Evidence-based risk assessment and recommendations for physical activity clearance: stroke and spinal cord injury

Relevance of the Get Active Questionnaire for Pre-Participation Exercise Screening in the General Population in a Tropical Environment

The Get Active Questionnaire (GAQ), developed by the Canadian Society for Exercise Professionals (CSEP), was recently recommended for pre-participation screening of the general population in Singapore before increasing their exercise levels. This literature review examines the evidence behind the GAQ and its relevance to our tropical environment. Searches were carried out via Pubmed, MEDLINE and the Cochrane Central Register of Controlled Trials. Resources referenced by the CSEPs were hand searched. The CSEP was also contacted for further information. The evidence behind each GAQ question was compared to international literature and guidelines, where applicable. Out of 273 studies, 49 were suitable for analysis. Two GAQ studies commissioned by the CSEP showed a high negative predictive value but high false negative rate. Of the nine GAQ questions, those on dizziness, joint pains and chronic diseases appear to be justified. Those on heart disease/stroke, hypertension, breathlessness and concussion require modification. The one on syncope can be amalgamated into the dizziness question. The remaining question may be deleted. No long-term studies were available to validate the use of the GAQ. Heat disorders were not considered in the GAQ. Modification of the GAQ, including the inclusion of environmental factors, may make it more suitable for the general population and should be considered.

Can post stroke walking improve via telerehabilitation? A systematic review in adults with stroke

Objectives

The purpose of this systematic review is to analyze primary studies investigating the effects of telerehabilitation on walking outcomes for the treatment of adult stroke survivors.

Methods

Data sources included PubMed, Embase and CINAHL searched until August 2022, using combinations of several keywords such as "telerehabilitation", "stroke", and "gait". Studies were required to have bidirectional form of videoconferencing with assessor presence, and include assessment of walking function (speed, endurance and/or balance). Data extraction was performed from each full text by one author, and quality and bias were assessed using the Physiotherapy Evidence Database (PEDro).

Results

Eight studies involving 248 participants met the inclusion criteria. Seven reported significant improvements in outcomes of balance and two showed improvements in endurance after telerehabilitation. Two studies observed greater balance improvements in the telerehabilitation group compared to control and/or in-person therapy. Differences in frequency, training duration, intervention type, and absence of an in-person therapy control group were identified as causes of variation between studies.

Conclusions

The effectiveness of telerehabilitation as a mode of therapy for walking could not be definitively determined due to the limited number of studies that directly measured walking speed or endurance. However, strong evidence was found for the use of telerehabilitation for balance improvements, which has implications for walking recovery.

Impact statement

Telerehabilitation appears to be safe, feasible and demonstrated high adherence. Our results highlighted limited studies using real-time supervision to administer telerehabilitation and lack of studies focusing on outcomes of walking speed and endurance, needed to fully determine the role of telerehabilitation for gait recovery.

Systematic review registration number

PROSPERO number CRD42021238197.

Mechanical disturbances applied by motorized ankle foot orthosis to adapt ankle muscles activation—A validation study

Background: Reduced function of ankle muscles usually leads to impaired gait. Motorized ankle foot orthoses (MAFOs) have shown potential to improve neuromuscular control and increase volitional engagement of ankle muscles. In this study, we hypothesize that specific disturbances (adaptive resistance-based perturbations to the planned trajectory) applied by a MAFO can be used to adapt the activity of ankle muscles. The first goal of this exploratory study was to test and validate two different ankle disturbances based on plantarflexion and dorsiflexion resistance while training in standing still position. The second goal was to assess neuromuscular adaptation to these approaches, namely, in terms of individual muscle activation and co-activation of antagonists.

Methods: Two ankle disturbances were tested in ten healthy subjects. For each subject, the dominant ankle followed a target trajectory while the contralateral leg was standing still: a) dorsiflexion torque during the first part of the trajectory (Stance Correlate disturbance—StC), and b) plantarflexion torque during the second part of the trajectory (Swing Correlate disturbance—SwC). Electromyography was recorded from the tibialis anterior (TAnt) and gastrocnemius medialis (GMed) during MAFO and treadmill (baseline) trials.

Results: GMed (plantarflexor muscle) activation decreased in all subjects during the application of StC, indicating that dorsiflexion torque did not enhance GMed activity. On the other hand, TAnt (dorsiflexor muscle) activation increased when SwC was applied, indicating that plantarflexion torque succeeded in enhancing TAnt activation. For each disturbance paradigm, there was no antagonist muscle co-activation accompanying agonist muscle activity changes.

Conclusion: We successfully tested novel ankle disturbance approaches that can be explored as potential resistance strategies in MAFO training. Results from SwC training warrant further investigation to promote specific motor recovery and learning of dorsiflexion in neural-impaired patients. This training can potentially be beneficial during intermediate phases of rehabilitation prior to overground exoskeleton-assisted walking. Decreased activation of GMed during StC might be attributed to the unloaded body weight in the ipsilateral side, which typically decreases activation of anti-gravity muscles. Neural adaptation to StC needs to be studied thoroughly in different postures in futures studies.

Preventiometer, a Novel Wellness Assessment Device, Used With Healthy Volunteers: A Phase 2 Study

Background

We previously reported on a pilot study to assess the incorporation of a novel wellness assessment device, the Preventiometer (iPEx5 GmbH, Greifswald, Germany), into an academic medical practice. The present follow-up study expands on those data and evaluates the acceptability of the assessment process in a larger sample population.

Objective

The aim of this study was to evaluate participant satisfaction with the Preventiometer wellness assessment.

Methods

A total of 60 healthy volunteers participated. Each participant underwent a comprehensive wellness assessment with the Preventiometer and received data from more than 30 diagnostic tests. A 32-question survey (with a numeric rating scale from 0 to 10) was used to rate the wellness assessment tests and participants' impressions of the wellness assessment.

Results

Each assessment had a significantly higher rating than 7 (P < .001), and the majority of participants agreed or strongly agreed that they were satisfied (98.3%), and they strongly agreed that they were engaged the entire time (93.2%), and liked the instant test results feature of the Preventiometer device (93.2%).

Conclusion

This study confirms findings from our previous pilot study regarding the feasibility of the Preventiometer as a wellness assessment tool. The study further demonstrated that 98% of participants were satisfied with the assessment and that all of them would recommend it to others.

Translation, Cultural Adaptation, and Reproducibility of the Physical Activity Readiness Questionnaire for Everyone (PAR-Q+): The Brazilian Portuguese Version

Background: The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) is the international standard for pre-participation risk stratification and screening. In order to provide a practical and valid screening tool to facilitate safe engagement in physical activity and fitness assessments for the Brazilian population, this study aimed to translate, culturally adapt, and verify the reproducibility of the evidence-based PAR-Q+ to the Brazilian Portuguese language.

Method: Initially, the document was translated by two independent translators, before Brazilian experts in health and physical activity evaluated the translations and produced a common initial version. Next, two English native speakers, fluent in Brazilian Portuguese and accustomed to the local culture, back-translated the questionnaire. These back translations were assessed by the organization in charge of the PAR-Q+, then a final Brazilian version was approved. A total of 493 Brazilians between 5 and 93 yr (39.9 ± 25.4 yr), 59% female, with varying levels of health and physical activity, completed the questionnaire twice, in person or online, 1–2 weeks apart. Cronbach's alpha was used to calculate the internal consistency of all items of the questionnaire, and the Kappa statistic was used to assess the individual reproducibility of each item of the document. Additionally, the intraclass correlation coefficient and its 95% confidence interval (CI) were used to verify the general reproducibility (reliability) of the translated version.

Results: The Brazilian version had an excellent internal consistency (0.993), with an almost perfect agreement in 93.8% of the questions, and a substantial agreement in the other 6.2%. The translated version also had a good to excellent total reproducibility (0.901, 95% CI: 0.887–0.914).

Conclusion: The results show this translation is a valid and reliable screening tool, which may facilitate a larger number of Brazilians to start or increase physical activity participation in a safe manner.

Neuroplastic effects of end-effector robotic gait training for hemiparetic stroke: a randomised controlled trial

Detecting neuroplastic changes during locomotor neurorehabilitation is crucial for independent primal motor behaviours. However, long-term locomotor training-related neuroplasticity remains unexplored. We compared the effects of end-effector robot-assisted gait training (E-RAGT) and bodyweight-supported treadmill training (BWST) on cortical activation in individuals with hemiparetic stroke. Twenty-three men and five women aged 53.2 ± 11.2 years were recruited and randomly assigned to participate in E-RAGT (n = 14) or BWST (n = 14) for 30 min/day, 5 days/week, for 4 weeks. Cortical activity, lower limb motor function, and gait speed were evaluated before and after training. Activation of the primary sensorimotor cortex, supplementary motor area, and premotor cortex in the affected hemisphere significantly increased only in the E-RAGT group, although there were no significant between-group differences. Clinical outcomes, including the Fugl-Meyer assessment (FMA), timed up and go test, and 10-m walk test scores, improved after training in both groups, with significantly better FMA scores in the E-RAGT group than in the BWST group. These findings suggest that E-RAGT effectively improves neuroplastic outcomes in hemiparetic stroke, although its superiority over conventional training remains unclear. This may have clinical implications and provides insight for clinicians interested in locomotor neurorehabilitation after hemiparetic stroke.Trial Registration: ClinicalTrials.gov Identifier NCT04054739 (12/08/2019).

German recommendations for physical activity and physical activity promotion in adults with noncommunicable diseases

Background

Existing physical activity guidelines predominantly focus on healthy age-stratified target groups. The objective of this study was to develop evidence-based recommendations for physical activity (PA) and PA promotion for German adults (18–65 years) with noncommunicable diseases (NCDs).

Methods

The PA recommendations were developed based on existing PA recommendations. In phase 1, systematic literature searches were conducted for current PA recommendations for seven chronic conditions (osteoarthrosis of the hip and knee, chronic obstructive pulmonary disease, stable ischemic heart disease, stroke, clinical depression, and chronic non-specific back pain). In phase 2, the PA recommendations were evaluated on the basis of 28 quality criteria, and high-quality recommendations were analysed. In phase 3, PA recommendations for seven chronic conditions were deducted and then synthesised to generate generic German PA recommendations for adults with NCDs. In relation to the recommendations for PA promotion, a systematic literature review was conducted on papers that reviewed the efficacy/effectiveness of interventions for PA promotion in adults with NCDs.

Results

The German recommendations for physical activity state that adults with NCDs should, over the course of a week, do at least 150 min of moderate-intensity aerobic PA, or 75 min of vigorous-intensity aerobic PA, or a combination of both. Furthermore, muscle-strengthening activities should be performed at least twice a week. The promotion of PA among adults with NCDs should be theory-based, specifically target PA behaviour, and be tailored to the respective target group. In this context, and as an intervention method, exercise referral schemes are one of the more promising methods of promoting PA in adults with NCDs.

Conclusion

The development of evidence-based recommendations for PA and PA promotion is an important step in terms of the initiation and implementation of actions for PA-related health promotion in Germany. The German recommendations for PA and PA promotion inform adults affected by NCDs and health professionals on how much PA would be optimal for adults with NCDs. Additionally, the recommendations provide professionals entrusted in PA promotion the best strategies and interventions to raise low PA levels in adults with NCDs. The formulation of specific PA recommendations for adults with NCDs and their combination with recommendations on PA promotion is a unique characteristic of the German recommendations.

Training-Induced Neural Plasticity and Strength Are Amplified After Stroke

Following stroke, sensorimotor brain networks and descending regulation are compromised but spinal interlimb neural connections remain morphologically intact. After cross-education strength and locomotion training, amplified neural plasticity and functional responses are observed in chronic stroke compared with neurologically intact participants. We hypothesize that poststroke neuroplasticity is amplified because of the involvement of interlimb neural connections that persist from our quadrupedal ancestry.

Effects of upper-body resistance exercise training on serum nesfatin-1 level, insulin resistance, and body composition in obese paraplegic men

BACKGROUND

As a recently discovered adipokine, nesfatin-1 is conducive to insulin sensitivity, lipid profile, energy balance, and probably obesity.

OBJECTIVE

The aim of the present study was to investigate the effect of upper-body resistance exercise training (RET) on nesfatin-1 levels, insulin resistance, lipid profile, and body composition in obese paraplegic men.

METHODS

Twenty obese paraplegic men were randomly assigned into control and upper-body RET groups. Upper-body RET was performed for 8 weeks, 3 sessions per week at an intensity corresponding to 60-80% maximum amount of force that can be generated in one maximal contraction in 5 stations (bench press, seated rows, sitting lat pulldown, arm extension, and arm curls). Body fat percentage was determined according to 4-sites skinfold protocol of Durnin and Womersley and Siri equation. Obesity for spinal cord injury patients in the current study was set at BMI >22 kg/m². Data were statistically analyzed by paired and independent t-test (P < 0.05).

RESULTS

We found significant improvements in serum levels of nesfatin-1 (21.13%), insulin sensitivity (8.95%), and high-density lipoprotein (10.87%). Other lipid profile markers, i.e. low-density lipoprotein (4.32%), cholesterol (8.20%), and triglyceride (15.10%) reduced significantly after upper-body RET. Moreover, upper-body RET led to a significant reduction in body mass index (2.36%), body fat percentage (2.79%), and waist-to-hip ratio (2.40%).

CONCLUSION

Upper-body RET improved insulin sensitivity, lipid profile, and body composition in paraplegic men. Serum nefastin-1 may be a potential marker of success in weight management in this population.

Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice for persons with spinal cord injury. The European PRM position (UEMS PRM Section)

INTRODUCTION

Spinal cord injury (SCI) is a devastating condition and a challenge for every health system and every society. This EBPP represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians for people with SCI. The aim of the paper was to improve Physical and Rehabilitation Medicine (PRM) physicians' professional practice for persons with SCI in order to improve their functionality, social and community reintegration, and to overcome activity limitations and/or participation restrictions.

EVIDENCE ACQUISITION

A systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section.

EVIDENCE SYNTHESIS

The systematic literature review is reported together with thirty-eight recommendations resulting from the Delphi procedure.

CONCLUSIONS

The professional role of PRM physicians who have expertise in the rehabilitation of SCI is to run rehabilitation programmes in multi-professional teams, working in an interdisciplinary way in a variety of settings to improve the functioning of people with SCI.

Rhythmic arm cycling training improves walking and neurophysiological integrity in chronic stroke: the arms can give legs a helping hand in rehabilitation

Training locomotor central pattern-generating networks (CPGs) through arm and leg cycling improves walking in chronic stroke. These outcomes are presumed to result from enhanced interlimb connectivity and CPG function. The extent to which rhythmic arm training activates interlimb CPG networks for locomotion remains unclear and was assessed by studying chronic stroke participants before and after 5 wk of arm cycling training. Strength was assessed bilaterally via maximal voluntary isometric contractions in the legs and hands. Muscle activation during arm cycling and transfer to treadmill walking were assessed in the more affected (MA) and less affected (LA) sides via surface electromyography. Changes to interlimb coupling during rhythmic movement were evaluated using modulation of cutaneous reflexes elicited by electrical stimulation of the superficial radial nerve at the wrist. Bilateral soleus stretch reflexes were elicited at rest and during 1-Hz arm cycling. Clinical function tests assessed walking, balance, and motor function. Results show significant changes in function and neurophysiological integrity. Training increased bilateral grip strength, force during MA plantarflexion, and muscle activation. "Normalization" of cutaneous reflex modulation was found during arm cycling. There was enhanced activity in the dorsiflexor muscles on the MA side during the swing phase of walking. Enhanced interlimb coupling was shown by increased modulation of MA soleus stretch reflex amplitudes during arm cycling after training. Clinical evaluations showed enhanced walking ability and balance. These results are consistent with training-induced changes in CPG function and interlimb connectivity and underscore the need for arm training in the functional rehabilitation of walking after neurotrauma. NEW & NOTEWORTHY It has been suggested but not tested that training the arms may influence rehabilitation of walking due to activation of interneuronal patterning networks after stroke. We show that arm cycling training improves strength, clinical function, coordination of muscle activity during walking, and neurological connectivity between the arms and the legs. The arms can, in fact, give the legs a helping hand in rehabilitation of walking after stroke.

Long-Term Plasticity in Reflex Excitability Induced by Five Weeks of Arm and Leg Cycling Training after Stroke

Neural connections remain partially viable after stroke, and access to these residual connections provides a substrate for training-induced plasticity. The objective of this project was to test if reflex excitability could be modified with arm and leg (A &amp; L) cycling training. Nineteen individuals with chronic stroke (more than six months postlesion) performed 30 min of A &amp; L cycling training three times a week for five weeks. Changes in reflex excitability were inferred from modulation of cutaneous and stretch reflexes. A multiple baseline (three pretests) within-subject control design was used. Plasticity in reflex excitability was determined as an increase in the conditioning effect of arm cycling on soleus stretch reflex amplitude on the more affected side, by the index of modulation, and by the modulation ratio between sides for cutaneous reflexes. In general, A &amp; L cycling training induces plasticity and modifies reflex excitability after stroke.

The lingering effects of a busted myth--false time limits in stroke rehabilitation

It was once falsely believed that neurological and functional recovery after stroke occurred only in the first 6 months after lesion. The perception of this "6-month myth" continues to negatively impact the attitudes of patients towards their rehabilitation and on the clinicians and therapists making optimal training plans. Here we briefly outline some evidence that debunked the 6-month myth, where the concept of this temporal limit may have originated, and the lingering misunderstanding that individuals with stroke reach a plateau of recovery after 6 months even with rehabilitation training. We present evidence that significant functional improvement can occur years after stroke when rehabilitation training is applied. We frame the concepts of active and passive neurological recovery and that active neurological recovery continues far beyond any temporal limit. Because the effects of this busted 6-month myth persist, we aim to remind active physicians, therapists, exercise professionals, and those with stroke to continuously seek opportunities for active rehabilitation training. Meanwhile, trained and certified exercise professionals can play critical roles in facilitating rehabilitative training for community-dwelling stroke survivors.

Exploiting Interlimb Arm and Leg Connections for Walking Rehabilitation: A Training Intervention in Stroke

Rhythmic arm and leg (A&L) movements share common elements of neural control. The extent to which A&L cycling training can lead to training adaptations which transfer to improved walking function remains untested. The purpose of this study was to test the efficacy of A&L cycling training as a modality to improve locomotor function after stroke. Nineteen chronic stroke (>six months) participants were recruited and performed 30 minutes of A&L cycling training three times a week for five weeks. Changes in walking function were assessed with (1) clinical tests; (2) strength during isometric contractions; and (3) treadmill walking performance and cutaneous reflex modulation. A multiple baseline (3 pretests) within-subject control design was used. Data show that A&L cycling training improved clinical walking status increased strength by ~25%, improved modulation of muscle activity by ~25%, increased range of motion by ~20%, decreased stride duration, increased frequency, and improved modulation of cutaneous reflexes during treadmill walking. On most variables, the majority of participants showed a significant improvement in walking ability. These results suggest that exploiting arm and leg connections with A&L cycling training, an accessible and cost-effective training modality, could be used to improve walking ability after stroke.

Pathways Mediating Activity-Induced Enhancement of Recovery From Peripheral Nerve Injury

This article outlines the novel hypothesis that exercise promotes axon regeneration after peripheral nerve injury through neuronal brain-derived neurotrophic factor (BDNF), and there are three required means of promoting BDNF expression: 1) increased signaling through androgen receptors, 2) increased cAMP-responsive element-binding protein expression, and 3) increased expression of the transcription factor SRY-box containing gene 11.

Restoring symmetry: clinical applications of cross-education

The "restoring symmetry" hypothesis poses that cross-education of strength--a crossed-limb adaptation after unilateral training--is best applied to clinical conditions presenting with asymmetries. Cross-education mechanisms should be viewed as evolutionarily conserved circuits that have a small impact on daily life but a meaningful impact for rehabilitation. Two recently published examples are hemiparesis after stroke and unilateral orthopedic injury.

Systematic framework to classify the status of research on spinal cord injury and physical activity

OBJECTIVES

To systematically classify the physical activity research for individuals with a spinal cord injury by using the behavioral epidemiologic framework; and to identify where the physical activity research for individuals with a spinal cord injury has focused between 2000 and 2012.

DESIGN

Relevant research was identified and then categorized into 1 of 5 phases by following the coding rules of the behavioral epidemiology framework. Phase 1 studies link physical activity and health outcomes, phase 2 studies validate or develop measures of physical activity, phase 3 studies identify factors that influence behavior or examine explanatory theories of behavior, phase 4 studies evaluate interventions, and phase 5 studies disseminate health promotion programs or policies and translate research into practice.

SETTING

Specific keywords were identified and then searched through EBSCOhost, PubMed, and Google Scholar.

PARTICIPANTS

Not applicable.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

One hundred and thirteen articles met the criteria. Of the articles, 55% were categorized as phase 1, 12% as phase 2, 24% as phase 3, 5% as phase 4, and 4% as phase 5.

CONCLUSIONS

Most studies were categorized as phase 1, 2, or 3, which implies that this field is still in the early stages of development and research should focus on intervention development and dissemination.

High-intensity unilateral dorsiflexor resistance training results in bilateral neuromuscular plasticity after stroke

Hemiparesis after stroke decreases ability to dorsiflex the more-affected ankle during walking. Increased strength would be beneficial, but the more-affected limb is often too weak to be trained. In neurologically intact participants, training one limb induces strength gains in the contralateral, untrained limb. This approach remains unexplored post-stroke. The aim of this study was to test the hypothesis that unilateral dorsiflexor high-intensity resistance training on the less-affected side increases strength and motor output bilaterally following stroke. 19 participants (84.1 ± 77.6 months post-infarct) performed 6 weeks of maximal isometric dorsiflexion training using the less-affected leg. Voluntary isometric strength (dorsiflexion torque, muscle activation), reciprocal inhibition (RI), walking ability (gait speed, kinematics, EMG patterns), and clinical function were measured within 1 week before and 4 days following training. Post-intervention, dorsiflexion torque increased by ~31 % (p < 0.05) in the more-affected (untrained) and by ~34 % (p < 0.05) in the less-affected (trained) legs. Muscle activation significantly increased bilaterally, by ~59 and ~20 % in the trained and untrained legs, respectively. Notably, 4 participants who were unable to generate functional dorsiflexion on the more-affected side before training could do so post-intervention. Significant correlations between muscle activation and size of RI were noted across muscle groups before and after training, and the relation between size of RI and level of muscle activation in the more-affected tibialis anterior muscle was significantly altered by training. Thus, significant gains in voluntary strength and muscle activation on the untrained, more-affected side after stroke can be invoked through training the opposite limb. We demonstrate residual plasticity existing many years post-stroke and suggest clinical application of the cross-education effect where training the more-affected limb is not initially possible.

Neural control of rhythmic arm cycling after stroke

Disordered reflex activity and alterations in the neural control of walking have been observed after stroke. In addition to impairments in leg movement that affect locomotor ability after stroke, significant impairments are also seen in the arms. Altered neural control in the upper limb can often lead to altered tone and spasticity resulting in impaired coordination and flexion contractures. We sought to address the extent to which the neural control of movement is disordered after stroke by examining the modulation pattern of cutaneous reflexes in arm muscles during arm cycling. Twenty-five stroke participants who were at least 6 mo postinfarction and clinically stable, performed rhythmic arm cycling while cutaneous reflexes were evoked with trains (5 × 1.0-ms pulses at 300 Hz) of constant-current electrical stimulation to the superficial radial (SR) nerve at the wrist. Both the more (MA) and less affected (LA) arms were stimulated in separate trials. Bilateral electromyography (EMG) activity was recorded from muscles acting at the shoulder, elbow, and wrist. Analysis was conducted on averaged reflexes in 12 equidistant phases of the movement cycle. Phase-modulated cutaneous reflexes were present, but altered, in both MA and LA arms after stroke. Notably, the pattern was "blunted" in the MA arm in stroke compared with control participants. Differences between stroke and control were progressively more evident moving from shoulder to wrist. The results suggest that a reduced pattern of cutaneous reflex modulation persists during rhythmic arm movement after stroke. The overall implication of this result is that the putative spinal contributions to rhythmic human arm movement remain accessible after stroke, which has translational implications for rehabilitation.

Evidence-based risk assessment and recommendations for physical activity clearance: established cardiovascular disease1This paper is one of a selection of papers published in this Special Issue, entitled Evidence-based risk assessment and recommendations for physical activity clearance, and has undergone the Journal’s usual peer review process

Physical activity is an effective lifestyle therapy for patients at risk for, or with, documented cardiovascular disease (CVD). Current screening tools — the Physical Activity Readiness Questionnaire (PAR-Q) and the Physical Activity Readiness Medical Evaluation (PARmed-X) — require updating to align with risk/benefit evidence. We provide evidence-based recommendations to identify individuals with CVD at lower risk, intermediate risk, or higher risk of adverse events when participating in physical activity. Forms of exercise and the settings that will appropriately manage the risks are identified. A computer-assisted search of electronic databases, using search terms for CVD and physical activity risks and benefits, was employed. The Appraisal of Guidelines for Research and Evaluation were applied to assess the evidence and assign a strength of evidence rating. A strength rating for the physical activity participation clearance recommendation was assigned on the basis of the evidence. Recommendations for physical activity clearance were made for specific CVD groups. Evidence indicates that those who are medically stable, who are involved with physical activity, and who have adequate physical ability can participate in physical activity of lower to moderate risk. Patients at higher risk can exercise in medically supervised programs. Systematic evaluation of evidence indicates that clinically stable individuals with CVD may participate in physical activity with little risk of adverse events. Therefore, changes in the PAR-Q should be undertaken and a process of assessment and consultation to replace the PARmed-X should be developed. Patients at lower risk may exercise at low to moderate intensities with minimal supervision. Those at intermediate risk should exercise with guidance from a qualified exercise professional. Patients at higher risk should exercise in medically supervised programs.

Evidence-based risk assessment and recommendations for exercise testing and physical activity clearance in apparently healthy individuals1This paper is one of a selection of papers published in this Special Issue, entitled Evidence-based risk assessment and recommendations for physical activity clearance, and has undergone the Journal’s usual peer review process

Increased physical activity (PA) is associated with improved health and quality of life in the general population. A dose–response effect is evident between increasing levels of PA participation and a lower relative risk for cardiovascular disease and all-cause mortality. However, there is also clear evidence that PA acutely increases the risk of an adverse cardiovascular (CV) event and sudden cardiac death (SCD) significantly above levels expected at rest. Adverse CV events during PA may be triggered acutely by the physiological stress of exercise. This investigation will review the available literature describing the CV risks of exercise testing and PA participation in apparently healthy individuals. A systematic review of the literature was performed using electronic databases, including Medline, CINAHL, SPORT discus, EMBASE, Cochrane DSR, ACP Journal Club, and DARE; additional relevant articles were hand-picked and the final grouping was used for the review using the AGREE process to assess the impact and quality of the selected articles. Six hundred and sixteen relevant articles were reviewed with 51 being identified as describing adverse CV events during exercise and PA. Data suggests the risks of fatal and nonfatal events during maximal exercise testing in apparently healthy individuals rarely occur (approximately <0.8 per 10 000 tests or 1 per 10 000 h of testing). The incidence of adverse CV events is extremely low during PA of varying types and intensities, with data limited almost exclusively to fatal CV events, as nonfatal events are rarely reported. However, this risk is reduced by 25%–50% in those individuals who have prior experience with increased levels of PA, particularly vigorous PA. Throughout a wide age range, the risk of SCD and nonfatal events during PA remain extremely low (well below 0.01 per 10 000 participant hours), but both increasing age and PA intensity are associated with greater risk. In most cases of exercise-related SCD, undetected pre-existing disease is present and SCD is typically the first clinical event. The risks of an adverse CV event during exercise testing and PA are rare and are outweighed by the health benefits. Given this risk-benefit relationship, the PAR-Q is an appropriate method to identify those at higher risk across a wide age span and should be used in conjunction with appropriate clinical guidelines for guiding individuals towards graduated PA. There are not adequate data to describe the risks of PA in those individuals considered to be at higher risk but without cardiovascular disease.

Enhancing the effectiveness of clearance for physical activity participation: background and overall process1This paper is one of a selection of papers published in the Special Issue entitled Evidence-based risk assessment and recommendations for physical activity clearance, and has undergone the Journal's usual peer-review process

Recent feedback from physical activity (PA) participants, fitness professionals, and physicians has indicated that there are limitations to the utility and effectiveness of the existing PAR-Q and PARmed-X screening tools for PA participation. The aim of this study was to have authorities in exercise and chronic disease management to work with an expert panel to increase the effectiveness of clearance for PA participation using an evidence-based consensus approach and the well-established Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. Systematic reviews were conducted to develop a new PA clearance protocol involving risk stratification and a decision-tree process. Evidence-based support was sought for enabling qualified exercise professionals to have a direct role in the PA participation clearance process. The PAR-Q+ was developed to use formalized probes to clarify problematic responses and to explore issues arising from currently diagnosed chronic disease or condition. The original PARmed-X tool is replaced with an interactive computer program (ePARmed-X+) to clear prospective PA participants for either unrestricted or supervised PA or to direct them to obtain medical clearance. Evidence-based validation was also provided for the direct role of highly qualified university-educated exercise professionals in the PA clearance process. The risks associated with exercise during pregnancy were also evaluated. The systematic review and consensus process, conforming to the AGREE Instrument, has provided a sound evidence base for enhanced effectiveness of the clearance process for PA participation of both asymptomatic populations and persons with chronic diseases or conditions.