Table 1

Recommendations regarding qualified exercise professionals

RECOMMENDATION	*LEVEL^{^^†}**	GRADE^{^†^‡}
Clinical exercise stress testing can be conducted by qualified exercise physiologists (ie, university-trained exercise physiologists with advanced training and certification), provided that a physician and emergency response equipment are readily available	II	A
Qualified exercise professionals should be trained to deliver patient-centred care, work in interdisciplinary teams, perform evidence-based best practice, employ quality improvement and control processes, and make use of information technology to improve patient care	IV	C
Qualified exercise professionals should possess a series of discipline-specific core competencies before working with those with higher-risk conditions (eg, pregnancy, various chronic diseases). These core competencies include the following: an in-depth knowledge of the acute and chronic responses, as well as adaptations, to physical activity in both healthy and clinical populations; a clear understanding of how commonly used medications influence the response to physical activity; an understanding of how various comorbidities affect the response to physical activity; a comprehensive knowledge of the design and implementation of safe and effective exercise prescriptions for patients with chronic disease, functional limitations, or disabilities; a critical, in-depth understanding of diagnostic stress testing protocols and procedures; an ability to interpret both resting and exercise 12-lead electrocardiograms and rhythm strips; a knowledge of effective risk factor stratification and modification; an ability to provide hemodynamic and electrocardiographic monitoring by telemetry; effective skills in educating about and counseling on health behaviour modification; the ability to accurately measure blood pressure at rest and during exercise by auscultation; a thorough knowledge of the indications and contraindications to physical activity; an ability to determine when to terminate exercise testing or training; an ability to respond to emergency situations (including the provision of effective cardiopulmonary resuscitation and automated external defibrillation, as appropriate); an ability to create and respond to a written emergency plan that is appropriate to the testing and training facility; and an understanding of the behavioural change model and strategies that need to be considered and appropriately applied when working with patients	IV	C
Graduates of exercise science programs destined for clinical employment should complete a clinical internship	IV	C
Practical skills in clinical exercise testing and prescription should be tested directly	IV	C
Physicians interested in health promotion and lifestyle behaviour modification should work in close collaboration with allied health professionals who have specialized training in these fields (including qualified exercise professionals) in order to optimize patient-centred care	IV	C
Qualified exercise professionals should pass rigorous, independent, national-level written and practical examinations to establish their competency to work with at-risk populations	IV	C

↵* Level I evidence includes randomized controlled trials; level II evidence includes randomized controlled trials with important limitations or observational trials with overwhelming evidence; level III evidence includes observational trials; and level IV evidence includes anecdotal evidence or expert opinion.
↵† A strong expert opinion recommendation would receive a IV-C rating.
↵‡ Grade A recommendations are strong; grade B recommendations are intermediate; and grade C recommendations are weak.