Evidence-based risk recommendations for best practices in the training of qualified exercise professionals working with clinical populations 1

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1 S232 REVIEW / SYNTHÈSE Evidence-based risk recommendations for best practices in the training of qualified exercise professionals working with clinical populations 1 Darren E.R. Warburton, Shannon S.D. Bredin, Sarah A. Charlesworth, Heather J.A. Foulds, Don C. McKenzie, and Roy J. Shephard Abstract: 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. Key words: physical activity, exercise professionals, exercise testing, exercise training, chronic disease, preventive medicine, rehabilitation. Résumé : Cette analyse documentaire traite de façon critique des «meilleures pratiques» dans la formation des professionnels qualifiés de l exercice. On porte une attention spéciale aux compétences de base et aux exigences en matière de formation pour œuvrer auprès de populations cliniques. On saisit l information pertinente au moyen d une recherche systématique dans 6 bases de données électroniques, d une vérification de concordance et des connaissances des auteurs dans le domaine. On détermine aussi le niveau et la qualité des données probantes. Au total, nos critères d acceptabilité nous font retenir 52 articles traitant des meilleures pratiques et (ou) des compétences de base en physiologie de l exercice clinique. Globalement, la documentation courante confirme la nécessité de professionnels qualifiés de l exercice, de l exigence d une certification de niveau supérieur et d une formation en sciences de l exercice s adressant particulièrement aux populations à risque. La documentation courante justifie l aspect sécuritaire et efficace des tests d effort et des programmes d entraînement des populations cliniques sous la supervision d un physiologiste de l exercice. Mots clés : activité physique, professionnel de l exercice, test d effort, programme d entraînement, maladie chronique, médecine préventive, réadaptation. [Traduit par la Rédaction] Introduction and study rationale Regular physical activity is important in the primary, secondary, and tertiary prevention of at least 25 chronic conditions (Mazzeo et al. 1998; Blair and Brodney 1999; Blair et al. 1989, 2001; Bouchard and Shephard 1994; Lee and Skerrett 2001; McAuley 1994; Paffenbarger et al. 1986; Puett and Received 10 March Accepted 12 April Published at on 29 July D.E.R. Warburton, S.A. Charlesworth, and H.J.A. Foulds. Cardiovascular Physiology and Rehabilitation Laboratory, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; Experimental Medicine Program, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; Physical Activity and Chronic Disease Prevention Unit, Cognitive and Functional Learning Laboratory, University of British Columbia, Vancouver, BC V6T 1Z3, Canada. S.S.D. Bredin. Physical Activity and Chronic Disease Prevention Unit, Cognitive and Functional Learning Laboratory, University of British Columbia, Vancouver, BC V6T 1Z3, Canada. D.C. McKenzie. School of Kinesiology and Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 1Z3, Canada. R.J. Shephard. Professor Emeritus, University of Toronto, 55 Harbord St, Toronto, ON, M5S 2W6, Canada. Corresponding author: Darren E.R. Warburton ( darren.warburton@ubc.ca). 1 This 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. Appl. Physiol. Nutr. Metab. 36: S232 S265 (2011) doi: /h11-054

2 Warburton et al. S233 Griffin 1994; Shephard 2001; Taylor et al. 2004; US Department of Health and Human Services 1991; Warburton et al. 2001a, 2001b, 2006a, 2006b, 2010). Chronic diseases particularly associated with physical inactivity include coronary heart disease, stroke, hypertension, breast cancer, colon cancer, type 2 diabetes mellitus, and osteoporosis (Warburton et al. 2007c, 2010). Physical inactivity has also been linked to the development of obesity, arthritis, and several psychological disorders (Katzmarzyk and Janssen 2004; Warburton et al. 2006a, 2006b). The risks associated with inactivity are thus substantial. Questionnaire-based studies suggest that physically active men and women have at least 20% 35% lower risks of all-cause and cardiovascular-related mortality than their inactive peers (Warburton et al. 2007c, 2010), and even greater risk differentials (>50%) are observed in investigations using objective measures of aerobic fitness. Findings are similar for other chronic conditions (Warburton et al. 2007c), with risk differentials of approximately 20% for breast cancer, 30% for colon cancer, and 40% 60% for diabetes (Warburton et al. 2007c, 2010) in regularly active individuals. Habitual physical activity is effective in reducing the risks of premature all-cause and disease-specific mortality in patients with established chronic diseases (including cardiovascular disease, breast cancer, and diabetes) (Warburton et al. 2007c). Physical activity interventions also have a widely demonstrated ability to improve the health status and quality of life in both healthy individuals and those with chronic disease (Warburton et al. 2006a, 2006b, 2007c). Moreover, as discussed in the companion articles (Chilibeck et al. 2011; Eves and Davidson 2011; Goodman et al. 2011; Jones 2011; Rhodes et al. 2011; Riddell and Burr 2011; Thomas et al. 2011; Zehr 2011), the risks of a well-designed and appropriately supervised exercise intervention are relatively low, both for healthy individuals and for those with chronic disease (Pavy et al. 2006). Indeed, the continuing risks of being physically inactive far outweigh the transient risks of participating in a well-designed and appropriately supervised conditioning program (Warburton et al. 2010). Given the established health benefits of physical activity, there is clearly a need for exercise professionals who can provide appropriate programming (Franklin et al. 2009). However, the levels of experience and formal qualification needed to serve various populations (particularly those with chronic disease) remains to be clarified. Unfortunately, the field is as yet relatively unregulated, and a variety of companies and organizations can bestow certificates that apparently qualify individuals for this class of professional activity (Gillespie 1993). Numerous companies and organizations across the world claim that their certified or registered members have appropriate skills to work with a myriad of populations, including the high performance athlete, the elderly, the recently injured, and individuals with chronic disease; often, there is no requirement for advanced education in the exercise sciences and (or) clinical exercise physiology. The growth of for-profit organizations that gain financially from such certifications registrations is a particular concern (Warburton et al. 2007a, 2007b). The issue is not entirely new. As early as 1993, Gillespie wrote that the time has come for mandatory registration and licensure of practicing exercise professionals (Gillespie 1993). Unfortunately, most of the general population have great difficulty in discerning the level of training, education, and experience of those staffing health and fitness centres (Gillespie 1993; Warburton et al. 2007a, 2007b). Currently, the individual client must often make the difficult decision as to whether the qualifications are adequate. Lack of information on acceptable levels of training and competency coupled with the freedom of unqualified individuals to promote their services to the general public create a potentially dangerous situation (Warburton and Bredin 2005), particularly when dealing with moderate- to high-risk populations (as reviewed in the companion papers). Accordingly, our primary purpose is to provide evidence-based recommendations on the best practice in clinical exercise physiology, noting the core competencies, educational attainments, and practical experience needed to serve individuals with chronic disease. Our paper builds on the systematic reviews created for revision of the PAR-Q and PARmed-X, highlighting various conditions where there is irrefutable evidence that services should be provided by appropriately certified exercise professionals. A brief review of recent litigation involving fitness professionals also provides insight into the medico-legal requirements of being a qualified exercise professional. Methods Criteria used in selecting studies for this review Our research team used a systematic, evidence-based approach to look critically at the current levels of evidence relating to best practice in clinical exercise physiology and rehabilitation. The Medical Subject Headings (MeSH) were kept broad (Table 1 summarizes the search strategy and the key words that were used). We also made a search of case law relating to incidents of personal injury and (or) ordinary negligence lawsuits brought against exercise professionals. Only published, English language studies were included, but no restrictions were imposed in terms of study design. Our analyses thus included original research, major systematic reviews, meta-analyses, and consensus statements; a preponderance of the literature reflected expert opinion. Search strategy Literature searches were conducted using 6 electronic databases MEDLINE (1950 October 2010, OVID Interface), EMBASE (1980 October 2010, OVID Interface), CINAHL (1982 October 2010, OVID Interface), PsycINFO (1840 October 2010, Scholars Portal Interface), Cochrane Library ( October 2010), SPORTDiscus ( October 2010, OVID Interface). Search strategies were developed and conducted by researchers experienced with systematic reviews of the literature (D.E.R.W and S.A.C.). The citations and electronic versions of the articles (when available) were downloaded to an online research management system (RefWorks, Bethesda, Maryland, USA). Screening Two reviewers (S.A.C. and I.V.) independently screened the titles and abstracts of citations to identify articles for potential inclusion. The reviewers were not blinded to either au-

3 S234 Appl. Physiol. Nutr. Metab. Vol. 36, 2011 Table 1. Results of the MEDLINE literature search (1950 to October week ). MEDLINE search no. Key words No. of hits 1 Exercise professionals.mp Exercise physiologists.mp Healthcare professionals.mp Exercise scientists.mp or 2 or 3 or Staffing requirements.mp Emergency training.mp Competence/ or core competencies.mp Exercise standards.mp Testing training.mp Testing.mp Training/ 0 13 Supervised programs.mp Cardiac rehabilitation.mp. or heart rehabilitation/ Medical supervision.mp Training qualifications.mp Scope of practice/ , 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, or Asymptomatic populations.mp Clinical populations.mp or and 18 and and Limit 24 to (human and English language) 412 thors or journals. Duplicate citations were first removed. Bibliographies from key studies and reviews, together with personal files, were searched for additional articles. The full text of apparently relevant articles was obtained and data were extracted using a common template. In the event of disagreement, a full (100%) consensus was achieved in discussion with a third reviewer (D.E.R.W). Studies that were excluded during this screening process were recorded, along with reasons for the exclusion. Data extraction Two reviewers (S.A.C. and I.V.) completed the standardized data extraction forms, and their annotations were verified by 2 other reviewers (D.E.R.W. and S.S.D.B.). The collated information included the study design, the country where the study was conducted, participant characteristics, sample size, study objectives, methodologies, major outcomes, and the comments and conclusions that were reached. Level of Evidence The Level and Grade of Evidence favouring advanced education and training in exercise physiology was established based on pre-defined and objective criteria (Table 2), using the approach adopted when creating the Canadian clinical practice guidelines on the management and prevention of obesity in adults and children (Lau et al. 2007). The grading of each article provides information on how advanced exercise physiology training is effective and necessary for the testing and rehabilitation of patients with chronic disease (Table 2). Where applicable, this grading also informs the reader about the potential risks of inadequate training. Studies receiving the highest grading indicate clearly that the benefits outweigh the risks and make a strong recommendation for such training. Results A total of 2383 citations were identified during the electronic database search (Fig. 1): 412 in MEDLINE, 568 in EMBASE, 62 in Cochrane, and 1341 in the CINAHL Sport- Discus PsychInfo search. Seven hundred and sixty-four were duplicates, leaving 1619 unique citations. Of these articles, 1448 were excluded after scanning the titles for relevance. After assessing abstracts of the 171 remaining articles, a further 83 were excluded, leaving 88 for full review. Reasons for exclusion included lack of relevance (n = 42), other (n = 13), and unable to retrieve the article (n = 2). An additional 21 articles were added from the authors knowledge and personal files, yielding an ultimate total of 52 articles that were included in the systematic review of the literature. Importance of qualified exercise professionals in clinical exercise physiology Qualified exercise professionals are playing important roles in the exercise testing and training of healthy asymptomatic and clinical (symptomatic) populations in a variety of settings (Franklin et al. 2009), including a large body of randomized controlled trials and pre- and (or) postinterventions (as noted in the companion systematic reviews). Qualified exercise professionals have assumed increasingly the role of the primary specialist conducting clinical exercise stress tests; generally, they work in a medical setting with a physician in close proximity and with rapid access to emergency equipment needed to treat adverse events (Franklin et al. 2009). However, de-

4 Warburton et al. S235 Table 2. The Level and Grade of Evidence scale criteria applied to articles. Level of Evidence Level 1 Level 2 Level 3 Level 4 Grade of Evidence Grade A Grade B Grade C Criteria Randomized control trials without important limitations Randomized control trials with important limitations Observational studies (nonrandomized clinical trials or cohort studies) with overwhelming evidence Other observational studies (prospective cohort studies, case-control studies, case series) Inadequate or no data in population of interest Anecdotal evidence or clinical experience Strong recommendation (action can apply to most individuals in most circumstances) Benefits clearly outweigh risks (or vice versa) Evidence is at Level 1, 2, or 3 Weak recommendation (action may differ depending on individual s characteristics or other circumstances) Unclear whether benefits outweigh risks Evidence is at Level 1, 2, or 3 Consensus recommendation (alternative actions may be equally reasonable) Unclear whether benefits outweigh risks Evidence is at Level 3 or 4 Fig. 1. Results of the literature search using the key words shown in the text. Citations from electronic database search: MEDLINE 412 EMBASE 568 Cochrane 62 CINAHL SportDiscus PsycInfo 1341 Total Citations Downloaded to RefWorks: Total in RefWorks 2383 Total with duplicates excluded ( N=1619) Abstracts assessed for eligibility after scanning titles ( N=171) Citations excluded after scanning titles ( N=1448) Full articles assessed for eligibility after scanning abstracts ( N=88) Citations excluded after scanning abstracts ( N=83) Articles excluded after full review ( N=57) Reasons: - Not relevant ( N=42); - Other ( N=13) - Unable to locate ( N=2) Articles Included ( N=31) plus ( N=21) articles added based on authors knowledge of area Total = 52 bate continues as to whether direct physician supervision of clinical stress testing is required (Zecchin et al. 1999). In 1995, the American Heart Association (AHA) (Pina et al. 1995) declared that direct physician supervision was required for patients at higher risk; however, an appropriately trained healthcare professional (including an exercise specialist) could monitor the testing and recovery of lower risk patients if a physician was readily available. The American College of

5 S236 Appl. Physiol. Nutr. Metab. Vol. 36, 2011 Sports Medicine (ACSM) accepted that trained paramedical staff (such as qualified exercise physiologists) could also conduct stress testing in higher risk patients if a physician was in close proximity (ACSM 2006a; Franklin et al. 2009). Current American College of Cardiology AHA guidelines also indicate that exercise testing can be performed safely by properly trained paramedical professionals working under the supervision of a physician, who should be in the immediate vicinity (Gibbons et al. 2002). As discussed by several authors (Franklin et al. 2009; Knight et al. 1995; Zecchin et al. 1999), specially trained allied health professionals (including exercise physiologists) increasingly conduct clinical exercise stress testing, in sharp contrast to clinical practice prior to 1980, when as many as 93% of tests were supervised directly by physicians (Stuart and Ellestad 1980). Our systematic review disclosed 19 articles that examined the risks associated with exercise stress testing (Table 3). One study (de Paola et al. 1995) examined the incidence of exercise-induced ventricular arrhythmias in patients with chagasic cardiomyopathy who performed a Bruce treadmill test; it found ventricular tachycardia in 44 of 69 patients (64%) during exercise testing (5 sustained and 39 nonsustained episodes). Owing to the special nature of this sample and the markedly disparate findings, we have not included this study in our summary analyses. The remaining 18 articles were published over a 34-year period, from 1971 to 2005; a total of test results were reported, averaging tests per study (median = ; range ). The total incidence of adverse events was 390 (as expressed per tests), with a total mortality of 17.9 (per tests); however, the median score for nonfatal adverse events was 3.2 per tests, with 0.0 deaths per tests. It should be highlighted that these studies involved many high risk participants living with a chronic disease (particularly cardiovascular disease) (Table 3). The overall findings are similar to those established by Goodman et al. (2011), although the earlier report included studies that did not identify clearly the qualifications of the personnel conducting the tests. A summary of available findings from nonphysician supervised exercise testing is provided in Table 3. To our knowledge, no randomized controlled trials have compared the incidence of adverse events between physician and nonphysician supervised stress testing. However, a large body of observational and pre- and post- (Level 2 3) studies show no significant differences between direct physician and nonphysician administered clinical exercise stress testing; there seems compelling evidence that paramedical staffing (including qualified exercise professionals) does not increase the risks of clinical stress testing, provided that appropriate training, resources, and emergency procedures are available (Shephard 1991). Recommendation no. 1: Clinical exercise stress testing can be conducted by qualified exercise physiologists (i.e., university-trained exercise physiologists with advanced training and certification) if a physician and emergency response equipment are readily available (Level 2, Grade A). Core competencies of the qualified exercise professional Although clinical exercise physiology remains largely unregulated, qualified exercise professionals are considered as important allied health professionals (American Heart Association 1994; Franklin et al. 2009) and are increasingly essential members of the interdisciplinary health care team (Brehm et al. 1999; Rutledge et al. 1999; Tong et al. 2001). As such, general best practices for other allied health professions also apply to qualified exercise professionals. A committee of the Institute of Medicine of the National Academies (Greiner and Knebel 2003) evaluated critically the core competencies required for health care professionals, including those trained in medicine, nursing, pharmacy, and allied health professions. Their discussions provide an important insight into the requisite competencies of exercise professionals who are working in clinical settings (Table 4). The committee recommended All health care professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics (Greiner and Knebel 2003). Allied health professionals arguably need many core competencies. However, the authors of this report indicated that 5 general competencies were particularly relevant for health care professionals (regardless of discipline). From the perspective of best practice, it seems prudent to recommend that qualified exercise professionals be required to adhere to these standards. Allied health professions (such as physiotherapy, exercise physiology, occupational therapy, and massage therapy) have overlapping scopes of practice. However, it is also clear that each of these disciplines brings a specialized expertise to patient care. The qualified exercise professional possesses clear profession-specific core competencies (Franklin et al. 2009); their particular training and expertise is focused on acute and chronic responses to exercise in asymptomatic and symptomatic populations (Franklin et al. 2009). We conducted a systematic review of the available literature on the core competencies needed for clinical exercise testing and prescription. Unfortunately, little has been published regarding the specific competencies required by exercise professionals working in clinical settings. Information to date is often opinion-based (Boone 1998), with limited discussion of the key core competencies required to deal safely and effectively with clinical populations (American Heart Association 1994; Balady et al. 1998, 2000; Fletcher et al. 1995, 2001). Nevertheless, a critical review of the literature identifies important key requirements. A series of papers (Franklin et al. 1997, 2009) and texts include seminal work by the ACSM (ACSM 2006a, 2006b) and the Canadian Society for Exercise Physiology (CSEP 2007). Also, other authoritative national bodies have outlined core competencies required for qualified exercise professionals who seek to work with clinical populations in their respective countries (for instance, the Australian Association for Exercise and Sports Science (AAESS 2007) and the British Association of Sport and Exercise Sciences (BASES 2008) (Table 5)). These requirements provide the foundation for clinical certification (Table 4); they have been progressively revised as the evidence-base has increased. Early recommendations (consensus based; Level 4, Grade C) developed standards for the exercise testing and training of asymptomatic and symptomatic populations (1994; Fletcher et al. 1995, 2001), thus establishing guidelines for the future training of exercise professionals. In 1990, the

6 Table 3. Complication rates with exercise stress testing conducted by physicians and nonphysician specialists. The listing includes only those studies that identified the level of training of personnel conducting clinical exercise stress testing. Reference Year Stress tests Exercise-related adverse events (per ) Mortality (per ) Total complications (per ) Health professional supervisor Participant group Atterhög et al Physicians High- and low-risk patients Bruce et al Physicians High- (45%) and low- (55%) risk patients Cahalin et al Physical therapists Patients with CAD (41%); high-risk (8%) and low-risk (51%) patients without CAD DeBusk Nurses Patients Franklin et al Exercise physiologists or nurses High- (15% 20%) and low- (80% 85%) risk individuals Gibbons et al Physicians High- ( 3%) and low- ( 97%) risk patients Irving and Bruce Physicians High- (45%) and low- (55%) risk patients Karha et al Physicians High-risk patients with unstable angina pectoris or non-st elevation myocardial infarction Knight et al Exercise physiologists Individuals of all ages Lem et al Nurses Patients Madriago et al Physician assistants Hospital outpatients: high- (0.5%), moderate- (31%), and low- (68.5%) risk Rochmis and Blackburn Physicians Patients Scherer and Kaltenbach Physicians Athletes Scherer and Kaltenbach Physicians Patients with coronary heart disease Squires et al Exercise physiologists Patients with chronic heart failure or nurses Stuart and Ellestad Physicians Patients Young et al Physicians Patients with malignant ventricular arrhythmias Young et al Physicians Low-risk patients Zecchin et al Nurses Higher risk patients Zoller and Boyd Physicians Patients Total Average Median Minimum Maximum Range Note: Adverse events include life-threatening events. CAD, cardivascular disease. Warburton et al. S237

7 Table 4. Recommended core competencies of an allied health professional and (or) a qualified exercise professional. Organization or author(s), country (Reference) Title Recommended core competencies ACSM, USA (ACSM 2010b) ACSM, USA (ACSM 2010a) American Association of Cardiovascular and Pulmonary Rehabilitation, USA (Southard et al. 1994b) ACSM-registered clinical exercise physiologist ACSM exercise specialist Cardiac rehabilitation professionals Knowledge of cardiovascular and pulmonary disease, metabolic disease, orthopaedic musculoskeletal disease, neuromuscular disease, and immunological haematological disease Experience working with individuals with controlled cardiovascular pulmonary and (or) metabolic disease Knowledge and experience performing clinical exercise testing Knowledge of interpretations of exercise testing Knowledge and ability to interpret ECGs at rest and during exercise Experience developing complex exercise prescriptions Experience performing exercise counselling Minimum Requirements Master s degree from college or university in exercise science, exercise physiology, or kinesiology Current basic life support provider or CPR for the Professional Rescuer ACSM Exercise Specialist Certification or 600 h of clinical experience Knowledge and experience working with clinical populations as follows: 200 h experience in clinical cardiovascular 100 h experience in clinical pulmonary 120 h experience in clinical metabolic 100 h experience in clinical orthopaedic musculoskeletal 40 h experience in clinical neuromuscular 40 h experience in clinical immunological hematological Knowledge of cardiovascular and pulmonary physiology Knowledge of metabolic disease Experience working with individuals with controlled cardiovascular pulmonary and (or) metabolic disease Knowledge and experience performing clinical exercise testing Knowledge of interpretations of exercise testing Knowledge and ability to interpret ECGs at rest and during exercise Minimum requirements Bachelor s degree in kinesiology, exercise science or other exercise-based degree Course work in anatomy, physiology, and minimum 18 credits in exercise science course work, including courses in exercise physiology, biomechanics (kinesiology), exercise prescription, and fitness testing Practical experience in a clinical exercise program Minimum 400 h from a COAES accredited university curriculum program or Minimum 500 h from a non-coaes accredited university curriculum program Current certification as basic life support provider or CPR for the professional rescuer Discipline specific core competencies Organized according to 4 major clinical process categories: Needs assessment Goal setting Intervention Outcome evaluation Each clinical process category was subdivided into additional groups including: Pathophysiology and comorbidity Professional communication S238 Appl. Physiol. Nutr. Metab. Vol. 36, 2011

8 Table 4 (continued). Organization or author(s), country (Reference) Title Recommended core competencies Standards of practice Restoration of functional capacity Biopsychosocial Risk factor management Emergency procedures American Association of Cardiovascular and Pulmonary Rehabilitation, USA (Southard et al. 1994a) AHA, USA (Fletcher et al. 1990) AHA, USA (Fletcher et al. 1995) Pulmonary rehabilitation professionals Individuals who provide exercise testing and training to persons with and without cardiovascular disease Physician-specific Health care professionals (who provide exercise testing and training) Extensive reference to exercise physiology in restoration of functional capacity Discipline specific core competencies Organized according to 3 major clinical process categories: Assessment Intervention Outcome evaluation and follow-up Each clinical process category was subdivided into additional groupings including: Pathophysiology and comorbidity Professional communication Patient education and training Exercise Psychosocial Emergency procedures Extensive reference to exercise physiology in exercise section Discipline specific core competencies Knowledge of the absolute and relative contraindications to exercise testing Knowledge of exercise physiology Knowledge of the absolute and relative indications for terminating exercise testing Knowledge regarding the normal and abnormal responses during exercise Knowledge of effective emergency procedures including the ability to provide cardiopulmonary resuscitation The ability to measure blood pressure The ability to use and interpret 12-lead ECG, including the capacity for proper skin preparation and electrode placement Knowledge of effective exercise prescription for apparently healthy individuals and patients with cardiovascular disease Knowledge of the risks associated with exercise The authors updated the previous work (Fletcher et al. 1990) regarding the qualifications of health care professionals who provide exercise testing and (or) training. They stated that exercise testing should be conducted only by well-trained personnel with a basic knowledge of exercise physiology. Only technicians and physicians familiar with normal and abnormal responses during exercise can recognize or prevent untoward events. Equipment, medications, and personnel trained to provide cardiopulmonary resuscitation (CPR) must be readily available. Cardiac rehabilitation sessions involving continuous ECG monitoring should be conducted by personnel who understand the exercise principles involved and have a basic knowledge of electrocardiography. The sessions should also be supervised by either a physician or a nurse trained in emergency CPR, preferably with previous experience in intensive cardiac care. Warburton et al. S239

9 Table 4 (continued). Organization or author(s), country (Reference) Title Recommended core competencies AHA, USA (Fletcher et al. 2001) American Society of Exercise Physiologists, USA (Boone 2003) AAESS, Australia (AAESS 2007) Health care professionals (who provide exercise testing and training) Exercise physiologist AEP The authors updated the previous work (Fletcher et al. 1995) regarding the qualifications of health care professionals who provide exercise testing and (or) training. They stated that exercise testing should be conducted only by well-trained personnel with a sufficient knowledge of exercise physiology. Only technicians, physiologists, nurses, and physicians familiar with normal and abnormal responses during exercise can recognize or prevent adverse events. Equipment, medications, and personnel trained to provide advanced cardiopulmonary resuscitation (CPR). Cardiac rehabilitation sessions involving continuous ECG monitoring should be conducted by personnel who understand the exercise principles involved and have a working knowledge of electrocardiography and arrhythmia detection. The sessions should also be supervised by either a physician or a nurse trained in emergency CPR, preferably with previous experience in intensive cardiac care. Such individuals should have recently completed an AHA-sponsored course in advanced cardiac life support Monitored sessions should also include symptom assessment by the staff, blood pressure recording, the subject s rating of perceived exertion, and instructions to subjects about selection and proper use of exercise equipment. ECG-monitored sessions should include instruction for different modes and progressions of exercise. Through a series of commentaries the American Society of Exercise Physiologists has outlined the importance of advanced training in exercise physiology. Some of the key areas include Degree with course work in functional anatomy, chemistry, physics, biology, nutrition, computer science, exercise physiology, applied exercise physiology, psychophysiology of health and exercise, physiological assessment, cardiac rehabilitation, sports biomechanics, sports nutrition, advanced exercise physiology, electrocardiography, stress testing, research design, and data collection The AAESS provides a series of criteria for the accreditation as an AEP. A general summary of the areas required is provided below. In addition to these criteria is the requirement for a minimum of 500 h of clinical practice. Applicants are required to exhibit 2 broad types of criteria including knowledge (i.e., processing and understanding information ) and application (i.e., using new knowledge to develop skills and competencies for practice as a clinical exercise practitioner ). Knowledge of Chronic disease management and functional conditioning Applicable AAESS Code of Professional Conduct and Ethical Practice, legislation and compensation, ability to deliver appropriate Workers Compensation and Compulsory Third Party services Pathological and pathophysiological conditions, and common clinical outcomes of common surgical, medical, and allied health treatments of these conditions Stages of disease, risk factors, complications, and comorbidities Common surgical, medical, and allied health treatments effects on exercise responses Common medications prescribed clinical conditions and their effects on exercise responses Screening for exercise clearance and appropriate exercise for clinical populations Evidence-based exercise effects for clinical populations Safe exercise limits for individuals with angina, claudication, dyspnoea, light headedness syncope Adverse signs and symptoms that may arise during exercise or recovery, including recognition of vaso-vegal episodes, hypotension hypertension related to exercise, ischaemia, depleted breathing reserve, general or localized fatigue, cardiopulmonary arrest, neurological neuromuscular target pathologies symptoms, autonomic dysreflexia, elevated core temperature, hypoglycaemia, hyperglycaemia Blood tests of glucose tolerance, random blood glucose, fasting blood glucose, A1C, total cholesterol, HDL, LDL, and triglycerides cholesterol Applied movement analysis, loading characteristics of tissue with and without pathology Communication and other cognitive, emotional and social processes that could be affected by neurological neuromuscular target pathologies or mental health disorders S240 Appl. Physiol. Nutr. Metab. Vol. 36, 2011

10 Table 4 (continued). Organization or author(s), country (Reference) Title Recommended core competencies Issues concerning exercise with cancer patients following chemotherapy, radiotherapy, surgery, and other treatments before blood tests, after prolonged bed rest, and in conjunction with medications used to treat cancer patients Acute musculoskeletal pain injuries, medical emergencies, including new or worsening pain or neurological deficit, failure to achieve expected gains in exercise capacity Appropriate leadership, interpersonal communication skills Experience of Exercise capacity, functional capacity, functional conditioning and occupational rehabilitation testing, exercise testing, and exercise prescription, including designing and implementing exercise programs with clinical populations Monitoring and interpreting: self-report, heart rate and rhythm, oxygen saturation, blood pressure, breathing, balance and movement, obstructive airway patterns, FVC, FEF peak, FEV 1, predicted or measured MVV, _V E at peak exercise, breathing reserve, exercise-induced asthma, O 2 sat% during rest, exercise, and recovery Interpreting electrocardiography 12-lead ECG at rest, exercise, and recovery, including common patterns such as ectopy, atrial fibrillation, atrial flutter, sinus block arrest, electrolyte disturbances, digitalis toxicity, atrio-ventricular blocks, bundle branch blocks, axis deviations, real vs. pseudo ST depression in exercise, pre-excitation syndrome, ventricular tachycardias, ventricular fibrillation and cardiac arrest, symptomatic brady-arrhythmias, and symptomatic tachy-arrythmias Progressively varying tissue loading characteristics in response to specific pathology, physical status or work demand task and BASES, United Kingdom (BASES 2008, 2010) BASES accredited sport and exercise scientist (physiology specialism) experience developing loading strategies for tissue with and without specific pathology The BASES outlines a series of specific core competencies that are required for BASES accredited sport and exercise scientist (with physiology specialty). Below is a summary of the items, for further information refer to the main source (BASES 2010). Scientific knowledge Be able to demonstrate a detailed scientific knowledge and understanding relevant to the domain of expertise Technical skills Be able to demonstrate full understanding and application of relevant scientific techniques Application of knowledge and skills Ability to demonstrate the application of knowledge and technical skills to the relevant delivery environment Understanding and use of research Be able to demonstrate a training in research which enables the understanding and application of research findings Self Evaluation and professional development Ability to self reflect, take responsibility for own actions, and to demonstrate that continuous professional development occurs Communication Ability to communicate orally and in writing to colleagues, peers, and clients Management of self, others and practice Be able to demonstrate an understanding of management requirements and to mange self and others Understanding of the delivery environment Be able to demonstrate a knowledge of and integration into the specific delivery environment Professional relationships and behaviours Be able to demonstrate adherence to the highest standard of ethical and professional behaviour and team work in working with colleagues and clients Warburton et al. S241

11 Table 4 (continued). Organization or author(s), country (Reference) Title Recommended core competencies BACR, United Kingdom (BACR 2010) Exercise professionals working in cardiac rehabilitation Essential competencies Specific experience, knowledge, and skills are required to lead a safe and effective exercise component within a cardiac rehabilitation program. These essential competences are listed below and may be met by 1 exercise professional that has all these competences and therefore can lead the exercise component, or may be met collectively by the CR team, including the exercise professional Experience of Delivering exercise in a cardiac rehabilitation environment Planning, leading, and evaluating exercise sessions for the cardiac population Working effectively as a team member Knowledge of Relevant national standards, policies, and guidelines, and application to practice in this field Health-related benefits of regular physical activity and exercise An applied understanding of cardiovascular anatomy and exercise physiology and principles of exercise prescription for cardiovascular training Coronary heart disease (including signs and symptoms and recognition of progression of disease) and its implications for risk stratification and exercise programming A range of cardiovascular conditions and comorbidities encountered on a typical cardiac rehabilitation programme; the programming adaptations and contraindications to exercise Cardiovascular medications and any exercise-related considerations Common cardiac investigations and interventions and relevance of results to exercise programming The process of behaviour change and appropriate models and strategies that are used to assess a patient s current state of physical activity behaviour and support change towards achieving long term adherence to a physically active life Skills and abilities to Make clinical decisions regarding the suitability, eligibility and adaptability of each patient s exercise programme (clinical leadership) Conduct screening and a comprehensive assessment, including interpretation of clinical investigations, and conduct appropriate submaximal tests to provide a baseline assessment of functional capacity and apply these findings to exercise programming Risk stratify and prescribe safe and effective exercise programs that are appropriately individualized Competently lead and instruct the exercise component Monitor, evaluate, and adapt an individual s exercise program while considering comorbidities and the complexity of their cardiac condition Respond and manage emergency situations, including cardiac arrest (i.e., hold an appropriate qualification a minimum of immediate life support ) Choose and use appropriate educational, counselling, and motivational techniques with individuals and groups of patients to guide individuals to be physically active Give appropriate evidence-based advice for discharge planning in relation to long term activity goals independent activity S242 Appl. Physiol. Nutr. Metab. Vol. 36, 2011

12 Table 4 (continued). Organization or author(s), country (Reference) Title Recommended core competencies Buser et al., USA (Buser and Kornspan 2004) CACR, Canada (CACR 2009) CSEP, Canada (CSEP 2009) Exercise physiologist (working in cardiac rehabilitation settings) Exercise therapist CSEP certified exercise physiologist The preparation of exercise physiologists (working in cardiac rehabilitation settings) should include advanced training in exercise prescription, supervision and monitoring, stress testing, blood pressure measurement, ECG monitoring, and heart rate monitoring Exercise physiologists should also receive training in conducting entrance assessment and patient interviews The authors also demonstrated that most cardiac rehabilitation programs provided internships for exercise physiologists. Some also required the completion of clinical internships prior to hiring Advanced certifications (such as that provided by the ACSM) and ACLS and CPR BLS certification was also often required by employers Primary responsibilities Develop exercise prescriptions, including exercise progression and home programs Design and supervise exercise sessions Assist in patient, client, and family education Provide ongoing psychosocial and motivational support in exercise class Assist in safety features of the class, including checking medications and compliance to prescribed exercise program Provide ongoing support for risk factor management Provide exercise stress testing services in coordination with medical staff Assess program participants for signs and symptoms of cardiovascular distress, and assist participant in self-evaluation Monitor the patients response to exercise Provide leadership in emergency procedures Maintain effective communications with all team members Participate in multidisciplinary team meetings regarding planning, implementation, and revision of patient care programs Function as an educational resource for patients, families, and team members Maintain clear and concise patient care records Participate in clinical research and program evaluation in the areas of CR and CVD prevention Provide motivational support to patients and families regarding long-term behaviour modification CSEP has created a comprehensive outline of the core competencies and training required for CSEP Certified Exercise Physiologists. Below is a general outline of these areas Generalized core competencies Data management and analysis Health promotion and disease prevention Client education Professional practice Outcome evaluation Discipline specific core competencies Anatomy and biomechanics Exercise physiology Human development and aging Physical fitness assessment applications for health, function, and work or sport Physical activity and exercise prescription applications for health, function, and work or sport Nutrition and weight management Psychosocial aspects of human behaviour in relation to physical activity, exercise, rehabilitation, and exercise therapy Warburton et al. S243

13 Table 4 (continued). Organization or author(s), country (Reference) Title Recommended core competencies Physical activity exercise strategies and considerations for persons with chronic diseases, functional limitations, and disabilities associated with musculoskeletal conditions, cardiopulmonary conditions, metabolic conditions, neuromuscular conditions, and aging conditions Pharmacology: commonly used agents for persons with chronic diseases, functional limitations, and disabilities associated with cardiopulmonary metabolic conditions, musculoskeletal conditions, neuromuscular conditions, and aging Evaluation: additional procedures for persons with chronic diseases, functional limitations, and disabilities associated with cardiopulmonary metabolic conditions, musculoskeletal conditions, neuromuscular conditions, and aging Davis et al., USA (Davis et al. 2001) Elder et al., USA (Elder et al. 2003) Fletcher et al., USA (Fletcher et al. 1995, 2001) Franklin et al., USA (Franklin et al. 1997) Franklin et al., USA (Franklin et al. 2009) Gillespie, USA (Gillespie 1993) Gutin et al., USA (Gutin et al. 1986) Exercise physiologist (working in cardiac rehabilitation settings) Exercise scientist Health care professionals (including exercise physiologists responsible for clinical exercise stress testing) Paramedical staff (including exercise physiologists) responsible for clinical exercise stress testing Clinical exercise physiologists Clinical exercise physiologists Exercise physiologists (working in clinical exercise testing) Clinical exercise prescription The exercise physiologist should have training in basic life support, advanced cardiac life support, CPR, exercise prescription, exercise physiology, human physiology, and nutrition The authors evaluated 235 institutions with exercise science undergraduate programs to determine their adherence to curricular guidelines and the competencies required of various professional organizations. Through this process a series of areas were deemed important for the training of the undergraduate exercise scientist. The authors argued that the exercise curricula should include appropriate field experience in addition to training in exercise prescription, health promotion, exercise testing and implementation, emergency safety, exercise physiology, biomechanics, human anatomy, human physiology, nutrition, and resistance training The authors reviewed the revised standards and guidelines for exercise testing and training. These guidelines are addressed to all health care professionals, including exercise physiologists. Individuals involved with exercise testing are required to have training in CPR and should have training and knowledge in interpretation of ECG monitoring. Exercise physiologists should be familiar with both normal and abnormal responses during exercise and should be familiar with the AHA guidelines. Core competencies include knowledge of blood pressure, heart rate and _V O 2 responses to exercise, complications to exercise testing, and have knowledge and experience conducting exercise testing with clinical populations Franklin and colleagues evaluated the literature to determine the risks associated with exercise stress testing when conducted by physicians and nonphysicians. Through this analysis, they highlighted a series of core competencies that are required for safe and effective exercise stress testing. This includes knowing when not to perform a test, when to stop a test, and being prepared for an emergency The authors also highlighted the training that they have employed for clinical exercise physiologists, including extensive clinical (on-site) training, resting and exercise ECG examinations, training in basic CPR and advanced cardiac life support, and certification via ACSM The clinical exercise physiologist should have a bachelor s degree (often an advanced degree) in exercise science, physiology, or a related field, complete a clinical internship and certification, perform a comprehensive examination, be certified to administer CPR, and have 600 h or relevant clinical experience Gillespie reviewed a model for the licensure of clinical exercise physiologists. The requirements for certification include a Masters degree in clinical exercise physiology, ACSM certification as an exercise specialist, advanced clinical life support certification, and a specified number of hours of practical field experience Gutin and colleagues surveyed laboratories and centres where clinical exercise testing is conducted to determine the organizational structure, staffing utilized, and staff qualifications as well as an overview of general testing conducted Overall qualifications highlighted by the authors as required for working in clinical exercise testing include basic life support training and knowledge and abilities to interpret ECGs S244 Appl. Physiol. Nutr. Metab. Vol. 36, 2011