A survey of diagnostic stress testing centers in New York City

Evidence-based risk recommendations for best practices in the training of qualified exercise professionals working with clinical populations

This systematic review examines critically "best practices" in the training of qualified exercise professionals. Particular attention is given to the core competencies and educational requirements needed for working with clinical populations. Relevant information was obtained by a systematic search of 6 electronic databases, cross-referencing, and through the authors' knowledge of the area. The level and grade of the available evidence was established. A total of 52 articles relating to best practices and (or) core competencies in clinical exercise physiology met our eligibility criteria. Overall, current literature supports the need for qualified exercise professionals to possess advanced certification and education in the exercise sciences, particularly when dealing with "at-risk" populations. Current literature also substantiates the safety and effectiveness of exercise physiologist supervised stress testing and training in clinical populations.

Professional Practice in Exercise Science

This article describes the current outlook for professional practice for graduates majoring in exercise science. A review of professional and experimental literature reveals that graduates of undergraduate programmes in exercise science are not as prepared as they should be in order to provide professional and comprehensive advice on exercise and human performance, because of the focused academic and professional requirements of exercise physiology. In contrast to the direction of training in other allied health professions, this trend of narrowing of the exercise science curriculum to focus on exercise physiology, at the expense of other subdisciplines in kinesiology, has contributed to a decreasing scope of practice and lack of uniqueness, and has reduced the effectiveness of exercise science graduates. This review focuses on an accumulating body of evidence indicating that improving the training in biomechanics and motor behaviour could increase the professional expertise of exercise science graduates. Small improvements in the exercise science curriculum in biomechanics and motor behaviour are proposed that would move toward greater balance and integration of the academic disciplines in kinesiology and better professional practice in exercise science. The drift away from a balance and integration of academic preparation in exercise science represents a threat to the acceptance of exercise science graduates as exercise professionals that needs to be corrected for the field to advance.

A survey of exercise testing: methods, utilization, interpretation, and safety in the VAHCS

BACKGROUND

Healthcare organizations are being graded in terms of their adherence to practice guidelines. The authors sought information on practice patterns of exercise testing within the Veterans Affairs Health Care System (VAHCS) to determine how well current practice patterns adhere to current guidelines. In addition, we sought to update past surveys to determine methods, indications, utilization of alternative diagnostic modalities, criteria for interpretation, safety, and physician supervision of exercise testing within the VAHCS.

METHODS

Questionnaires were sent to 72 of the largest Veterans Affairs Medical Centers with cardiology divisions. The centers were queried regarding volume and type of exercise testing (standard, nuclear, and echocardiographic), indications, safety, protocols used, and criteria for interpretation.

RESULTS

Seventy-one questionnaires were returned, comprising a total of 75,828 exercise tests performed within the last year. Virtually all indications for exercise testing fit the American Heart Association/American College of Cardiology (AHA/ACC) guidelines Class I criteria; 46% of patients were tested for the evaluation of chest pain; 14% were tested to evaluate patients at high risk for coronary artery disease; 10% were preoperative evaluations; and 8% were post-myocardial infarction evaluations. The most commonly used diagnostic test was the standard exercise electrocardiogram; a patient was five times more likely to undergo a standard exercise electrocardiogram or nuclear exercise test than an exercise or pharmacologic echocardiogram. The largest proportion of centers (49%) used 1.0-mm horizontal or downsloping ST depression as a criterion for an abnormal test, although 22% considered 1.5-mm upsloping ST depression to be abnormal, and 25% relied on a treadmill score. Seventy-eight percent of respondents used the treadmill, and of these, 82% used the Bruce or modified Bruce protocol. Four major cardiac events were reported (three myocardial infarctions, one sustained ventricular tachycardia) representing an event rate of 1.2/10,000. A physician was present during 73% of all standard exercise tests; 21% of respondents reported that a physician was required to be present "only for high-risk patients."

CONCLUSION

Indications for exercise testing are in close agreement with the AHA/ACC guidelines; thus, the test continues to have an important role in diagnosis and prognosis among patients with or suspected of having coronary artery disease. The exercise test is an extremely safe procedure, with an event rate similar to other recent surveys. However, a great deal of variation exists in terms of criteria for abnormal results and whether physician presence is required during exercise testing.

Survey of cardiac rehabilitation centers in New York City

Out-patient cardiac rehabilitation centers in New York City were surveyed in order to determine current practices. All 24 centers operating as of May, 1987 were sent questionnaires; 16 responded for a return rate of 67 percent. In general, practices of the centers were in accord with guidelines of the American Heart Association (AHA) and the American College of Sports Medicine. The incidence of medical complications in the centers was quite rare, perhaps accounting for the failure of centers to follow all emergency guidelines of the AHA, such as daily testing of the defibrillator. The major aim of the centers was to enhance physiological status, rather narrowly defined as aerobic fitness and cardiovascular function. Little attention was paid to nutrition, body composition and strength, despite the fact that the value of broadening the concept of fitness to include these parameters is becoming evident. Lifestyle counseling to help in long-term rehabilitation was also rare. Third party payers should be encouraged to support such components of a rehabilitation program so that centers would be more likely to incorporate them.