Physical
Assessment: An Often
Over-Looked
Portion of Exercise Testing and Prescription
Mark Kaelin, EP,CSCS
Exercise Physiologist
Pulmonary Rehabilitation
Program Coordinator
Southern Indiana Rehabilitation
Hospital
New Albany, IN
Looking back at my own experience
in school and working with a number of interns from several exercise physiology
programs, I have seen one crucial element missing in my own education as
well as the education of the interns. That one important piece to
working with patients in rehabilitation is "physical assessment and examination
skills". It is described in Tabors (1) as the examination
of the body by auscultation, palpitation, percussion, inspection, and olfaction.
Students can generally quote
exercise principles, MET levels, GXT contraindications, and ECG specs.
But, my experience is that they lack basic physical assessment skills.
Many program directors and chairs appear to believe that the student's
internship is the place where these skills should be learned. A few, however,
believe that the student should be well versed in physical assessment and
exercise skills before becomeing an intern. It is logical that the
time spent at the intern site should be spent in refining skills not teaching
the basics. Furthermore, Transmittal AB-01-56 from the Health Care Financing
Agency (2) released in April of 2001 states: “Services
provided by a student are not reimbursed under Medicare Part B. Medicare
pays for services of physicians and practitioners authorized by statute.
Students do not meet the definition of practitioners.” Many intern sites
and academic programs will have to revamp how and what activities students
perform at facilities to insure compliance with these new guidelines.
The purpose of this article
is to provide an overview of physical assessment as described in Tabors
and examples of how these skills are employed in an exercise physiologist's
daily interaction with their clients. In this first of four sections, I
will review how to record a medical history and to look for what the assessment
may mean.
Although the intern may not
realize it, "History and Physicals" (HP) are usually the most important
part of the pre-exercise test evaluation (3). It’s
at this point an exercise physiologist can stop an evaluation. For example,
when I started graduate school, I worked at a local health and wellness
facility. I assumed that a Physical Activity Readiness Questionnaire (PAR-Q)
or some sort of screening tool was given to new members before initial
training sessions were scheduled. One night while leading a middle-age
man through his first workout, I neglected to do an HP. I put the
man on an Air dyne and started him at a low workload (level .5-1.0 or 2.4
to 3 METs) to warm up for 5-10 minutes while I asked him some questions
regarding his fitness goals. Repeatedly, I had to get this gentlemen to
slow down. After the warm up, he stated, “I guess you need to know I had
a heart attack (myocardial infraction, MI) five years ago but I’m O.K.
now.” At that point, a simple training session became much more.
In addition to discussing his goals, preferences in exercise, and possible
time constraints. I asked several questions regarding his previous medical
history and current medications. Did he have nitroglycerin tablets,
if needed? Had he been through cardiac rehabilitation? Did
his doctor know what he was doing?
Another example of the value
of performing a complete HP occurred later at that same facility when I
had started to do the majority of the screenings for the clubs weight loss
program. One night while evaluating a 40-year old female, she stated, “I
was taking heart medication but I didn’t like the side effects so I quit
taking it. Upon further questioning, I found the heart medication she had
been taking was an anti-arrhythmic. She further stated, “I haven’t had
any problems since I quit taking it.” I finished the interview portion
of the examination, excused myself, and discussed the what I learned with
the director. It was my opinion that the woman should be discharged from
the facility until she had received a physician's clearance. She was very
angry when informed of the decision. However, she placed herself
and the facility in a great deal of danger. We assured her that once she
received physician clearance she would be allowed to participate in the
program.
In both instances I was very
lucky. The gentlemen who had experienced an MI was medically stable.
He had completed cardiac rehabilitation and was a good candidate for membership
in the club. However, it was important that we were aware of his
past history and that emergency contact numbers were on file just in case.
In the second instance, by performing a thorough HP, I was able to stop
an evaluation from going any further (which might have endangered the life
of the person and/or my employer's livelihood. Since then, any member I
worked with completes a PAR-Q in writing or verbally (see below ).
I also perform a systems review with them.
PAR-Q
For most people, physical
activity should not pose any problems or hazard. PAR-Q has been designed
to identify the small number of adults for whom physical activity might
be inappropriate or those who should have medical advice concerning the
type of activity most suitable.
Yes
No
1. ___ ___ Has
your doctor ever said you have heart trouble?
2. ___ ___ Do
you frequently have pains in your heart and chest?
3. ___ ___ Do
you often feel faint or have spells of severe dizziness?
4. ___ ___ Has
a doctor ever said your blood pressure was too high?
5. ___ ___ Has
your doctor ever told you that you have a bone or joint problem such
as arthritis that has been aggravated by or might be made
worse by exercise?
6. ___ ___ Is
there a good physical reason not mentioned here why you should
not follow an activity program even if you wanted to?
7. ___ ___ Are
you over 65 and not accustomed to vigorous exercise?
If a person answers "yes'
to any question, vigorous exercise or exercise testing should be postponed.
Medical clearance may be necessary (3).
In many cases, the client
might answer, “yes” to one or more of these questions. The client
might also respond further by saying, “My health care provider told me
I need to exercise and recommended your facility.” In addition, the
client may have physician clearance to begin exercising. Now, what
do you do? In short, you need to find out more information.
One method is by performing a client history and a systems review.
A thorough client history
should include:
• Name, age, and
sex
• Occupation (current or
prior if retired)
• Family health history
• Emergency contacts names
and numbers
• Physician's names and
phone Numbers
• Medical and surgical history
• Medication list: Here,
it is important to ask how the drugs are prescribed and how the client
takes them.
• Systems Review: A screening
process that provides information about the bodily systems.(4)
Systems Review
Have you ever been diagnosed
or experienced problems with:
Yes No
____ ____ Cerebral
Vascular Accident (CVA)
____ ____ Transient
Ischemic Attacks (TIA)
____ ____ Hypertension
____ ____ Heart
____ ____ Lung
____ ____ Liver
____ ____ Kidney
____ ____ Diabetes
Mellitus: Insulin Dependent (IDDM)
____ ____ Diabetes
Mellitus: Non Insulin Dependent (NIDD)
____ ____ Vision
____ ____ Seizures
____ ____ Orthopedic
____ ____ Gastrointestinal
____ ____ Genitourinary
Depending on where you work
(clinic vs. wellness facility), it may be important to document and review
some additional points:
1. Client pain levels (This
is now the fifth vital sign, recorded daily.)
2. Barriers to communication
(e.g., vision, hearing, and language)
3. Signs of abuse or neglect
4. Learning style
5. Patient input into care
and patient goals
At this point, you are probably
thinking, this will takes hours. Do I really need to know all this?
The answer is "Yes". Many times an exercise physiologist, either
in the clinic or a wellness center, might see a client for a primary diagnosis
(dx) of de-conditioning. Yet, the question is, "Does the client have any
secondary concerns and issues that the staff members need to know about?"
As an example, let’s say your working with a 68-year old male at your gym
who has been referred by his doctor because of complaints of fatigue and
shortness of air (SOA) with exertion. Upon gathering the history, you find
he was frequently exposed to chemical solvents and solutions hazardous
to lung tissue in his occupation. He also frequently neglected to wear
protective equipment because it was uncomfortable. Is the man’s SOA
due to de-conditioning or from occupational exposure to chemicals that
have caused some form of obstructive or restrictive pulmonary disease?
Can you diagnose the problem in anticipation of the right training program?
NO! But, if concerned, you can contact the man’s physician and request
more information. Maybe, after speaking with the man's physician, you learn
that the physician and the man are interested in beginning the exercise
to see if the cause of the SOA is just de-conditioning. You then track
his ratings of SOA and aerobic exercise tolerance in METs over an eight
week period. At week eight, the client still reports severe SOA with exercise
with the performance of some ADLs and is going to see his physician regarding
this. To provide additional insight, you could supply this client with
a letter describing the clients complaints, what has been done at your
facility to alleviate them, and what progress has been made (e.g., aerobic
capacity and muscular strength).
A thorough HP enables exercise
physiologists to make educated and knowledgeable decisions. Does this member
or client need a medically supervised exercise test before beginning training?
Would a cardiac or pulmonary patient’s aerobic capacity be more effectively
assessed by performing a six-minute walk versus a graded exercise test
(GXT). Also, by being knowledgeable of a client's medical history, exercise
physiologists can design the optimal intervention to reduce the chance
of morbidity and improve quality of life.
As our population ages, exercise
physiologists will be challenged to keep people active and independent.
To make the best exercise recommendations, exercise physiologists need
to know how to deal with multiple clinicial concerns and issues. For example,
did you know? In long term stroke survivors, cardiac disease is the
most common cause of death. It occurs more frequently than a subsequent
stroke (5). Individuals with severe COPD are at risk
of death from congestive heart failure (6). Falls
are the third leading cause of death in the elderly (7).
By knowing the client's medical
history, the exercise physiologist can more effectively address all of
a client's morbidity and design a program that will reduce as many risk
factors as possible. With practice, experience, and training, the exercise
physiologist can conduct a thorough evaluation in a short period of time.
However, it is also important to use this time to begin building rapport
with the client and to insure that the client's exercise program is safe,
enjoyable, and worthwhile.
In summary, the basics of
how to perform the history portion of a physical assessment have been described.
In the August issue, a review of the auscultation basics and techniques
will be presented.
References
1.
Taber’s cyclopedic medical dictionary. (19th edition). Philadelphia, PA:
F.A.DavisCo.2001.
2.
Transmittal AB-01-56. Available: www.hcfa.gov
3.
ACSM. Guidelines for exercise testing and prescription. (4th edition).
Philadelphia, PA: Lea and Febiger.
4.
Hall CM and Brody LT. (1999) Therapeutic exercise: moving toward function.
Philadelphia, PA: Lippincott Williams and Wilkins.
5.
Roth EJ.(1994). Heart disease for patients with stroke. Part II: Impact
and implications for rehabilitation. Archives of Physical Medicine and
Rehabilitation 75:94-101.
6. Zielenski
J, MacNee W,Wedzicha J,Ambosino N,et al. (1997). Causes of death in patients
with COPD and chronic respiratory failure. Monaldi Archives Chest Disease.
52(1): 43-47.
7.
Nevitt MC, Cummings SR, Kidd S, Black D. (1989). Rick factors for recurrent
non-syncopal falls: a prospective study. JAMA 261:163-168.
Please forward any questions
and comments to the author at mkaelin@sirh.org
Copyright
©1997-2001 American Society of Exercise Physiologists. All Rights
Reserved.
ASEP
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