays qui utilisent le Q-AAP a se doter dun pro gramme de formation semblable ; par la meme occasion, on devrait donner aux diplomes en activite physique plus de res ` ponsabilite sur le plan du depistage relatif a la pratique de lactivite physique. ` Mots-cles : barrieres, pratique de lactivite physique, Q-AAP, X-AAP, stratification des risques, physiologiste certifie de lactivite physique. [Traduit par la Redaction]

The PAR-Q and its shortcomings

The Physical Activity Readiness Questionnaire (PAR-Q) was developed in Canada from mass-screening questionnaires used by Bailey et al. (1974) and Chisholm et al. (1975). The original intent of the PAR-Q was to offer a simple and cost-effective alternative to physician clearance for a progressive step test of aerobic fitness (Bailey et al. 1974; Chisholm et al. 1975). The underlying assumption was that the physical demands of the step test would be much greater than those to which participants were normally accustomed.

The PAR-Q was subsequently adopted as a simple method of screening people who were planning to begin a personal fitness program. The questionnaire was revised by Thomas et al. (1992), and again by a committee chaired by N. Gledhill (CSEP Expert Advisory Committee 2002a). In addition to its use in Canada, the PAR-Q has been adopted widely throughout the United States (Balady et al. 1998; Franklin et al. 2000), and was recently accepted by the United Kingdom as the standardized pre-screening form for participation in an exercise or physical activity program (Craig et al. 2001). Hence, PAR-Q screening has an impact on

Received 19 March 2007. Accepted 25 June 2007. Published on the NRC Research Press Web site at apnm.nrc.ca on 13 November 2007. V.K. Jamnik1 and N. Gledhill. School of Kinesiology and Health Science, Faculty of Health, York University, Room 355, Bethune College, 4700 Keele Street, Toronto, ON M3J 1P3. R.J. Shephard. Faculty of Physical Education and Health, and Department of Public Health Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A1.
1Corresponding

author (e-mail: ronij@yorku.ca).

doi:10.1139/H07-128
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1192 Fig. 1. Physical Activity Readiness Questionnaire (PAR-Q; revised 2002).

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the physical activity participation of millions of people world-wide. The current version (CSEP Expert Advisory Committee 2002a) of the PAR-Q (Fig. 1) is a seven-question tool designed to screen individuals who are planning to undergo a fitness assessment or to become much more physically ac-

tive. However, these qualifiers are often overlooked and the PAR-Q is widely used as a screening tool for all physical activity participation. Since physical activity is highly recommended for almost the entire population, it is important that a misinterpretation of the purpose of the PAR-Q not become a barrier for either asymptomatic or symptomatic indi#

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Jamnik et al. Fig. 1. (concluded).

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viduals who are planning to undertake light- to moderateintensity, low-impact activities such as walking. Participants who provide a positive response to any of the seven PAR-Q questions are directed to consult a physician for clearance to engage in either unrestricted or restricted physical activity. Unfortunately, many family practitioners lack detailed knowledge of absolute and relative contraindications to physical activity. If they provide a note of

medical clearance for the client, this may be neither safe nor sufficient, and on occasion they may deter an individual who could safely engage in low- to moderate-intensity activity. In addition, reports from fitness professionals and an evaluation of risk-management procedures indicate that the medical clearance process is often perceived as so onerous that clients elect either to remain inactive or to become active without any form of clearance (McInnis et al. 2001).
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Furthermore, to minimize risks, the PAR-Q screening process is intentionally conservative; averaging over all ages, approximately 1/10 of respondents are referred to a physician, but the percentage of referrals is substantially greater for older age groups (Thomas et al. 1992). The exclusion of some participants by the PAR-Q may be unwarranted and this could easily be resolved by probing the respondents reasons for a particular response. Thus, a thorough revision of the PAR-Q instrument is required.

The PARmed-X and its limitations

Individuals who are medically referred after completion of the PAR-Q are given a form called the Physical Activity Readiness Medical Examination (PARmed-X) to take to their physician (Chisholm et al. 1987). The PARmed-X was introduced in 1978 as a complement to the PAR-Q; it was revised in 1995 (CSEP Expert Advisory Committee 1995) and again in 2002 (CSEP Expert Advisory Committee 2002b). It was designed to assist physicians in assessing any apparent contraindications to physical activity in their patients (Chisholm et al. 1987). Recent feedback from fitness professionals, physical activity participants, family physicians, and the College of Family Physicians of Canada, indicates that the PARmed-X form is too lengthy and not user friendly. As well, some aspects of the form are either out-of-date or opinion- rather than evidence-based, and the PARmed-X provides little guidance on appropriate forms of physical activity. When this feedback is considered in the context of a limited knowledge of absolute and relative contraindications to physical activity and the many problems currently faced by family physicians (an ever-increasing workload, information overload, and a lack of time for discussion with individual patients), it is clear that a revision of the PARmed-X could facilitate this process. On the other hand, physical activity must be kept as safe as possible, maximizing health benefits and minimizing any negative impact on either the individual or the economics of the health care system. Before introduction of the PAR-Q and PARmed-X, Canadians who wanted to take a fitness test or to become more active were advised to be screened by their family physicians. The PAR-Q has reduced physician clearances by as much as 90% (Thomas et al. 1992) a very cost-effective approach. Nevertheless, there remains scope to make physical activity clearance even more cost effective, without compromising patient safety.

dated for persons under the age of 15 years, despite the disconcerting trend in recent years for adolescents to be less physically active. During the past 30 years, the health status and desire to be physically active has also changed considerably in persons over the age of 69 years. Everyone over this age is currently advised to seek an initial physician clearance (CSEP Expert Advisory Committee 2002a). Clearly, the extension of the PAR-Q to these two age groups would highlight the importance of physical activity throughout the life span, while removing an important barrier to greater physical activity in a substantial segment of the national population. The first aim of the proposed project is that some positive responses to the PAR-Q will be clarified and, where appropriate, cleared by qualified university-educated fitness professionals (for example, CSEP Certified Exercise Physiologists (CSEP CEP)) and (or) other competent health care practitioners who are licensed to diagnose constraints to an increase in physical activity (for example, physiotherapists, nurse practitioners, and chiropractors). In particular, responses to PAR-Q questions 4, 5, and 7 should be further probed, allowing resolution of many conditions with straightforward relative contraindications to physical activity without physician referral. This will likely be accomplished in the format of a decision tree that provides consistent advice regarding clearance and an appropriate exercise prescription to participants based on the probing clarification provided. There are few medical conditions for which some form of physical activity is not beneficial and this is as true for clients over 69 years of age as it is for younger individuals. It is highly probable that those clients with medical conditions for which physical activity is absolutely contraindicated will already be under medical supervision. Nevertheless, for clients over the age of 69, or who are currently screened out by responses to PAR-Q questions 1 and 6, it is advisable to recommend tailored, low-intensity, progressive physical activity (such as walking) until additional information has been gathered. A second aim of the proposed project is to make the PARmed-X evidence based and user friendly for both the patient and the physician. In addition, the PARmed-X warnings will be supplemented by web links to appropriate physical activity advice, allowing physicians to provide up-todate and comprehensive guidelines for all potential exercisers, particularly patients who have absolute or relative contraindications to exercise.

The optimal solution: a thorough revision of both the PAR-Q and the PARmed-X
The Canadian Society for Exercise Physiology (CSEP) and the Canadian Academy of Sports Medicine recently agreed to partner in an extensive project aimed at reducing the number of physician referrals from the PAR-Q and revising the PARmed-X to make it more effective and user friendly. An evidence-based consensus approach will be adopted. The expected outcomes of this initiative will include a reduction in unnecessary barriers to physical activity participation, a facilitation of the task of overloaded physicians, and a decrease in public expenditures on medical clearance. Opportunity will also be taken to extend the age range of the PAR-Q. The current PAR-Q has not been vali-

American College of Sports Medicine (ACSM) risk stratification

The pre-participation screening guidelines of the ACSM advocate that, in addition to completion of a PAR-Q form, qualified fitness professionals should document any confirmed diagnosis of cardiovascular, pulmonary, or metabolic disease and stratify a clients coronary heart disease risk as low, moderate, or high (Balady et al. 1998; Franklin et al. 2000). The risk factors included in this assessment are the clients immediate family history of heart disease or sudden death, cigarette smoking, a high resting blood pressure, an adverse blood lipid profile, high fasting blood glucose levels, a body mass index 30 kg/m2, a waist circumference >
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Jamnik et al. Table 1. University educational requirements for the Canadian Society for Exercise Physiology Certified Exercise Physiologist (Canadian Society for Exercise Physiology 2006). Physical activity and exercise-related core competency domains Anatomy and biomechanics Exercise physiology Humangrowth, psychomotor development, and aging Physical fitness assessments for health, function, and work or sport for all ages Physical activity and exercise prescription for health, function, and work or sport for all ages Nutrition and weight management Data management and analysis Health promotion and disease prevention Psychosocial aspects of human behavior in relation to physical activity, exercise, rehabilitation, and exercise therapy Physical activity and exercise strategies and considerations for persons with chronic diseases, and functional limitations and disabilities associated with musculoskeletal conditions, cardiopulmonary conditions, metabolic conditions, neuromuscular conditions, and aging Pharmacology: medications commonly used by persons with chronic diseases, functional limitations, and disabilities associated with cardiopulmonary or metabolic conditions, musculoskeletal conditions, neuromuscular conditions, and aging Evaluation: additional procedures for persons with chronic diseases, functional limitations and disabilities associated with cardiopulmonary or metabolic conditions, musculoskeletal conditions, neuromuscular conditions, and aging Clinical exercise prescription Client education Professional practice Outcome evaluation Cardio-pulmonary resuscitation and first aid

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1.02 m for men or > 0.88 m for women, and currently being physically inactive (Balady et al. 1998; Franklin et al. 2000). The low-risk group includes asymptomatic males < 45 years of age and asymptomatic females < 55 years of age, each with no more than one coronary heart disease risk factor. The moderate-risk group includes all males age 45 years or older and all females age 55 years or older, or individuals of any age having two or more risk factors. The high-risk group includes individuals with one or more signs and symptoms of cardiovascular or pulmonary disease or individuals with diagnosed cardiovascular, pulmonary, or metabolic disease (Balady et al. 1998; Franklin et al. 2000). This information assists in (i) selecting intensity-appropriate fitness assessment protocols and (ii) designing intensityappropriate restricted or unrestricted physical activity programs. The revision of the PAR-Q and PARmed-X will include a consideration of this risk stratification.

ing and healthy lifestyle education for apparently healthy individuals and populations with medical conditions, functional limitations or disabilities through the application of physical activity, for the purpose of improving health, function and work or sport performance.

Interim solution: assignment of greater screening responsibility to qualified university-educated fitness professionals
Over the past decade, the qualifications of fitness professionals have been progressively upgraded, to the point that they are now capable of assuming greater responsibility in physical activity screening. The highest qualification for fitness professionals in Canada is the CSEP CEP. We recommend that all fitness facilities have a CSEP CEP on staff. We believe that this certification should serve as a model for developing similar qualifications in other countries. The CSEP CEP
...performs assessments, prescribes physical activity conditioning, provides physical activity supervision, counsel-

The CSEP CEP must have completed a 4-year degree in Physical Activity or Exercise Sciences with formal preparation in health-related and work- or sport-related fitness applications for both asymptomatic and symptomatic populations. Their university curriculum must cover the competency domains listed in Table 1. In addition to meeting all of the qualifications listed in Table 1, the CSEP CEP candidate must successfully complete standardized written and practical qualifying examinations covering all aspects of their preparation (Canadian Society for Exercise Physiology 2006). Completion of the PAR-Q and PARmed-X revision project is expected to take up to three years. Therefore, an interim solution to reduce existing barriers to physical activity would be very welcome. Discussions with qualified university-educated fitness professionals confirm that considerable probing of positive PAR-Q responses and subsequent clearance for physical activity is already taking place. This probing has facilitated physical activity clearance for many individuals and, to date, there have been no reports of adverse consequences. Such probing must be tempered by the known incidence of sudden cardiac deaths (SCDs) during vigorous exercise (Shephard and Bonneau 2003). In reality, the absolute risk of SCD during any particular episode of vigorous exertion is extremely low in men; 1 SCD per 1.51 million episodes of vigorous exertion (Albert et al. 2000) and even lower in women; 1 SCD per 36.5 million hours of exertion (Whang et al. 2006). On the positive side,
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Table 2. The enhanced screening responsibilities of the Canadian Society for Exercise Physiology Certified Exercise Physiologist (Canadian Society for Exercise Physiology 2006). The CSEP CEP is sanctioned and insured to: Administer appropriate assessment protocols for the evaluation of physical fitness and prescribe physical activity for individuals who have been screened by the PAR-Q, have signed an informed consent form, and (or) who have been cleared for unrestricted or restricted activity by a licensed health care professional. Provide physical activity clearance following further queries if there are positive responses to questions 4, 5, and (or) 7 on the PAR-Q. For example, an individual could be cleared for physical activity and exercise by a CSEP CEP if the following were determined: (i) that the dizziness reported on question 4 was associated with over-breathing on hot days, or during heavy exercise, or after sudden postural changes; (ii) that a joint problem reported in question 5 was an old injury to the knee, ankle, shoulder, or other joint; and (iii) that in question 7 the individual had a cold or relative contraindication such as, but not limited to, controlled diabetes or stable medicated blood pressure. Provide physical activity clearance to clients who are screened out by PAR-Q questions 1 and (or) 6, since these clients are already under the care of a physician. In these instances, the CSEP CEP can recommend tailored, low-intensity, progressive physical activity (such as walking) until additional information is gathered. Seek medical clearance for clients of any age who are screened out by PAR-Q questions 2 and (or) 3 (e.g., potential heart problems) before providing physical activity recommendations. Provide physical activity clearance and recommend intensity-appropriate, progressive physical activity for clients over age 69 years who do not respond positively to PAR-Q questions 2 and (or) 3 (e.g., potential heart problems). Provide physical activity clearance and recommend intensity-appropriate physical activity for youths under age 15 who have the consent of their parent or guardian. A CSEP CEP is not sanctioned to: Administer assessment protocols and prescribe exercise and (or) therapy to acutely injured and diseased individuals who lie outside the boundaries of the above scope of practice. Diagnose pathology based on any assessment that is performed.

habitual vigorous exercise attenuates the relative risk of SCD in men (Albert et al. 2000), and women who exercise 4 h/week or more have a significant reduction (59%) in the long-term risk of SCD (Whang et al. 2006). The goal must always be to strive for the safest course of action, whether dealing with asymptomatic or symptomatic populations. Qualified university-educated fitness professionals must be fully cognizant of conditions for which it is necessary to obtain a written referral from a heath care practitioner who is licensed and trained to diagnose the constraint and identify absolute or relative contraindications to physical activity. Based on these considerations, the CSEP National Health and Fitness Program has provided an interim solution within the scope of practice of the CSEP CEP (Table 2; Canadian Society for Exercise Physiology 2006).

Concluding statement
We fully endorse this interim solution, which will assign greater screening responsibility to qualified universityeducated fitness professionals. We also believe that until the revision of the PAR-Q and PARmed-X has been completed, this approach will be of substantial help in reducing barriers to physical activity.

Summary of key points

.

The current PAR-Q and PARmed-X clearance process presents a barrier to physical activity participation for many individuals, particularly for those over the age of 69. Because they cannot be cleared by the current PAR-Q, all persons under age 15 and over age 69 must currently be referred to a physician for exercise screening. The PARmed-X is too long, is not user friendly, and

many aspects of the form are out of date or opinion rather than evidence based. The Canadian Society for Exercise Physiology and the Canadian Academy of Sports Medicine are partnering in an extensive project aimed at reducing the number of physician referrals generated by the PAR-Q and revising the PARmed-X to make it more effective, user friendly, and evidence based. Since revision of the PAR-Q and PARmed-X will take up to 3 years to complete, an interim solution is recommended, based on assigning greater responsibility to a specific group of highly-trained fitness professionals (the CSEP CEP), as specified in the scope of practice of the CSEP CEP. The CSEP CEP is the highest level of qualification for fitness professionals in Canada. These individuals must, as a minimum, have completed a 4 year degree in Physical Activity or Exercise Sciences, with formal preparation in health-related and work- or sport-related fitness applications for both asymptomatic and symptomatic populations. The requirements for this certification should serve as a model for other countries that need to develop similarly qualified fitness professionals who could be assigned greater responsibility for exercise screening. We fully endorse this interim solution and believe that until the revision of the PAR-Q and PARmed-X has been completed, this approach will be of substantial help in reducing barriers to physical activity.

References
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Jamnik et al. Bailey, D.A., Shephard, R.J., Mirwald, R.L., and McBride, G.A. 1974. Development of the Canadian Home Fitness test. Can. Med. Assoc. J. 114: 675679. Balady, G.J., Chaitman, B., Driscoll, D., Foster, C., Froelicher, E., Gordon, N., et al. 1998. AHAACSM scientific statement. Recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Circulation, 97: 22832293. PMID:9631884. Chisholm, D.M., Collis, M.L., Kulak, L.L., Davenport, W., and Gruber, N. 1975. Physical activity readiness. Br. J. Col. Med. 17: 375376. Chisholm, D.M., Stewart, G., and Cooks, R. 1987. PAR-Q/PAR-X, correspondence to Fitness Canada. Fitness Canada, Ottawa, Ont. Craig, A., Dinan, S., and Smith, A. Taylor, and Webborn, N. 2001. National quality assurance framework for exercise referral systems. UK Department of Health, London, UK. Canadian Society for Exercise Physiology. 2006. Health and fitness programs Certified Exercise Physiologist certification guide. Canadian Society for Exercise Physiology, Ottawa, Ont. CSEP Expert Advisory Committee. 1995. Physical activity readiness medical examination. Canadian Society of Exercise Physiology, Ottawa, Ont. CSEP Expert Advisory Committee. 2002a. Physical activity readi-

1197 ness questionnaire. Canadian Society of Exercise Physiology, Ottawa, Ont. CSEP Expert Advisory Committee. 2002b. Physical activity readiness medical examination. Canadian Society of Exercise Physiology, Ottawa, Ont. Franklin, B.A., Whaley, M.H., and Howley, E.T. 2000. ACSMs guidelines for exercise testing and prescription. 6th ed. Lippincott Williams and Wilkins, Philadelphia, Pa. McInnis, K., Herbert, W., Herbert, D., Herbert, J., Ribisl, P., and Franklin, B. 2001. Low compliance with national standards for cardiovascular emergency preparedness at health clubs. Chest, 120: 283288. doi:10.1378/chest.120.1.283. PMID:11451850. Shephard, R.J., and Bonneau, J. 2003. Supervision of occupational fitness assessments. Can. J. Appl. Physiol. 28: 225239. PMID:12825332. Thomas, S., Reading, J., and Shephard, R.J. 1992. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Can. J. Sport Sci. 17: 338345. PMID:1330274. Whang, W., Manson, J.E., Hu, F.B., Chae, C.U., Rexrode, K.M., Willett, W.C., et al. 2006. Physical exertion, exercise and sudden cardiac death in women. JAMA, 295: 13991403. doi:10. 1001/jama.295.12.1399. PMID:16551711.

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