PED027 Module 2 – Contemplation Stage
Outcomes: Upon completion of this module, the trainees shall have achieved the following
while the student, the trainees’ coach motivates them to go through the contemplation
stage of change and maintains or progresses his own fitness level:
1. Assessed their readiness to indulge in regular physical activity particularly, exercise.
2. Defined the success of their engagement in exercise with set goals and established
priorities.
3. Identified ways of controlling their lives for the success of their exercise engagement.
4. Screened themselves with the end goal of classifying themselves according to the risk
stratification for participation in exercise.
Estimated Duration: one week
STUDENT’S PLATFORM:
Teaching-Learning Activities:
ACTIVITY 1: (RELATIVE and NON RELATIVE)
For the Trainees: The student asks his trainees to accomplish the following and discusses the
outputs with them:
1. Answer the following questions:
a. Where am I now in my life? How did I get here?
b. What do I like about myself, my body? What do I not like?
c. What is it about my body and mind that I am unhappy with that could be positively
affected by exercising regularly?
d. What would I like to change, if anything, and why?
e. What is going on in my life that would facilitate behavior change? Inhibit it?
f. Where am I now in my physical activity level?
g. Have I tried regular exercise before and failed to stick with it?
h. Currently, what do I estimate my potential to stick with an exercise program to be?
i. What unmet personal needs am I thinking of attempting to meet?
j. Am I ready, really ready, to try it? Would I really like to change, even if it means giving up
something I am accustomed to?
k. Do I think that I can mobilize the mental strength if that is what I want or need to do?
l. What has my previous experience with personal health behaviour change been? Good?
Bad? Some success? None? Will that help me this time around?
m. What can I learn from experience that will help this time? Am I being realistic about this?
n. What is my self- image?
o. Do I think of myself as good-looking? Attractive? Not attractive? Healthy? Unhealthy?
p. What do I see when I look in the mirror?
q. What kinds of feelings do those images elicit?
r. If I am planning to exercise to help in weight loss or simply to shape up a currently out of
shape body, will I be able to use the facts that smaller size clothing now fits and that my
waist is getting smaller as measures of success, rather than scale weight (which might or
might not change much, even as I am redistributing body mass)?
s. And further, if I am going to exercise primarily for weight loss, is my true goal to become
really ‘‘thin,’’ rather than somewhat thinner?
ACTIVITY 2: (RELATIVE and NON RELATIVE)
2. Based on your answers to the questions above, write an essay about their readiness to
engage in exercises indicating the following:
a. SMART (Specific, Measurable, Achievable, Realistic, and Timely) Goals
b. Daily or weekly prioritized activities including its schedule
c. Ways to control factors that hamper your goals
ACTIVITY 3: (RELATIVE and NON RELATIVE)
3. Accomplish the Physical Activity Readiness Questionnaire below. The student coach will
help the trainee interpret the answers to the questions below.
ACTIVITY 4
For the Student: Continue following the ongoing exercise prescription if you have not
progressed yet. Otherwise:
1. Record your new anthropometric measurements that include:
a. Weight in kilogram
b. Body mass index
c. Waist circumference in centimeter
2. Revise your exercise prescription using the FITT format for both cardiovascular
conditioning and strengthening based on your progress at the end of the last prescription.
Use the format in Annex A.
3. Document randomly the activities by video or photograph the activities involved in the
implementation of your newly revised cardiovascular conditioning and muscular resistance
training program.
4. Tabulate the parameters obtained in each session as shown in Annexes B and C.
Basic Concept: The student discusses with the trainee these notes prior to accomplishing the
PAR-Q form by the latter.
Risks of exercising -- Putting it in perspective
Before discussing the risk of exercising, it is important to begin by asking the question, ’’Is
the person safe to remain sedentary?’’ Physical inactivity has been identified by the World
Health Organization as the fourth leading risk factor for global mortality (6% of deaths
globally).
The risks of participation in exercise range from the most common – muscle soreness and
musculoskeletal injury to the most serious – myocardial infarctions and sudden cardiac
death, which will be discussed here. Vigorous physical activity has been shown to transiently
increase the risk of sudden cardiac death and myocardial infarction (heart attack) among
individuals with both diagnosed and occult cardiac conditions. The absolute risk of sudden
cardiac death during vigorous physical activity has been estimated at one per year for every
15,000 - 18,000 people. Although these rates are low, the risk is relatively higher in
sedentary unscreened individuals who engage in unaccustomed vigorous activity. As such,
sedentary individuals who intend to exercise should begin with low to moderate intensity
exercises. For these individuals, an appropriate pre-participation screening process should
be administered to further lower the risk.
The important points on risk of exercising can be summarized below:
• Exercise generally does not provoke cardiovascular events in healthy individuals with
normal cardiovascular systems.
• Risk of sudden cardiac arrest or myocardial infarction is very low in healthy individuals
performing moderate intensity activities.
• Risk of sudden cardiac death and/or myocardial infarction increases transiently and acutely
in individuals performing vigorous exercise with diagnosed or occult cardiovascular disease.
Even in patients with known cardiac disease undergoing a supervised rehabilitation
programs, the incidence of adverse cardiac events are rare: cardiac arrest = 1 in 117,000;
non-fatal myocardial infarction = 1 in 220,000; and death = 1 in 750,000 patient-hours of
participation.
Considering the overwhelming benefits of physical activity, the risk of inactivity and the
relatively rare serious side effects of exercise, almost all patients will benefit from physical
activity; with some of them needing modifications or restrictions on their exercise program.
For patients with chronic diseases, it is important that the clinician performs a risk
stratification and exercise screening prior to initiating an exercise prescription.
Aims of Pre-Participation Health Screening
• Identify individuals with medical contraindications for exclusion from exercise programs
until these conditions have been addressed and optimized.
• Identify individuals with clinically significant disease(s) who should participate in a
medically supervised exercise programs.
• Identify individuals who are at increased risk for disease because of age, symptoms and
risk factors who should undergo further medical evaluation and exercise testing before
initiating an exercise program or increasing the frequency, intensity or the duration of the
current program.
• Identify individuals with special needs e.g. Elderly or disabled population etc. that may
affect exercise testing and programming.
A self-guided questionnaire such as the Physical Activity Readiness Questionnaire is the
recommended entry level for screening. This self-guided question screening tool is able
to quickly identify conditions or risk factors that require further assessment before
commencing exercise. If the trainees answers no to all 7 questions, he is at a LOW RISK
for health complications, and is generally safe to begin an exercise program without
supervision at any intensity. A student coach can expect to receive the New PAR-Q
from the trainees that require exercise clearance.
However, for most patients with chronic disease, the PAR-Q typically produces a positive
response for at least one of the questions. With that in mind, the algorithm presented in
the figure below outlines the screening process that the student coach and the
trainees can go through to determine the trainees risk level. This is called risk
stratification. This assessment process is based on ACSM’s recommendation available in
the eighth edition of ACSM’s Guidelines for Exercise Testing and Prescription.
Risk Stratification
The process of risk stratification is based on:
• Identifying the presence or absence of known cardiovascular, pulmonary and/or
metabolic disease.
• Identifying the presence or absence of signs and symptoms suggestive of
cardiovascular, pulmonary and/or metabolic disease. (see Table 1.1) for definition of
major signs and symptoms)
• Identifying the presence or absence of cardiovascular risk factors. (see Table 1.2 for
Cardiovascular Risk Factors Threshold)
ACSM Risk Stratification Categories
Low risk:
• No signs/symptoms of or no diagnosed cardiovascular, pulmonary and/or metabolic
disease.
• No more than one cardiovascular risk factor.
• Low risk of acute cardiovascular event.
Physical activity/exercise program may be pursued safely without the necessity of
medical examination and clearance 23
Moderate risk:
• No signs/symptoms of or no diagnosed cardiovascular, pulmonary and/or metabolic
disease.
• Two or more cardiovascular risk factors.
• Increased risk of acute cardiovascular event.
• Individuals at moderate risk may safely engage in low to moderate intensity physical
activities while awaiting medical clearance.
• Medical clearance and exercise testing prior to participation in vigorous intensity
exercise is recommended.
High risk:
• One or more signs and symptoms of or diagnosed cardiovascular, pulmonary and/or
metabolic disease.
• High risk of acute cardiovascular event.
• Thorough medical examination and clearance must be sought prior to initiation of
physical activity or exercise at any intensity.
Placement of your trainees in the HIGH, MODERATE, or LOW RISK categories helps the
student coach determine the need for further testing and supervision during exercise.
HIGH RISK: Trainees should undergo further medical testing before starting an exercise
program. Clinical supervision is recommended during exercise and stress testing.
* Clinical supervision = under the direct supervision of a health/fitness professional
possessing a combination of advanced college training and certification equivalent to
the ACSM Registered Clinical Exercise Physiologist and Exercise Specialist or above
MODERATE RISK: Tainee is safe to begin light- or moderate-intensity exercise (should
undergo further medical assessment before partaking in vigorous-intensity exercise)
Supervision by a fitness professional during exercise is often recommended (depends on
the reason for falling into this category)
* Professional supervision = under the supervision of a health/fitness Professional
possessing a combination of academic training and certification equivalent to the EIMP
Clinical Fitness Professional or above.
LOW RISK: Trainee is safe to begin exercising without further assessment. Exercise
supervision is not necessary.
It is also important to note that trainees may require supervision for reasons other than
a medical condition. These may include learning to use the exercise equipment,
familiarization with exercise technique and if either the student coach or the trainees
feels that exercising under supervision will motivate trainees to continue regular
exercise.
Algorithm for the screening process:
Important considerations for risk stratification
The algorithm serves as a guide that may be modified at the discretion of the student
coach. Some of the information may not be available to the student coach at the
screening to assess the risk level accurately. Under these circumstances, student
coach are encouraged to use existing information and make a conservative estimate of
the trainees risk level.
• If the trainees disease is well controlled e.g. metabolic or pulmonary disease such as
thyroid and asthma and other stable chronic diseases or conditions) the student will
remain at HIGH RISK; however, the intensity of his exercise may be increased at the
discretion of the relevant specialist or cardiologist.
• A trainees in the moderate risk category based on cardiac risk factors may be
progressed to LOW RISK if the risk factors resolve (e. g. quitting smoking, losing
weight, or no longer sedentary).
• Hypertensive trainees with resting SBP ≥ 200 mm Hg or DBP ≥ 110 mm Hg should
not undergo exercise testing nor be allowed to exercise. It is important to establish
blood pressure control and assess for presence of end organ disease before initiating
exercise. For asymptomatic hypertensive trainees with BP < 180/110 mm Hg and no
evidence of end organ disease, they may begin low to moderate intensity aerobic
exercises without the need for exercise testing.
• For individuals with type 2 Diabetes (T2DM) desiring to participate in low-intensity
physical activity like walking, physicians should use clinical judgment in deciding
whether to recommend pre exercise testing. Conducting exercise stress testing before
walking is unnecessary. No evidence suggests that it is routinely necessary and
requiring it may create barriers to participation.
• To avoid automatic inclusion of lower-risk individuals with T2DM, exercise stress
testing is recommended primarily for previously sedentary T2DM trainees who want to
undertake activity more intense than brisk walking. The goal is to more effectively target
individuals at higher risk for underlying cardiovascular disease. In general, ECG stress
testing may be indicated for individuals matching one or more of these criteria in the
Table 1.3 below.
For a more in-depth look at pre-participation screening, please see the National Sports
Safety Committee’s report 2007 which can be downloaded from the website below:
[Link]
losures/sports_safety_committee.[Link]/Sports_Safety _Committee_26SEPO7.pdf
In this module, we have outlined both the health risks that trainees face if they remain
inactive, as well as the risks of exercising. Although most students will benefit from
participating in regular exercise, students should be screened prior to initiating an exercise
program. For many, this will consist of the short PAR-Q, in which they are able to answer NO
to each of the questions. These students are safe to begin an exercise program of any
intensity without supervision.
For trainees who answer YES to at least one of the New PAR-Q questions, the screening
process needs to continue to assess their level of risk. The risk level (low, moderate, or high)
that the student is assessed at will determine:
a. Whether he needs further medical assessment prior to beginning an exercise program.
b. The intensity at which he is safe to exercise.
c. Whether he needs supervision during his physical activity.
