Special Medical Reports

ACSM/AHA Release Recommendations for Fitness Facilities

SHARON SCOTT MOREY

The American College of Sports Medicine (ACSM) and the American Heart Association (AHA) have developed recommendations for cardiovascular screening of participants in physical activities at health/fitness facilities. The recommendations also discuss the qualifications for staff working at such facilities and the policies that should be in place to ensure that staff respond expeditiously and appropriately to medical emergencies.

The recommendations were subjected to peer review by representatives from the ACSM, the AHA, the American College of Cardiology, the International Health Racquet and Sports Clubs Association and the Young Men's Christian Association They are published in Circulation (vol. 97, pp. 2283­93). A single reprint of the document, titled "Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness Facilities," may be obtained by calling 800-242-8721 or by writing the American Heart Association, Public Information, 7272 Greenville Ave., Dallas, TX 75231-4596. The document is reprint No. 71-0140.

In addition to cardiovascular screening of prospective clients, the recommendations include information on risk stratification, the qualifications of personnel in health/fitness facilities, the emergency policies needed in fitness facilities and general considerations for selecting a health/fitness facility. The following highlights the ACSM and AHA recommendations.

Screening Prospective Members

The recommendations note that cardiovascular screening at health/fitness facilities is increasingly important because of the trend in cardiac rehabilitation to refer low-risk, stable patients to community facilities instead of specialized, costly cardiac programs. For this reason, the number of clients with a history of cardiovascular disease will likely increase at health/fitness facilities.

According to the recommendations, all facilities that offer exercise equipment or services should perform cardiovascular screening of new members. Preparticipation screening should identify both persons who are known to be at risk of a cardiac event during exercise and persons without risk factors. The recommendations advocate the use of a self-administered questionnaire, completed by prospective clients, to elicit information about cardiovascular fitness (see the accompanying questionnaire).

Screening Questionnaire for Prospective Users of Health/Fitness Facilities The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

The recommendations state that efforts should be made to educate all prospective members about the importance of obtaining a health appraisal and, if indicated, a medical evaluation before beginning exercise training. Persons with known cardiovascular disease who fail to complete the questionnaire or who fail to obtain a recommended medical evaluation may be prohibited from participating in activities at the fitness facility to the extent permitted by the law. Persons without known cardiovascular disease who do not obtain a medical evaluation as recommended may be permitted to participate if they sign a release or waiver.

Classifying Cardiovascular Risk

The recommendations categorize clients at health/fitness facilities into four classes of risk, depending on the initial health appraisal and, if indicated, the medical evaluation. The categories are as follows:

Class A: Persons who are apparently healthy. This group includes younger persons who are healthy and other persons, regardless of age, who are either healthy or at increased risk but have a normal maximal exercise test.

Class B: Persons with known, stable cardiovascular disease with a low risk of problems during vigorous exercise but a slightly greater risk than apparently healthy persons. This category includes persons with coronary artery disease, valvular heart disease, congenital heart disease, cardiomyopathy and abnormalities on exercise testing. Persons with abnormal findings on exercise testing may include those whose heart disease places them in New York Heart Association (NYHA) Class I or II.

Class C: Persons at moderate or high risk for cardiac complications during exercise and/or who are unable to self-regulate activity or understand the recommended activity level. Persons in this category may have previously had two or more myocardial infarctions, may be in NYHA Class III or greater and may have ischemic ST-segment depression of 1 mm or exercise-induced angina at a workload of 6 METS (metabolic equivalents) or less. Exercise for persons in Class C should be prescribed by medical personnel. In addition, medical supervision, monitoring for adverse signs and symptoms, electrocardiographic monitoring of heart rate and rhythm, and blood pressure monitoring are recommended during initial exercise sessions until the safety of exercise for such individuals is documented.

Class D: Persons who have unstable conditions and activity restriction. This group includes persons with unstable angina, uncompensated heart failure, uncontrolled arrhythmias, severe and symptomatic aortic stenosis, hypertrophic cardiomyopathy or cardiomyopathy from recent myocarditis, severe pulmonary hypertension and other conditions that could be aggravated by exercise. No physical activity is recommended for conditioning purposes in such persons.

Staffing and Emergency Policies

The report decribes five levels of health/fitness facilities. Level 1 facilities have only an unsupervised exercise room and no personnel. Level 2 facilities have a single exercise leader to supervise the exercise room. Level 3 facilities are commonly called fitness centers, and are intended for healthy clients. Staff at level 3 facilities may include a general manager, a health/fitness instructor and an exercise leader. Level 4 facilities serve clinical populations, and level 5 facilities provide medically supervised exercise programs.

The recommendations state that personnel at health/fitness facilities must meet the professional standards as stipulated by ACSM. Staff at levels 3, 4 and 5 facilities may include the general manager of the facility, the medical liaison, the fitness instructor and the exercise leader. The medical liaison may be a physician, a registered nurse trained in advanced cardiac life support or an emergency medical technician. Medical liaisons are recommended for facilities that are levels 2, 3, 4 and 5.

According to the recommendations, all health/fitness facilities must have emergency policies and procedures, and such procedures must be reviewed and practiced regularly. In addition, staff who supervise exercise activities should be skilled in basic life support. Emergency drills are recommended once every three months, or more often if staff turnover mandates it. The recommendations state that staff training and preparedness for emergencies are especially important at facilities that serve persons with medical conditions such as cardiovascular disease.

An emergency plan is recommended for all types of health/fitness facilities, and emergency equipment ranges from a telephone and "what-to-do-in-case-of-an-emergency" signs in exercise rooms at level 1 facilities to resuscitation equipment at level 5 facilities. Levels 2, 3 and 4 facilities should have a telephone, in-case-of-emergency signs, a blood pressure kit and a stethoscope available. In addition to this equipment, level 5 facilities (supervised cardiac rehabilitation) should also have a defibrillator, oxygen and a crash cart.

Questionnaire reprinted with permission from Balady GJ, Chaitman B, Driscoll D, Foster C, Froelicher E, Gordon N, et al. Recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Circulation 1998;97:2283-93.

---

American College of Chest Physicians Issues
Consensus Statement on the Management of Cough

VERNA L. ROSE

To provide physicians and their patients with information on the management of cough manifested both as a defense mechanism and as a symptom of diseases, such as asthma, gastroesophageal reflux disease (GERD) or bronchogenic carcinoma, the American College of Chest Physicians (ACCP) convened a panel of experts and published their recommendations in a supplement to the August 1998 issue of Chest. Richard S. Irwin, M.D., University of Massachusetts Medical School, served as chair of the panel that developed the statement. The ACCP statement, endorsed by the American and Canadian Thoracic Societies, can also be obtained by calling the ACCP at 847-498-1400 or 800-343-2227. A modified version is available for the general public.

The statement is divided into five chapters: an introduction, a discussion of cough as a defense mechanism, a discussion of cough as a symptom, guidelines for evaluating cough and pharmacologic treatment. The following information has been summarized from the 48-page document:

Cough is one of the most common reasons for which patients see their physician. The annual cost of treating cough in the United States, including the cost of nonprescription medications, is over $1 billion.

Evaluating Chronic Cough The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

The two categories of cough are acute (lasting less than three weeks) and chronic (lasting three to eight weeks or longer). These categories are not mutually exclusive. Acute cough is almost always caused by the common cold. The most common causes of chronic cough in nonsmokers in all age groups are postnasal drip syndrome from upper respiratory tract conditions, asthma and GERD. In these patients, the cough can manifiest as dry or productive. Less common causes of chronic cough include chronic bronchitis, bronchiectasis, postinfectious cough, bronchogenic carcinoma, cough induced by use of angiotensin-converting enzyme inhibitors, psychogenic cough and habit cough, and chronic interstitial pulmonary disease. The most common causes of cough in children are asthma, upper and lower respiratory tract infections and GERD. Less common but important causes of chronic cough in young children include congenital anomalies, heart disease, foreign bodies, aspiration and environmental factors.

The cause of chronic cough can be determined in most patients; specific therapy will usually be successful if chronic cough is systematically evaluated. The ACCP guidelines discuss when it is sufficient to take only a personal history and do a physical examination and when more expensive tests are needed for a diagnosis. Guidelines and algorithms for evaluating acute and chronic cough in immunocompetent and immunocompromised adults, and for evaluating cough in children, are presented in the report. The algorithm for evaluating chronic cough in immunocompetent adults is included in this report (see page 698). One section of the ACCP statement provides detailed guidance for using this algorithm.

According to the statement, pharmacologic treatment of cough is either antitussive (to prevent, control or eliminate cough) or protussive (to make cough more effective). Antitussive therapy is indicated when cough serves no useful function such as clearing the airways. The two kinds of antitussive therapy are specific and nonspecific. Specific antitussive therapy is directed at the etiology or mechanism causing cough (e.g., cigarette smoking). Nonspecific antitussive therapy is directed at the symptom and is prescribed to control cough.

Because of the high probability of being able to determine the causes of cough and prescribe specific treatment, there is a limited role for nonspecific antitussive therapy. The ACCP committee recommends that nonspecific antitussive therapy be prescribed only when specific therapy cannot be given because the cause is not known or because specific theapy has not had a chance to work or will not work (e.g., inoperable lung cancer). Protussive therapy is indicated when cough performs a useful function and needs to be encouraged (e.g., in patients with cystic fibrosis).

Algorithm reprinted with permission from Managing cough as a defense mechanism and as a symptiom; a consensus panel report of the American College of Chest Physicians. Chest 1998;114 (Suppl):133S-181S.

---

Copyright © 1999 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.