13/07/2023

Clinical
Exercise Physiology
Principles of CEP &
Health Screening
By Matt Wood & Matthew Stratton

Online Introduction

Learning Outcomes
1. Professional skills associated with CEP
2. Principles of pathophysiology

3. Principles of pharmacology
4. Health screening

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Textbook Chapters

Chapters 2 & 3

Professional Skills
• Professional conduct & ethical behaviour
• Client wellbeing is a priority – “first do no harm”

• Tailored

• Collaborative shared decision making

• Empower clients with knowledge and independent skill-set

• Appropriate environment/s

Professional Skills
• Professional conduct & ethical behaviour (cont.)
• Supportive – family, friends, groups

• Consent, rights, autonomy, freedom of choice

• Scientific basis, acknowledge limitations and avoid

exaggeration

• On-going professional development

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Professional Skills
• Professional conduct & ethical behaviour (cont.)
• Clients are commonly in a vulnerable state and/or labile emotional state

• Legal considerations

• “Reasonable care”

• Confidentiality and privacy

• Honest & fair practice, avoid exploitation or misrepresentation

Professional Skills
• Professional rapport
• Welcoming, authentic, confidence, maintain a comfortable & judgement free environment

• Relatedness - understand client perspective, empathy, active listening, telling them that
you hear and understand their concerns. Consider verbal & non-verbal cues

• Clinical conduct
• Interactions are confidential. Information should remain private and protected.

• Emergency risk management

• Health & safety

Industry & Client Networks

• Client support network
• Community, family, friends & others

• Industry network
• Multi-disciplinary care
• Appreciation for health and fitness services

• Developing awareness, partnerships & referrals

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Principles of Pathophysiology
1. Pathology vs Pathophysiology
• Study of the disease vs. functional changes an individual undergoes due to
disease

2. Common / Less Common / Rare

3. Disease progression
4. Standard care pathway
• Public and private healthcare

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Common Medical Terms

• Symptoms – subjective feelings reported by a patient; e.g. pain
• Signs – objectively identifiable aberration or consideration e.g. ↓ in blood
pressure
• Syndrome – a set of signs and symptoms that occur together e.g. irritable
bowel syndrome
• Diagnosis – the process of identifying a condition by examining signs and
symptoms
• Prognosis – the probable outcome of a disease
• Acute – a condition of relatively short duration, often with severe symptoms
• Chronic – a condition that lasts for an extended period of time
• Lesion – abnormal area of tissue that has suffered damage as a result of
injury or disease

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Common Medical Terms

• Necrosis – the premature death of groups of cells due to injury or disease
• Oedema – build up of fluid resulting in swelling
• Malignant (tumour) – presence of cancerous cells and capable of invading
other tissue
• Benign (tumour) – without the presence of cancerous cells and does not
invade other tissue
• Remission – condition that is not getting worse
• Embolism – reduction of blood flow within a vessel caused by any material
e.g. blood, air, fat
• Thrombosis – reduction of blood flow within a vessel caused by a blot clot
(thrombus)

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Pathophysiology – Biochemical
Blood tests
• Complete blood count • Iron studies

• Lipid tests • Inflammatory profile

• Diabetic profile • Serum b12 & folate

• Liver function • Thyroid function

• Others…
• Renal function

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Pathophysiology – Medical Imaging

X-ray
• Uses a small amount of radiation that passes
through the body to quickly capture a single
image of your anatomy to assess injury (fractures
or dislocations) or disease (bone degeneration,
infections or tumours). Dense objects, such as
bone, block the radiation and appear white on
the X-ray picture.

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Pathophysiology – Medical Imaging

Computed tomographic Scan (CT)
• Combines X-rays with computers to
produce 360 degree, cross-sectional
views of your body. CT is able to image
bone, soft tissue and blood vessels all at
the same time. It provides details of
bony structures or injuries, diagnosing
lung and chest problems, and detecting
cancers.

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Pathophysiology – Medical Imaging

Magnetic resonance imaging (MRI)

• Combines a powerful magnetic field with an
advanced computer system and radio waves to
produce accurate, detailed pictures of organs, soft
tissues, bone and other internal body structures.
Differences between normal and abnormal tissue is
often clearer on an MRI than CT. There is no
radiation exposure with MRI machines.

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Pathophysiology – Medical Imaging

Positron emission tomography (PET)
• Uses a nuclear material (radiotracer) that
is swallowed or injected and is absorbed
by the body. The machine then detects
and records the energy given off by the
tracer and converts it into a 3d image.

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Pathophysiology – Medical Imaging

Ultrasound
• uses high frequency sound
waves, to create a live video
feed image of the inside of the
body. Images are captured in
real-time during ultrasound,
they can also show movement
of the body’s internal organs as
well as blood flowing through
blood vessels

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Pathophysiology – Medical Imaging

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Pathophysiology – Hospital Admissions

Hospital length of stay

• TKJR = 3-5 days • Stoke = 15 – 19 days

• THJR = 5-7 days • COPD = 7-10 days

• Stent = 3 days • KD = 4-6 days

• CABG = 5 days • Depressive disorders

variable

TKJR = Total Knee Joint Replacem ent, THJR = Total Hip Joint Replacem ent, COPD = Chronic Obstructive
Pulm onary Disease, CABG = Coronary Artery Bypass Graft, KD = Kidney Disease

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Pathophysiology - Inflammation

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Pathophysiology - Inflammation
Cardiovascular Disease
Allergic Reaction
Neurological Disease
Chemical Irritants
Lupus
Acute Chronic
Infection
Inflammation
Vs. Inflammation Cancer
Trauma Injury
Rheumatoid Disease
Burns
Autoimmune Disease
Cuts, Wounds
Fibromyalgia
Frostbite
Chronic Fatigue Syndrome

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Pathophysiology – Acute vs Chronic

Inflammation
Acute Chronic
Causative Agent Pathogens, injured tissue Persistent acute inflammation due to non
degradable pathogens, foreign bodies, or
autoimmune reaction
Cells involved Mainly neutrophils, mononuclear Mononuclear cells (monocytes, macrophages,
cells (monocytes, macrophages) lymphocytes, plasma cell), fibroblasts
Onset Immediate Delayed
Duration A few days Months - years
Outcomes Resolution, abscess formation, Tissue destruction, fibrosis
chronic inflammation
Vascular changes Prominent (vasodilation, increased Not prominent
permeability)
Cardinal Signs Prominent Not prominent

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Principles of Pharmacology
1. Common medications associated with medical conditions
2. Resting and exercise effects

3. Principles of pharmacology
4. Medication adherence

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Principles of Pharmacology
Medications have generic and brand/trade names

Generic name identifies the drug no matter

who the manufacturer is e.g. Aspirin
Trade name name given by manufacturer e.g.
Panadol

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Principles of Pharmacology
• Pharmacokinetic – the effect of the body on the drug
• How it is absorbed, distributed, metabolised, and excreted

• Practical application: Different effects at different times of day, drug

interactions, individual variability

• Pharmacodynamic – the effect of the drug molecules in the body

• Therapeutic effects and side effects

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Principles of Pharmacology
Dose-response

• Relationship between amount of drug and the body’s response

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Principles of Pharmacology
Factors that effect drug response

• Age • Co-existing disease

• Body mass • Ambient environment

• Gender • Time of day

• Genetics • Food

• Effect of exercise • Mood, placebo or nocebo effect

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Principles of Pharmacology
Effect of exercise

• Redistribution of blood flow may affect absorption (e.g. gastrointestinal),

metabolism (e.g. liver) and elimination (e.g. renal)

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Principles of Pharmacology
Mechanisms of action
• Agonist – activates receptor sites e.g. morphine
• Antagonist – blocks receptor sites e.g. beta-blockers

• Enzyme – inhibition or activation e.g. penicillin

• Non-specific other e.g. laxatives

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Principles of Pharmacology
Issues of non-compliance
• Absence of symptoms
• Health beliefs and health literacy

• Cognitive impairment

• Drug-related side effects

• Multiple medications

• Repeat prescriptions

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Principles of Pharmacology
Improper medication use
• Take at the wrong time
• Over or underuse

• Taking the wrong medicine

• Not finishing medication

• Using another person’s medication

• Using old, possibly expired medication

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Principles of Pharmacology
Strategies to reinforce compliance:
• General support & education
• Checks prior to exercise

• Reinforce self monitoring

• Structure/routine

• Mobile Apps or daily alarms

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Principles of Pharmacology
Practical application:

Resting and exercise effects of common medications associated with each

condition

• Information of NZ medications

• Medsafe website for general considerations

• Research, ACSM & CEP textbooks for specific exercise effects

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Time for a 5-minute break…

Develop your critical thinking skills…

Please ask questions

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Clinical Exercise Assessments

1. Preparation
• Gain access and read medical or other reports

• Review evidence and develop tailored assessment plan

• Prepare environment, equipment and documents

2. Welcome, overview of assessment

3. Informed consent

4. Exercise pre-participation health screening cognitive and behavioural strategies

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Clinical Assessments
5. Resting measures
• Blood Pressure

• Anthropometric

• Condition specific – spirometry, blood glucose, other

6. Cardiopulmonary Exercise Test (CPET)

8. Balance

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Clinical Assessments

8. Muscular Strength

9. Flexibility/ROM

10. Interpretation for client

11. Action plan

12. Report & programme

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Informed Consent
• Participant understands the purposes, risks,
benefits associated with participation

• Should be verbally explained

• Ethical and legal considerations

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Informed Consent - Components

• Purpose & explanation of procedures

• Risks & discomforts

• Benefits

• Questions

• Privacy process

• Freedom of consent / voluntary participation

• Signatures

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Interview & Examination Skills

• General interview topics include:
• Demographic information
• Medical history & medications

• Family & social history

• History of physical activity & exercise

• Goal setting

• Behavioural & support strategies

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Interview - Demographics
• Age - independent predictor of survival for many conditions
• Sex - differences in onset of disease
• Ethnicity (unique genetic considerations)
• Can be difficult to distinguish in NZ due to genetic mix
• Some ethnic differences may be related to socioeconomic considerations,
values, perceptions, behavioural, environmental, and other factors
• Some known ethnic-related differences include: obesity, chronic renal
insufficiency, hypertension and diabetes

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Interview – Family, Social & Exercise History

• Restrict to first-degree relatives—parents, siblings, and offspring
• Identify relevant heritable disorders such as:
• Certain cancers, Diabetes, Familial hypercholesterolemia
• Marital/family status
• Occupation

• Social/leisure activities

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Interview – Family, Social & Exercise History

• Nutrition patterns and habits
• Physiological & perceived stress & sleep habits
• Substance abuse can influence exercise therapy
e.g. smoking & alcohol
• Prior and current exercise habits
• Functional capacity (estimate)

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Interview – Family, Social & Exercise History

VO 2
(m l.kg.m in)

10.5
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17.5
21

24.5
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Considerations: frequency, time, relative intensity, using a submaximal intensity to estimate capacity

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Interview – Medical History

• Questionnaires should be customised to suit

• Will be covered in the tutorial

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Interview – Medical History

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Interview – Medical History

• Ask about:
• Region

• Date of symptom onset, timing & chronicity

• Current state

• Types of symptoms & severity

• Exacerbating or alleviating factors

• Use of prescribed medications

• Other treatments

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Interview – Medical History

• Do you have adequate information?
• Do you need to refer?
• General Practitioner

• Clinical Exercise Physiologist

• Dietitian

• Physiotherapist

• Other

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Interview – Medical History

• What is the relationship between exercise and the following?
• Signs & symptoms

• Behaviour

• Diagnosed condition

• What are the absolute & relative contraindications?

• Special considerations for assessment, prescription, monitoring,

psychosocial & behavioural strategies?

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“Risk” Stratification – ACSM

• Process used to identify known conditions and/or symptoms suggestive of these
conditions:

• Cardiovascular
• Metabolic

• Renal
• Specific respiratory

• Specific cancers and/or stages of cancer

• Care should be taken interpreting signs and symptoms

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Risk Stratification – ACSM

• Major Signs & symptoms:
• Pain, discomfort in the chest, neck, jaw or arms
• Shortness of breath at rest or mild exertion
• Dizziness or syncope
• Orthopnoea or paroxysmal nocturnal dyspnoea
• Ankle oedema
• Palpitations or tachycardia
• Intermittent claudication
• Heart murmur
• Unusual fatigue of shortness of breath with usual activities

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Risk Stratification – ACSM

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Known CV,

“Old” Risk Pulmonary,

Metabolic disease?

Stratification process YES NO

M ajor Signs or Sym ptom s

E.g.: Chest pain, Suggestive of CV,
SOB, Dizziness Pulm onary, M etabolic
Disease?

YES NO

E.g.: Fam ily Number of CAD

History, Age,
Risk Factors
Sm oking

≥2 <2

“High Risk” “Moderate “Low Risk”

Risk”

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Riebe et al. (2015). Updating ACSM’s recommendations for preparticipation health screening. Med Sci Sports Exerc, 47 (11):2473-9

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M a io ra n a , A . J., W illia m s, A . D ., A ske w , C . D ., L e vin g e r, I., C o o m b e s, J., V ice n zin o , B ., ... & S e lig , S . E . (2 0 1 8 ). E x e rcise p ro fe ssio n a ls w ith a d va n ce d clin ica l
tra in in g sh o u ld b e a ffo rd e d g re a te r re sp o n sib ility in p re -p a rticip a tio n e x e rcise scre e n in g : a n e w co lla b o ra tive m o d e l b e tw e e n e xe rcise p ro fe ssio n a ls a n d
p h ysicia n s. Sp o rts m e d icin e , 4 8 (6 ), 1 2 9 3 -1 3 0 2 .

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Cognitive & Behavioural Strategies

• Goal setting

• Applied learning – develop a “real-world” skill-set

• Education, demonstration, practice & feedback

• Self monitoring

• Problem solving

• Individual & social support

• Relapse prevention

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Goal Setting - SMARTS

• Specific: best options to achieve goals
• Measurable: track progression and maintenance

• Action-orientated: what needs to be done

• Realistic: should be achievable

• Timely: appropriate progression within a realistic timeframe

• Self-determined: co-created with the client

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Social Support
• Powerful source of motivation & a fundamental component of many behavioural
theories and strategies

• Sources include:
1. Instructor (you)

2. Family & friends

3. Workout partner or group

4. Health professionals or other fitness professionals

5. Others

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Social Support
• Examples of social support:

• Guidance – advice, information & demonstration

• Supportive practice – mastery experiences lead to confidence

• Reliable alliance – support from others

• Reassurance of worth – recognition of one’s competence

• Connections – emotional attachment, sense of belonging & comfort, loss of identity

• Nurturance – providing assistance to others

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Relapse Prevention
• Strong relationship with an individuals ability to utilise coping strategies

• Prepare your client for challenges

• Variable exercise responses & adaptations

• Illness
• Weather

• Competing obligations e.g. work, family & friends

• Procrastination & boredom

• Travel & vacations

1Flora
PK, Strachan SM, Brawley LR, Spink KS. (2012). Exercise identity and attribution properties predict negative self-conscious
emotions for exerciserelapse. J Sport Exerc Psychol. Oct;34(5):647-60

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Relapse Prevention

Relapse can be complex,

dynamic and unpredictable

D yn a m ic m o d e l o f re la p se (W itkie w itz & M a rla tt, 2 0 0 4 )

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Workshops
• Health screening processes
• Resting measures
This workshop will cover the
importance of taking a thorough client
interview and provide you with a
framework for your interview process

1Flora
PK, Strachan SM, Brawley LR, Spink KS. (2012). Exercise identity and attribution properties predict negative self-conscious
emotions for exerciserelapse. J Sport Exerc Psychol. Oct;34(5):647-60

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