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Addressing cardiovascular risk as part of physical therapist practice- what about practice recommendations for physical therapists?


Physical therapists routinely make decisions as to the intensity and type of exercise or physical activity they prescribe pre·scribe
To give directions, either orally or in writing, for the preparation and administration of a remedy to be used in the treatment of a disease.
 as part of a plan of care. Exercise is an important component of an evidence based treatment for many conditions treated in physical therapy settings, and is an essential component of improving health. (1) While the benefits of exercise are evident, exercise may present health risks to patients with certain cardiovascular, pulmonary, and metabolic diseases. Therefore, it is important that physical therapists make sound decisions to identify which exercise interventions are appropriate and safe for individual patients. Physical therapists in acute care or cardiac and pulmonary settings are guided by American Heart Association (AHA) guidelines guidelines, a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks.
 (2) for activity restrictions, client monitoring, and medical clearance. Recommendations for exercise decision making or medical clearance in outpatient or community based physical therapy settings are limited. The American College of Sports Medicine sports medicine, branch of medicine concerned with physical fitness and with the treatment and prevention of injuries and other disorders related to sports. Knee, leg, back, and shoulder injuries; stiffness and pain in joints; tendinitis; "tennis elbow"; and  (ACSM ACSM American College of Sports Medicine. ) guidelines for pre-exercise screening and risk stratification risk stratification Medical decision-making The constellation of activities–eg, lab and clinical testing used to determine a person's risk for suffering a particular condition and need–or lack thereof–for preventive intervention  are intended for community settings, but it is unclear whether this system is applicable in outpatient physical therapy practice settings. (3) This commentary will review some implications and limitations of using the ACSM risk stratification system and medical clearance guidelines in outpatient physical therapy practice.


Physical activity guidelines indicate that all individuals should participate in 30 minutes of moderate activity 5 days a week in order to gain health benefits and prevent cardiac events. (4) There is a small but clinically significant risk of cardiac events during exercise. Within fitness centers, estimates are of 1 death per 82,000 members and 1 death per 2.5 million workouts. The risk of exercise related acute myocardial infarction acute myocardial infarction (·kyōōtˑ mī·ō·karˑ·dē·  (AMI) is 6.75 times higher than sudden cardiac death Sudden Cardiac Death Definition

Sudden cardiac death (SCD) is an unexpected death due to heart problems, which occurs within one hour from the start of any cardiac-related symptoms. SCD is sometimes called cardiac arrest.
. (5) Vigorous exercise vigorous exercise A form of exercise that is intense enough to cause sweating and/or heavy breathing/ and/or ↑ heart rate to near maximum; VE is formally defined as that which requires > 6 METs; there is a graded inverse relationship between total physical  increases the rate of exercise related MI events. Since there is a risk of cardiac events during exercise, pre-exercise screening of individuals prior to the initiation of exercise programs in community settings is recommended. Screening questionnaires such as the Physical Activity Readiness Questionnaire (PAR-Q) are recommended for use in fitness centers, so that the screening can be conducted by individuals with minimal exercise or medical training. (3,6) Individuals with any risk factors are required to receive medical clearance before participating in exercise. All exercise facilities should have a pre-exercise screening procedure; however, screening procedures are variable in settings such as fitness facilities or worksite wellness programs. (7) The use of the PAR-Q is likely to be inappropriate in physical therapy settings, where the physical therapist can obtain a specific medical history from the patient and perform a more detailed medical screen.

A more appropriate tool for pre-exercise screening of exercise readiness in community settings might be the American College of Sports Medicine (ACSM) risk stratification for exercise professionals. (8) Cardiovascular risk is classified as low, moderate, or high based on the presence of well-defined risk factors. The ASCM ASCM Agreement on Subsidies and Countervailing Measures
ASCM Anti-ship Cruise Missile (US Navy)
ASCM American Congress on Surveying and Mapping (Gaithersburg, MD) 
 risk stratification includes determining the need for medical clearance prior to exercise and the selection of the appropriate baseline aerobic aerobic /aer·o·bic/ (ar-o´bik)
1. having molecular oxygen present.

2. growing, living, or occurring in the presence of molecular oxygen.

3. requiring oxygen for respiration.

 capacity test (Table 1). This system relies on well educated exercise professionals to make these decisions. Similar systems exist in other countries. (9) While this stratification stratification (Lat.,=made in layers), layered structure formed by the deposition of sedimentary rocks. Changes between strata are interpreted as the result of fluctuations in the intensity and persistence of the depositional agent, e.g.  system may be useful, little data exist on the frequency by which physical therapists use existing pre-exercise screening of cardiovascular risk in clinical practice. In a survey of orthopaedic physical therapists, 75% of respondents performed some type of cardiovascular screening, but only 64% correctly used ACSM guidelines for risk stratification. (10) The type of screening cannot be determined from these data. Screening and decision making in cardiac rehabilitation Cardiac Rehabilitation Definition

Cardiac rehabilitation is a comprehensive exercise, education, and behavioral modification program designed to improve the physical and emotional condition of patients with heart disease.
 settings are guided by the American Heart Association guidelines, (11) but these guidelines are designed for patients with current cardiovascular disease Cardiovascular disease
Disease that affects the heart and blood vessels.

Mentioned in: Lipoproteins Test

cardiovascular disease 
 and are not as helpful for the apparently healthy population. Therefore, a clinically relevant question is whether the use of ACSM guidelines for cardiovascular risk stratification is appropriate for physical therapists.


The purpose of the ACSM risk stratification system is to identify individuals with medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis.  that should be excluded from exercise or who require medical clearance and/or medically supervised exercise programs. (8) Risk stratification categorizes patients into low, moderate, or high risk. Low risk are younger individuals with 1 cardiovascular risk factor, moderate risk are those individuals with 2 or more cardiovascular risk factors. These risk factors include age, obesity, lack of physical activity, smoking, abnormal lipid profile lipid profile,
n a series of tests used to gauge a person's risk for coro-nary heart conditions. Blood levels examined in a lipid profile include those for total cholesterol, LDL- and HDL-cholesterol, and triglycerides.
, hypertension, and abnormal blood glucose blood glucose Diabetology The principal sugar produced by the body from food–especially carbohydrates, but also from proteins and fats; glucose is the body's major source of energy, is transported to cells via the circulation and used by cells in the presence . Individuals are classified as high risk if they have a current cardiac, pulmonary or metabolic condition or signs and symptoms of a cardiopulmonary cardiopulmonary /car·dio·pul·mo·nary/ (kahr?de-o-pool´mah-nar-e) pertaining to the heart and lungs.

Of, relating to, or involving both the heart and the lungs.
 condition. In physical therapy practice, cardiovascular risk stratification can be captured from a medical screening assessment form, patient interview, and measurement of resting heart rate and blood pressure.

Medical clearance for exercise is recommended for all patients who are high cardiovascular risk and most patients who are moderate risk. The ACSM recommends that patients who are at moderate risk receive medical clearance if they are to begin a vigorous exercise program. In the apparently healthy but moderate risk group, vigorous exercise is defined as greater than 60% of aerobic capacity reserve (V[O.sub.2] reserve). Patients in physical therapy settings may have low levels of aerobic capacity compared to apparently healthy individuals; increasing the likelihood that they may inadvertently be performing vigorous exercise in the physical therapy setting. Medical clearance consists of a written release by the physician indicating that the patient is safe to begin exercise. The type and extent of medical release forms varies considerably, and is not well defined in the literature. If the ACSM guidelines are to be followed then medical clearance procedures should be defined in physical therapy practices.


What would be the impact of using the ACSM risk stratification and medical clearance guidelines in outpatient physical therapy practice? The ACSM guidelines would be applicable for both outpatient physical therapy and fitness settings. How many patients would potentially require medical clearance? In applying the pre-exercise screening procedures identified in the Australian Sports Medicine system, 44% to 73% of individuals would require medical clearance before participating in exercise. (12) These numbers would have significant implications regarding medical costs and loss of time in physical therapy care if this group of individuals all sought physician visits prior to exercise participation in physical therapy settings. Could physical therapists be considered appropriate health care providers able to make exercise readiness decisions (medical clearance) in a safe and effective manner? Little data exist on the frequency of patients with moderate or high cardiovascular risk in outpatient physical therapy settings. Some information can be gathered by examining individual risk factors such as hypertension, obesity, and lack of physical activity in physical therapy practice. A review of patients with diabetes referred for outpatient care found that 65% had high blood pressure as measured clinically. (13) A survey of comorbidities in outpatient physical therapy practice demonstrated that 7% of patients had heart disease as a comorbidity, which would indicate high cardiovascular risk. (14)

Cardiovascular risk stratification status based on ACSM guidelines has been collected on patients in outpatient settings by Regis University Campuses
Regis University has several campuses throughout the state of Colorado. The main campus is located in northwest Denver at 50th and Lowell Boulevard. Other sites include: Aurora, Longmont, Colorado Springs, Denver Tech Center, Fort Collins and Interlocken at Broomfield.
 entry-level DPT students as part of their clinical rotation clinical rotation Medical education A period in which a medical student in the clinical part of his/her education passes through various 'working' services3 in 1-4 month blocks  requirements. Of the 244 cases analyzed from the mean age of the subjects was 43.27 years (SD [+ or -] 18 years) and 43.8% were classified as low cardiovascular risk, 37.50% as moderate risk, and 18.8 % as high-risk. Regis University transition DPT students also collected risk stratification data as part of a class assignment. In 158 patients from outpatient PT practices, 41% were classified as low risk, 39% as moderate risk, and 20% as high risk. If the ACSM guidelines were followed, then as many as 60% of patients would require medical clearance before adding aerobic exercise aerobic exercise,
n sustained repetitive physical activity, such as walking, dancing, cycling, and swimming, that elevates the heart rate and increases oxygen consumption resulting in improved functioning of cardio-vascular and respiratory systems.
 to their physical therapist plan of care. Additional data is needed to adequately characterize PT practice, but these data suggests that identification of cardiovascular risk status may impact physical therapist plan of care.

New guidelines are emerging regarding the need for medical clearance before exercise. For example, the Australian Sports Medicine Association indicates that for patients with well controlled cardiovascular disease or diabetes, no medical clearance is needed before starting low or moderate level exercise. (9) The recently published Physical Activity Guidelines for Americans indicates that apparently healthy adults who increase physical activity slowly do not need to consult a health care provider before starting exercise. (15)

A movement is underway to allow university-trained exercise specialists who hold bachelor's degrees to make some medical clearance decisions regarding exercise participation. (16) A graduate of an accredited accredited

recognition by an appropriate authority that the performance of a particular institution has satisfied a prestated set of criteria.

accredited herds
cattle herds which have achieved a low level of reactors to, e.g.
 physical therapist educational program has knowledge which often exceeds these bachelor's trained exercise specialists. Every accredited physical therapist curriculum addresses the study of exercise; including foundational knowledge, pathology, interventions, prescription, and precautions/ contraindications based on the Commission on Accreditation in Physical Therapy Education (CAPTE CAPTE Commission on Accreditation in Physical Therapy Education
CAPTE Club de Aficionados de los Parques Temáticos Españoles (Spanish: Theme Park Enthusiasts Club) 
). (17) Accreditation items address this knowledge in the following criteria: CC 5.30a refers to aerobic capacity assessment, CC5.30m refers to muscle strength, power and endurance assessment, CC5.39a is therapeutic exercise intervention, and criteria CC5.50-5.52 address the physical therapists' role in prevention, health promotion, fitness, and wellness. In contrast, medical school curricula typically do not include the study of exercise, which often poorly prepares physicians for understanding the potential risks of exercise participation. Physical therapists' scope of practice also includes developing safe and effective exercise prescription for improving fitness in patients with chronic conditions. (18)

Thus, in both education and scope of practice, physical therapists have the knowledge to make well-educated decisions about exercise appropriateness particularly if the exercise is supervised in the physical therapy clinical setting. What types of patients under physical therapy care truly require additional medical clearance that is beyond the expertise of the physical therapist? Could physical therapists clear patients for exercise in lieu of Instead of; in place of; in substitution of. It does not mean in addition to.  what the ACSM calls medical clearance? Since the answers to these questions are unknown, it is time to develop new practice recommendations for exercise clearance that specifically target physical therapists and their clientele.


(1.) Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: The evidence. Can Med Assoc J. 2006;174:801-809.

(2.) Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: A statement for healthcare professionals from the American Heart Association. Circ. 2001;104:1694-1740.

(3.) Balady GJ, Chaitman B, Driscoll D, et al. Recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Circ. 1998;97:2283-2293.

(4.) Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: Recommendation from the American College of Sports Medicine and the American Heart Association. Circ. 2007;116:1094-1105.

(5.) Thompson PD, Franklin BA, Balady GJ, et al. Exercise and acute cardiovascular events placing the risks into perspective: A scientific statement from the American Heart Association Council on Nutrition, Physical activity, and Metabolism and the Council on Clinical Cardiology cardiology

Medical specialty dealing with heart diseases and disorders. It began with the 1749 publication by Jean Baptiste de Sénac of contemporary knowledge of the heart. Diagnostic methods improved in the 19th century, and in 1905 the electrocardiograph was invented.
. Circ. 2007;115:2358-2368.

(6.) Thomas S, Reading J, Shephard RJ. Revision of the physical activity readiness questionnaire (PAR-Q). Can J Sport Sci. 1992;17:338-345.

(7.) Morrey MA, Finnie SB, Hensrud DD, Warren BA. Screening, staffing, and emergency preparedness pre·par·ed·ness  
The state of being prepared, especially military readiness for combat.

Noun 1. preparedness - the state of having been made ready or prepared for use or action (especially military action); "putting them
 at worksite wellness facilities. Med Sci Sports Exerc. 2002;34:239-244.

(8.) American College of Sports Medicine., Whaley MH, Brubaker PH, et al. ACSM's guidelines for exercise testing and prescription. 7th ed, 30th Anniversary ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

(9.) McHugh IJ, Williams AD, Fell JW. Practical application of the sports medicine Australia pre-exercise screening system. J Sci Med Sport. 2008;11:182-184.

(10.) Scherer SA, Noteboom JT, Flynn TW. Cardiovascular assessment in the orthopaedic practice setting. J Orthop Sports Phys Ther. 2005;35:730-737.

(11.) Zoghbi GJ, Sanderson B, Breland J, et al. Optimizing risk stratification in cardiac rehabilitation with inclusion of a comorbidity index. J Cardiopulm Rehabil. 2004;24:813; quiz 14-15.

(12.) Norton K, Olds T, Bowes D, et al. Applying the sports medicine Australia pre-exercise screening procedures: Who will be excluded? J Sci Med Sport. 1998;1:38-51.

(13.) Kirkness CS, Marcus RL, LaStayo PC, et al. Diabetes and associated risk factors in patients referred for physical therapy in a national primary care electronic medical record database. Phys Ther. 2008;88:1408-1416.

(14.) Boissonnault WG. Prevalence of comorbid conditions, surgeries, and medication use in a physical therapy outpatient population: A multicentered study. J Orthop Sports Phys Ther. 1999;29:506-519; discussion 520-505.

(15.) Physical Activity Guidelines Committee. Physical activity guidelines for Americans Available at: Accessed July 15, 2009.

(16.) Jamnik VK, Gledhill N, Shephard RJ. Revised clearance for participation in physical activity: Greater screening responsibility for qualified university-educated fitness professionals. Appl Physiol Nutr Metab. 2007;32:11911197.

(17.) CAPTE Accreditation Portal. Available at: https://capteportal. Accessed July 22, 2009.

(18.) American Physical Therapy Association. Physical Fitness for Special Populations. Available at: Fitness_for_Special_Populations1&Template=/TaggedPage/ TaggedPageDisplay.cfm&TPLID=267&ContentID=30270. Accessed July 21, 2009.

Susan Scherer, PT, PhD

Associate Professor, School of Physical Therapy, Regis University, Denver, CO

Address correspondence to: Susan Scherer, Associate Professor, School of Physical Therapy, Regis University, Denver, CO 80221 Ph: 303-964-5252 (
Table 1. ACSM Cardiovascular Risk Stratification,
Medical Clearance, and Baseline Testing Recommendations

Category      clearance       Exercise testing

Low risk      Not necessary   1. Submaximal or
Vigorous                         maximal test
exercise                      2. No MD present
                              3. Emergency
                                 procedures in place

Moderate      Not necessary   1. Submaximal or
risk                             maximal test
                              2. No MD present
Moderate                      3. Emergency
exercise                         procedures in place

Moderate      Recommended     MD supervision
risk                          recommended for
Vigorous                      maximal exercise
exercise                      testing

High risk     Recommended     MD supervision
                              recommended for
Moderate &                    submaximal or maximal
vigorous                      exercise testing

Adapted from the American College of Sports Medicine, Whaley
MILL, Brubaker PH, et al. ACSM's Guidelines for Exercise
Testing and Prescription. 7th, 30th Anniversary ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
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Title Annotation:Clinical Commentary
Author:Scherer, Susan
Publication:Cardiopulmonary Physical Therapy Journal
Article Type:Clinical report
Geographic Code:1USA
Date:Sep 1, 2009
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