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Assertive screening: health checks prior to exercise programmes in older people
  1. A J Campbell
  1. Department of Geriatric Medicine, Dunedin School of Medicine, Dunedin, New Zealand
  1. Professor A J Campbell, Department of Medical and Surgical Sciences, Dunedin School of Medicine, Dunedin, New Zealand; john.campbell{at}

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Assertive screening, as opposed to defensive screening, is done for the participant’s benefit not the provider’s protection. It is used to identify and manage chronic health conditions and functional limitation. It is neither risk averse nor protective but an “enabling, pre-exercise medical review that will facilitate safe and effective recreational participation”.1 Such screening asserts the right of older and functionally very limited people to participate in exercise programmes.

Unnecessary safety screening, medical clearance and detailed questionnaires may be a disincentive for an older person already ambivalent about commencing an exercise programme. Such screening may be an unjustified barrier to participation and presage an unwarranted encroachment of medical services into normal human activities. In a review of safety monitoring before an exercise programme in older persons, Gill and colleagues2 conclude “any policy that further deters a large number of older persons from participating in an exercise programme may cause more harm than good”.

Not only may such defensive screening be counterproductive it is also unproved. Even in the most at-risk groups, there is no evidence that it is possible to predict the very rare, serious cardiac events that might occur during an exercise programme.3 In recent recommendations for physical activity in older adults the American College of Sports Medicine and the American Heart Association state that “evidence that risk management strategies can be effective comes from the observation that published exercise studies routinely implement risk management and serious adverse events in these studies are rare”.4 Serious adverse events in these studies are very rare5 but to attribute this to “risk management” is rather like the man who every day, when travelling to work on the bus, ripped up his ticket and sprinkled it out the window. When asked why, he replied that it was to keep the tigers away. “But there are no tigers” replied his colleagues. “Ah ha”, said he, “it shows it’s working.”

Pre-exercise screening may be used to identify those who are sedentary, those at risk of events such as falls and those with chronic disabling conditions, all of whom may benefit from a planned exercise programme.

Assertive screening through the use of a single question may be used to identify middle aged and elderly people who are sedentary. A high proportion of these, two-thirds in one study,6 may be willing to participate in lifestyle interventions including a “green prescription” for exercise.7

A single question about a fall in the previous year may be all that is needed to identify those older people who will benefit most from a strength and balance retraining programme. A subsequent health check by the instructor is necessary only to decide the level of difficulty at which the participant should start. This will be determined by the person’s usual level of activity, and whether or not activity has previously been limited by symptom development. Using such an approach we have had no serious adverse effects using a balance and ankle cuff weight strengthening programme in six controlled trials in which the median age has been well over 80 years.8 9 Our national insurance provider, the Accident Compensation Corporation, has introduced the programme throughout New Zealand without reported adverse events.

In older people with symptomatic illnesses, such as congestive heart failure, an exercise programme may be therapeutic as well as preventive.10 It should be designed to lower the risk of further events and to increase the person’s exercise tolerance and cardiovascular reserve. The purpose of the screening assessment is to set the starting point, plan progression and reassure the participant and the participant’s family.

Inactivity is greatest in those 65 years and older.11 There is strong evidence that exercise improves function in this age group.4 Assertive screening identifies those who would benefit from a planned exercise programme, asserts their right to participate and encourages involvement.



  • Competing interests: None.