PAR-Q+ and ePARmed-X+

Discussion

The new pre-participation risk stratification strategy was designed to enhance the ability of fitness and health care professionals to reduce the barriers to becoming physically active while ensuring safe and effective advice that is based on sound evidence.⁴ The new tools were derived from the systematic evaluation of more than 540 000 articles, with more than 1000 specific articles leading to more than 60 evidence-based exercise risk–specific recommendations.^3,6 This process included systematic reviews to identify exercise-related risks and establish effective risk stratification for prominent medical conditions (orthopedic conditions; cancer, heart, or cardiovascular conditions; metabolic conditions; psychological conditions; respiratory conditions; spinal cord injury; and stroke). Additional systematic reviews were conducted to evaluate the risks associated with exercise testing and training in the general population, the role of qualified exercise professionals (including the requisite core competencies required for working with varied chronic medical conditions), and the risks associated with exercise during uncomplicated pregnancy.^4,6 The entire process adhered to the international standards established by the Appraisal of Guidelines for Research and Evaluation instrument^7,8 and was consistent with the development of other clinical practice guidelines.⁹ This ensured that the highest standards for the development of evidence-based best practices were followed for the development of the new evidence-based PAR-Q+ and ePARmed-X+.¹

Through this process it was clearly established that the risks of being physically inactive far outweigh the small, transient risks seen after acute exercise in both asymptomatic and symptomatic populations across the lifespan.¹⁰ Moreover, there was no sound evidence base to support the age restriction of the old PAR-Q and PARmed-X. An evidence-based risk continuum (Figure 1) was created. Persons at low risk can exercise at low to moderate intensities with minimal to no supervision; persons at intermediate risk should exercise under the guidance of appropriately trained, qualified exercise professionals; and persons at high risk should exercise in medically supervised settings that include qualified exercise professionals. Appropriate intensity and mode progression of physical activity and exercise is critical throughout the risk continuum. This process also formally established the important role that qualified exercise professionals play in the physical activity clearance process for exercise testing and training.^4,11 The need to develop clinical exercise prescriptions for persons with chronic medical conditions was also clearly identified. It was recommended strongly that health care providers should avoid using generic physical activity guidelines (developed for use with healthy individuals¹²) in the treatment of persons living with prominent chronic medical conditions. This was based on an overwhelming body of research indicating that functional and health benefits are often observed in those living with prominent chronic medical conditions at an exercise volume that is well below that currently recommended for the apparently healthy population. A final important finding of the process was the need for researchers to clearly document all exercise-related adverse events.

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Figure 1

Risk continuum established through the systematic review process: Appropriate intensity and mode progression of physical activity and exercise is critical throughout the risk continuum.

There are several key features to the new PAR-Q+ and ePARmed-X+. For instance, the current PAR-Q+ is a 4-page document that contains a range of questions to identify any possible restrictions or limitations on physical activity participation. Using the PAR-Q+, clearance for physical activity participation is a straightforward process for a physician, exercise professional, or participant. The entire process takes approximately 5 minutes and can be completed in the waiting area of a physician’s office.

To begin, the participant simply answers the 7 new evidence-based questions on page 1 of the PAR-Q+. If the answer is no to all of the questions, he or she is cleared for unrestricted physical activity participation following the general physical activity guidelines for healthy asymptomatic populations.^12–14 If the participant answers yes to 1 or more of the questions, he or she is required to complete pages 2 and 3 of the PAR-Q+.

Pages 2 and 3 of the PAR-Q+ contain a series of follow-up questions on specific chronic medical conditions to either clear the respondent or refer the respondent to the online ePARmed-X+. If the participant answers no to all of the follow-up questions on pages 2 and 3 of the PAR-Q+ regarding his or her medical condition, he or she is cleared to become more physically active. The participant also receives advice on how to develop a safe and effective physical activity plan, including physical activity recommendations that are appropriate for lower-risk individuals with established chronic medical conditions (eg, 20 to 60 minutes of low to moderate intensity exercise, 3 to 5 times per week progressing toward 150 minutes per week). If the participant answers yes to 1 or more questions on pages 2 and 3, he or she is referred to a qualified exercise professional or to the ePARmed-X+ for further probing for pertinent information. At the end of the ePARmed-X+ process, the participant might be cleared for unrestricted physical activity participation or physical activity participation with restrictions. The participant is given a specially tailored exercise prescription to be monitored by a qualified exercise professional or is referred to a physician for additional medical probing or testing.

The result of this new screening strategy is that only a small proportion of participants (approximately 1%) are referred for additional medical screening, greatly reducing the burden experienced by physicians when using the old PAR-Q screening process. In this new process, persons previously screened out of physical activity participation are cleared (often self-screened via the PAR-Q+ or ePAR-med-X+) back into physical activity participation.⁴ The PAR-Q+ screening is valid for 12 months and the ePAR-med-X+ screening is valid for 6 months (to account for potential changes in health status).

The physical activity recommendations contained within the ePARmed-X+ and available to physicians are based on evidence-based best practices for participants’ particular chronic medical conditions. These recommendations are not based on generic physical activity guidelines provided to the general population. Tailored clinical exercise prescriptions have already been developed for a range of clinical populations and adopted into the ePARmed-X+. The use of the new clinical exercise prescriptions has already been shown to lead to substantial improvements in the overall health status of a range of clinical populations (including persons living with breast cancer, chronic kidney disease, and obesity).^15–17