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215
Journal of Aging and Physical Activity, 2008, 16, 215-233
© 2008 Human Kinetics, Inc.
Resnick is with the Dept. of Organized Systems & Adult Health, University of Maryland School of
Nursing, Baltimore, MD 21201. Ory, Hora, and Bolin are with the Health Science Center, Texas A&M
University, College Station, TX. Rogers is with Dept. of Human Performance Studies, Wichita State
University, Wichita, KS. Page is with The Hygenic Corporation, Baton Rouge, LA. Lyle is with Purdue
University, West Lafayette, IN. Sipe is with the Dept. of Kinesiology, University of North Carolina,
Charlotte, NC. Chodzko-Zajko is with the Dept. of Kinesiology, University of Illinois at Urbana–Cham-
paign, Urbana, IL. Bazzarre is with the Robert Wood Johnson Foundation, Princeton, NJ.
A Proposal for a New Screening Paradigm
and Tool Called Exercise Assessment
and Screening for You (EASY)
Barbara Resnick, Marcia G. Ory, Kerrie Hora,
Michael E. Rogers, Phillip Page, Jane N. Bolin,
Roseann M. Lyle, Cody Sipe, Wojtek Chodzko-Zajko,
and Terry L. Bazzarre
The Exercise Assessment and Screening for You (EASY) is a tool developed to
help older individuals, their health care providers, and exercise professionals
identify different types of exercise and physical activity regimens that can be
tailored to meet the existing health conditions, illnesses, or disabilities of older
adults. The EASY tool includes 6 screening questions that were developed based
on an expert roundtable and follow-up panel activities. The philosophy behind
the EASY is that screening should be a dynamic process in which participants
learn to appreciate the importance of engaging in regular exercise, attending to
health changes, recognizing a full range of signs and symptoms that might indi-
cate potentially harmful events, and becoming familiar with simple safety tips for
initiating and progressively increasing physical activity patterns. Representing a
paradigm shift from traditional screening approaches that focus on potential risks
of exercising, this tool emphasizes the benefits of exercise and physical activity
for all individuals.
Keywords: aging, physical activity, older adults
There is now substantial evidence documenting the many health benefits associ-
ated with physical activity for adults of all ages (Katzmarzyk, Janssen, & Ardern,
2003; Netz, Wu, Becker, & Tenenbaum, 2005; Palombaro, 2005; Prohaska et al.,
2006; Tardon et al., 2005; Wendel-Vos et al., 2004). Physical activity improves
health even for chronically ill or frail older adults for whom it is often falsely
believed that physical activity will exacerbate rather than ameliorate underlying
health problems (Hurley & Scott, 1998; Mallery et al., 2003; Roddy, Zhang, &
Doherty, 2005; Singh et al., 2005; Thompson et al., 2003).
216 Resnick et al.
Meta-analytic reviews have provided strong evidence that participation in either
nonspecific physical activity or specific aerobic or resistive exercise is associated
with a variety of health improvements such as decreased risk of coronary heart
disease and stroke (Cornelissen & Fagard, 2005; Kelley & Sharpe Kelley, 2001;
Lee, Folsom, & Blair, 2003; Wendel-Vos et al., 2004; Williams, 2001), decreased
progression of degenerative joint disease (Roddy et al., 2005), prevention of osteo-
porosis of the lumbar spine (Berard, Bravo, & Gauthier, 1997; Palombaro, 2005),
decreased incidence of falls (Chang et al., 2004; Weatherall, 2004), increased gait
speed if the activity is of sufficient intensity and dosage (Lopopolo, Greco, Sul-
livan, Craik, & Mangione, 2006), improved cognitive function in sedentary older
adults (Colcombe & Kramer, 2003) and in those with dementia (Heyn, Abren,
& Ottenbacher, 2004), a modest benefit in quality of life for frail older adults
(Schechtman & Ory, 2001), and a positive association with successful aging (Depp
& Jeste, 2006). Although there is some evidence of a dose–response relationship
between physical activity and health outcomes (Hurley & Scott, 1998; Rankinen
& Bouchard, 2002; Singh, 2002; Sutton, Muir, Mockett, & Fentem, 2001), sub-
stantial benefits can be achieved at even relatively low levels of exercise intensity
(Agency for HealthCare Research and Quality & Centers for Disease Control,
2002; Pescatello, 2001; U.S. Department of Health and Human Services, 2001),
and previously sedentary older adults are the most likely to benefit from physical
activity (Schnelle, MacRae, Ouslander, Simmons, & Nitta, 1995; Singh). The level
of exercise intensity, defined as the rate of energy expenditure during physical
activity and expressed in metabolic equivalents (METs), can vary depending on
the activity. Current public health recommendations stress the importance of all
adults engaging in at least 30 min of moderate-intensity activity (4.0–5.9 METs)
on most, if not all, days of the week (Agency for Healthcare Research and Quality
& Centers for Disease Control).
Despite repeated findings of the benefit of low- to moderate-intensity physical
activity for older adults, less than a third of older individuals engage in regular
physical activity, with the proportion meeting recommended guidelines dropping
with advanced age (Centers for Disease Control and Prevention, 2006). Physi-
cal activity rates could be increased if primary health care providers proactively
recommended physical activity to all patients. Unfortunately, most health care
providers do not encourage physical activity or take time to discuss its benefits
(Balde, Figueras, Hawkins, & Miller, 2003; Dauenhauer, Podgorski, & Karuza,
2006; Kerse, Elley, Robinson, & Arroll, 2005). In 423 videotaped physician–patient
encounters (Ory et al., 2006), only 39% were found to include a discussion about
physical activity. Approximately 50% of providers report that they do not prescribe
physical activity for older adults (Dauenhauer et al.). Patient recollections of the
frequency of physician recommendations related to physical activity are somewhat
higher, ranging from 50% to 62% (Balde et al.; Hirvensalo, Heikkinen, Lintunen,
& Rantanen, 2005). Ten percent of older patients reported that they received warn-
ings against participating in physical activity, and 34% reported receiving both
recommendations for and warnings against physical activity (Hirvensalo et al.).
Providers (physicians, nurse practitioners, and physician assistants), although they
report believing in the benefits of physical activity, admit to having insufficient
knowledge of what to recommend with regard to beginning a physical activity
program (Dauenhauer et al.).
A New Screening Tool 217
New practice guidelines associated with “Welcome to Medicare” (Centers for
Medicare and Medicaid Services, 2006) and the Healthcare Effectiveness Data and
Information Set (HEDIS) provide reimbursement and regulatory incentives for pro-
viders to take the time to discuss and encourage health-promotion activities such as
physical activity. It is critical, however, that these providers have information and
resources available for themselves and their patients so that recommendations can
be made to the patients that will enable them to choose activities that will optimize
their health and quality of life.
A screening tool, the Exercise Assessment and Screening for You (EASY), was
developed to provide health care providers and older adults with an easy-to-use
Web-based tool that would match underlying health problems with a physical activ-
ity program known to be safe and beneficial for individuals with those underlying
health problems. For example, it provides several exercise options for older adults
with arthritis. This tool builds off prior work in the area of screening for physical
activity among older adults and makes accessible for providers and older adults a
wide variety of professionally sanctioned physical activity options that meet the
needs of older adults across a wide range of ability levels and health conditions.
Recommendations for Screening
for Physical Activity in Older Adults
In light of the many benefits of physical activity and the relatively low risk of seri-
ous adverse events associated with low- and moderate-intensity physical activity,
current guidelines from a consensus group from the American Heart Association
and the American College of Cardiology (Gibbons et al., 1997; U.S. Preventive
Services Task Force, 2004) no longer recommend routine stress testing for those
initiating physical activity. For sedentary older people who are asymptomatic, low-
intensity physical activity can be safely initiated regardless of whether they have
had a recent medical evaluation (Cress et al., 2005; Pescatello, 2001). Screening of
some type, however, is still frequently recommended for older adults before their
being able to participate in research studies with a physical activity component or
physical activity classes or use exercise equipment in wellness centers (Resnick,
Ory, Coday, & Riebe, 2005). Legal concerns are often cited, although there are few
data indicating that lawsuits result from the lack of mandated screening programs
(Herbert & Herbert, 2002; Resnick et al., 2005).
The American College of Sports Medicine currently recommends a prepartici-
pation screening algorithm for older adults using either the PAR-Q or the American
College of Sports Medicine/American Health Association Questionnaire. The
exercise prescriber is encouraged to categorize the individual into one of several
ACSM risk strata. A decision tree indicates when further medical examination and
testing before participation in physical activity programs are needed. Although to
date the major emphasis of screening has been on prevention of life-threatening
cardiovascular events (Gill, DiPietro, & Krumholz, 2000; Shephard, 1994), exist-
ing screening tools are ineffective in correctly identifying the extremely small
number of individuals who are at risk for sudden death during exercise (Morey &
Sullivan, 2003). To compound the problem further, existing screening protocols are
associated with an unacceptably high rate of false positives that result in unneeded
218 Resnick et al.
and expensive office visits that can serve as a disincentive to begin physical activ-
ity (Ory, Resnick, Jordan, et al., 2005; Resnick, Ory, Coday, & Riebe, in press;
Shephard, 1994).
We, the authors, believe that screening tools could be redesigned to encourage
physical activity and serve as a guide to what kinds of activities can be recom-
mended to people with medical problems such as arthritis. Such screening tools can
likewise help identify individuals who might need additional clinical evaluation or
screening before initiating an exercise program. This type of preactivity screening
would be used to “tailor” an individual’s activity choices and thereby prevent serious
adverse cardiovascular events and the far more common adverse musculoskeletal
events that can accompany the initiation of physical activity (Keysor & Jette, 2001).
Even relatively minor musculoskeletal injuries can have an adverse impact on older
adults’ willingness to continue to be physically active (Edmond & Felson, 2003;
Resnick et al., 2005; Resnick, Vogel, & Luisi, 2006). Recognizing these risks, a
number of strategies have been recommended for preventing musculoskeletal events
during physical activity, such as starting with low-intensity physical activity and
increasing the intensity gradually over time (Cress et al., 2005; Pescatello, 2001),
performing exercises that increase muscle strength around weight-bearing joints
(Roddy et al., 2005), completing active stretching during the cool-down portions
of aerobic-exercise programs (Pescatello), and avoiding high-intensity vigorous
exercise (Pescatello; Singh et al., 2005).
Commonly Recommended Screening Tools
The most commonly recommended and frequently used preactivity screening tool
in the United States and Canada is the Physical Activity Readiness Questionnaire
(PAR-Q; Shephard, Thomas, & Weller, 1991). The PAR-Q focuses on assessment
of risk factors for potential cardiovascular events, with only minimal attention paid
to more common muscle, joint, or bone-related problems and other risk factors. To
increase the specificity of the PAR-Q, particularly when used with older adults, it
was revised to decrease the number of individuals who were responding affirma-
tively to screening questions because of benign symptoms or normal aging changes
(Shephard et al.). Individuals who responded affirmatively to any of the PAR-Q
items were referred to their primary health care provider for further evaluation to
determine whether medical or behavioral interventions were needed to reduce their
risk of negative health outcomes associated with exercise. Validity testing of the
revised PAR-Q (rPAR-Q) was done by coupling completion of the tool with data
from a national health survey. Those who did not pass the rPAR-Q had a crude
overall mortality risk ratio of 2.2 (Arraiz, Wigle, & Mao, 1992). Unfortunately
this type of validation does not answer the question of whether these individuals
were at risk for dying when engaging in physical activities or the equally important
question of whether physical activity might have extended or improved the quality
of their lives.
Use of the rPAR-Q rather than the original PAR-Q decreased the likelihood of
a false positive from 17% to 12% (i.e., 12% did not pass the screening). It is likely
the individuals who did not successfully pass the rPAR-Q are the ones who would
benefit the most from a physical activity program. Reliance on the rPAR-Q in these
situations might be a barrier to physical activity because the individual would need
A New Screening Tool 219
to go for further (possibly costly) evaluation from a health care provider and might
become fearful of engaging in physical activity because of potential health risks.
Even for individuals who do pass the rPAR-Q, the tool does not give health care
providers or older individuals the greatly needed guidance about what physical
activity regimen would be safe and useful for them to engage in. Moreover, screen-
ing tools such as the rPAR-Q are often viewed as a one-step process as opposed to
an ongoing and flexible risk-management plan that can be responsive to changing
situations and settings. Given the likelihood that older adults will have chronic
medical problems and be at risk for acute exacerbations of those problems, it is
critical that ongoing health status be considered before, during, and after physical
activity. Incorporating and encouraging the use of safety tips for physical activity
into the screening process can help providers and older individuals continually
monitor their safety with any given physical activity.
The proposed EASY screening tool addresses many of the weaknesses in
the currently available screening processes because it incorporates an interactive
Web-based system (www.easyforyou.info) to guide older individuals and health
care providers through a series of six questions. The purpose of these questions
is to identify any health problems an individual might have that could affect the
type of exercise that he or she should perform and highlight those that might best
benefit their clinical problems. The exercise programs that are recommended are
from respected professional organizations. In addition, older individuals completing
the EASY are encouraged to use the comprehensive listing of safety tips before,
during, and after physical activity. An example of the results of the EASY for an
older adult who has a history of dizziness is included in Table 1. Given the affir-
mative response to the second question, Do you currently experience dizziness or
lightheadedness? the individual is reminded to “Make sure your health care provider
knows about the dizziness or lightheadedness” and then has the opportunity to link
to exercise options for individuals with known dizziness.
Development of the Exercise/Physical Activity Assessment
and Screening for You (EASY)
The initial work toward the development of the EASY came out of the Behavioral
Change Consortium (BCC) Physical Activity Workgroup (Ory, Jordan, & Bazzarre,
2002). The workgroup considered the relationship between screening and recruit-
ment of participants and the history of adverse events associated with physical
activity interventions in each of the 11 BCC studies supported by the National
Institutes of Health (Ory et al., 2002). Despite the presence (55%) or absence (45%)
of preactivity screening in the BCC studies, no major adverse events were reported
in any of these studies (Ory, Resnick, Jordan, et al., 2005).
With support from the Robert Wood Johnson Foundation, a small group of
investigators from the BCC Physical Activity Workgroup explored the experiences
and beliefs of researchers, clinicians, and older adults regarding the value and
efficacy of preactivity screening (Resnick et al., 2005, in press). The findings from
these qualitative studies emphasized that there were pros and cons associated with
the screening process for older adults. Specifically, there were some older adults
and clinicians who felt that screening had a psychological benefit, because it
gave participants a sense of assurance that it was safe for them to start exercising.
220 Resnick et al.
Alternatively, there were some older individuals and clinicians who felt that
requiring medical screening was not needed and inconvenient, it sometimes can
be physically or psychologically traumatic, it is costly for the individual and the
health care system, and screening sometimes excludes the individuals who are most
likely to benefit from low- to moderate-intensity physical activities.
Using these findings the expert panel reviewed screening and assessment issues
related to the pros and cons of current physical activity screening practices and
seeming inconsistencies between clinical screening guidelines and current public
health recommendations to increase physical activity. They met at a screening
roundtable held in May 2005 to discuss current information about best practices
for promoting physical activity in older adults, introduce a new “tailored” screening
paradigm including the new EASY screening tool, and recommend actions for
identifying and monitoring adverse events in existing community programs. An
Table 1 EASY Results for an Individual With a History of Dizziness
Great! You are ready to start exercising. Visit First Steps to Active Health to begin. Use
recommendations below if you have answered yes to any of the questions for exercising
safely with your condition. Share the results with your health care provider and ask “Are
there any exercises that I should not do?”
EASY question
Older adult
response Recommendation from the EASY
1. Do you have pains, tightness, or
pressure in your chest during physical
activity (walking, climbing stairs,
household chores, similar activities)?
No
2. Do you currently experience dizziness
or lightheadedness?
Yes
View these links and tips.
a
Make
sure your health care provider
knows about the dizziness or
lightheadedness.
3. Have you ever been told you have high
blood pressure?
No If your blood pressure has not been
checked in the last 6 months, it is
recommended to get it checked with
a health care provider.
4. Do you have pain, stiffness, or swelling
that limits or prevents you from doing
what you want or need to do?
No
5. Have you fallen in the past year, or do
you feel unsteady or use a cane or
walker while standing or walking?
No If you use an assistive device it
is okay to exercise, but please
continue to use it while exercising
as appropriate.
6. Is there a health reason not mentioned
why you would be concerned about
starting an exercise program?
No
a
The links include exercise options for individuals with dizziness. In addition, the individual is provided
with the tips for safe exercise as shown in Table 3.
A New Screening Tool 221
annotated bibliography of existing literature was prepared, and conclusions and
recommendations from the screening roundtable were summarized in a report for the
White House Conference on Aging. The expert panel concluded that adverse events
occurring during light- to moderate-intensity physical activity were infrequent
across a wide variety of populations and settings. In addition, the panel believed that
a screening tool that provides some assurance to older adults that it can be safe for
them to begin physical activity, activity options that match their physical condition,
and safety tips to use before, during, and after physical activity was greatly needed.
Motivated older individuals searching for information about exercise, and health
care providers interested in providing patients with information about the benefits
of physical activity and the kinds of activities they can enjoy if they have specific
medical problems or needs, might benefit from the availability of this tool.
The expert panel felt was that screening should not be seen as a one-time activ-
ity and that participants need to appreciate the importance of attending to health
changes, be aware of signs and symptoms of potentially harmful events, and be
familiar with simple safety tips. Although health care providers are encouraged to
go through the EASY with older patients, older individuals are likewise encour-
aged to talk with their health care provider about their physical activity program.
This helps health care providers become champions for initiating physical activity
and helps patients take responsibility for making choices to improve and maintain
their health.
The Exercise Assessment and Screening for You (EASY) tool was modeled on
the commonly used rPAR-Q and based on prior experience and clinical research.
The questions in the r-PAR-Q and the EASY are similar (see Table 2). There are
profound differences, however, in how the tool guides respondents with respect to
their physical activity options. The rPAR-Q involves only a single yes/no response
to each item, and the individual either passes screening or does not. If the individual
fails the screening process, he or she is required to see his or her health care pro-
vider before beginning physical activity. Conversely, each question in the EASY
follows an algorithm such that the older adult or the health care provider is guided
toward a list of known and available physical activity programs that are effective
and appropriate for a given concern. In addition, the EASY provides all respondents
with a number of specific safety tips to follow before, during, and after physical
activity. It is only in the event that an individual is experiencing an acute medical
problem that has not been previously evaluated by a health care provider that the
individual is encouraged to see his or her provider before exercising. Each question
in the EASY is addressed briefly herein, with consideration given to the rationale
for asking the question and rationale for the recommendations provided.
Question 1: Do you have pain, tightness, or pressure in your chest during physi-
cal activity (walking, climbing stairs, household chores, similar activities)?
This question helps older adults identify acute cardiac problems that might result
in cardiac stress if an aerobic activity is initiated and guides them toward a physical
activity program that will result in cardiac benefits and will not aggravate symp-
toms. Not only is routine comprehensive cardiac stress testing no longer recom-
mended for older individuals before starting a physical activity program (Gibbons
et al., 1997), but questions have also been raised about the utility of preenrollment
screening questionnaires to identify individuals with cardiac risks associated with
222 Resnick et al.
physical activity (Franklin, 2004; Gill et al., 2000; Maron, 2000; Ory, Resnick,
Chodzko-Zajko, Buchner, & Bazzarre, 2005a, 2005b; Shephard, 2000; Thompson
et al., 2003).
Cardiovascular events in response to physical activity are both rare and
unpredictable. Neither stress tests nor screening instruments such as the rPAR-Q
effectively identify the tiny subset of individuals at risk for these events (Morey &
Sullivan, 2003; Shephard, 2000). At the same time there is significant risk associated
with screening through traditional graded exercise testing. Approximately 20% of
older individuals will have a positive stress test and consequently will be exposed
to more invasive testing (Kohl, Gibbons, Gordon, & Blair, 1990; Wennberg et al.,
1996). Both stress tests and existing preactivity questionnaires are associated with
unacceptably high false positive and false negative results (Morey & Sullivan).
Moreover, there is no prognostic value of exercise testing in asymptomatic indi-
viduals with regard to cardiovascular events (Mora et al., 2003).
Table 2 The Revised PAR-Q Questions Compared With the EASY
Questions
rPAR-Q question Comparable EASY question
1. Has your doctor ever said that you
have a heart condition and
recommended only medically
approved physical activity?
1. Do you have pains, tightness, or pressure
in your chest during physical activity
(walking, climbing stairs, household
chores, similar activities)?
2. Do you have chest pain brought
on by physical activity?
3. Have you developed chest pain
at rest in the past month?
4. Do you lose consciousness or lose
your balance as a result of dizziness?
2. Do you currently experience dizziness
or lightheadedness?
5. Do you have a bone or joint problem
that could be aggravated by physical
activity?
4. Do you have pain, stiffness, or swelling
that limits or prevents you from doing
what you want or need to do?
6. Is your doctor currently prescribing
medication for your blood pressure
or heart condition (e.g., diuretics or
water pills)?
3. Have you ever been told you have high
blood pressure?
7. Are you aware, through your own
experience or a doctor’s advice,
of any other reason against your
exercising without medical
approval?
6. Is there a reason not mentioned why
you would be concerned about starting
an exercise program?
5. Do you fall, feel unsteady, or use
an assistive device while standing
or walking?
A New Screening Tool 223
Asking about cardiac symptoms in Question 1 allows the older individual and
the health care provider to focus on these symptoms, particularly newly identified
symptoms; to pursue a more comprehensive assessment of the symptoms as indi-
cated; and to establish a physical activity program likely to improve underlying
cardiovascular disease. Physical activity focused on inducing a cardiovascular
benefit includes activities that involve large muscle groups and are continued for
20–60 min. These activities include, but are not limited to, walking, running, swim-
ming, and biking. The recommended goal is for 30 min of activity daily, although
guidelines suggest that individuals should build up to this level of activity if they
are initially inactive (Pescatello, 2001; Tackett, 2005). The EASY would guide an
individual with known heart disease, which has been previously evaluated by a
health care provider, to initiate a heart-healthy physical activity program such as
that recommended by the American Heart Association (www.americanheart.org).
Question 2: Do you currently experience dizziness or lightheadedness?
This question helps individuals and health care providers address dizziness, which
might be caused by a variety of underlying medical problems such as vertigo, car-
diovascular problems (e.g., atrial fibrillation or orthostatic hypotension), metabolic
problems such as high or low blood sugar, visual impairment, or side effects of
medications. In the event that the symptoms of dizziness are new to an individual
and have not been previously evaluated by a health care provider, the individual
should be directed to see his or her health care provider. If dizziness is a chronic
problem, the individual will be linked to physical activity programs for individu-
als who have known dizziness, such as those provided by the American Physical
Therapy Association (http://headtotoe.apta.org/kbase/frame/ug117/ug1176/frame.
htm), and the safety tips for physical activity (Table 3).
Question 3: Have you ever been told you have high blood pressure?
This question reminds older adults of the importance of regular blood-pressure
monitoring. It is not meant to serve as a deterrent to physical activity. Individuals
who do have high blood pressure are encouraged to continue to work with health
care providers to optimize treatment. In addition, they will be able to link to physi-
cal activity interventions that will further improve systolic and diastolic pressure
(Pescatello et al., 2004; Brennan et al., 2005; Stewart, Ouyang, Bacher, Lima, &
Shapiro, 2006), such as those recommended by the American College of Sports
Medicine (www.acsm.org/pdf/EOA.pdf). In addition, they will be linked to safety
tips to ensure safe participation in physical activity (Table 3).
Question 4: Do you have pain, stiffness, or swelling that limits or prevents you
from doing what you want or need to do?
This question helps older adults and their health care providers recognize chronic
musculoskeletal problems (e.g., arthritis) and identify acute exacerbations of these
problems so that the physical activity program the individual initiates will prevent
or manage these musculoskeletal conditions. The prevalence of arthritis in older
adults ranges from 25% in non-Hispanic whites to 40% in non-Hispanic blacks to
44% in Hispanics (Dunlop et al., 2005), and the associated pain and stiffness are
often used as reasons or excuses to avoid physical activity (Resnick & Spellbring,
2000; Thomas et al., 2002). Physical therapy and physical activity clearly benefit
older adults with arthritis (Kovar, Fitti, & Chyba, 1992; O’Reilly & Doherty, 2001;
224 Resnick et al.
Table 3 EASY Safety Tips for Initiation of Physical Activity
Safety tips before starting
physical activity
Safety tips for
when to
stop
physical activity
Safety tips to recognize
times when physical activity
should
not
be initiated
• Always wear comfortable,
loose-fitting clothing and
appropriate shoes for your
activity.
• Warm up: Perform a low- to
moderate-intensity warm-up
for 5–10 min.
• Drink water before, during,
and after your exercise
session.
• When exercising outdoors,
evaluate your surroundings
for safety: traffic, pavement,
weather, and strangers.
• Wear clothes made of
fabrics that absorb sweat
and remove it from your
skin.
• Never wear rubber or
plastic suits. These could
hold the sweat on your
skin and make your body
overheat.
• Wear sunscreen when you
exercise outdoors.
• Start low and build with
regard to time and intensity
of any physical activity.
• If you always feel dizzy or
off balance, do your
exercises sitting down.
• You have pain or
pressure in your
chest, neck,
shoulder, or arm.
• You feel suddenly
dizzy or sick.
• You break out in a
cold sweat.
• You have muscle
cramps.
• You feel sudden
acute (not just
achy) pain in your
joints, feet, ankles,
or legs.
• Slow down if you
are out of breath.
You should be
able to talk while
exercising without
gasping for breath.
• Do not do hard exercise
for 2 hr after a big meal.
• Do not exercise when you
have a fever or viral
infection accompanied by
muscle aches.
• Do not exercise if your
systolic blood pressure is
greater than 200 and your
diastolic is greater than 100.
• Do not exercise if your
resting heart rate is higher
than 120 beats per minute.
• Do not exercise if you have
a joint that you are using
to exercise (such as a knee
or an ankle) that is red and
warm and painful.
• Stop exercising if you
experience severe pain
or swelling in a joint.
Discomfort that persists
should always be evaluated.
• Do not exercise if you have
a new symptom that has not
been evaluated by your
health care provider, such
as pain in your chest,
abdomen, or a joint; swelling
in an arm, leg, or joint;
difficulty catching your
breath at rest; or a fluttering
feeling in your chest.
Note. Additional safety information is provided at the National Institutes of Health Web page:
www.nlm.nih.gov/medlineplus/safety.html
O’Reilly, Muir, & Doherty, 1999; Roddy et al., 2005; Thomas et al.). Moreover,
there is limited risk of falls or minor adverse events (incidence rate ranging from 0
to 11.8%) for older adults with arthritis who engage in either aerobic or strength-
ening physical activity (Coats, McGee, Stokes, & Thompson, 1995; Ettinger et
al., 1997; Hopman et al., 2000; Kuptniratsaikul, Tosayanonda, Nilganuwong, &
Thamalikitkul, 2002; Minor, Hewett, Webel, Anderson, & Kay, 1989; Schilke,
Johnson, Housh, & O’Dell, 1996; Thomas et al.; Topp, Woolley, Hornyak, Khuder,
A New Screening Tool 225
& Kahaleh, 2002; Wyatt, Milam, Manske, & Deere, 2001). Individuals with known
arthritis will be linked to physical activity programs specifically geared toward
decreasing the progression of the arthritis and managing the symptoms, such as
those recommended by the American College of Rheumatology (www.rheumatol-
ogy.org/public/factsheets/exercise_new.asp).
Question 5: Do you fall, feel unsteady, or use an assistive device while stand-
ing or walking?
This screening question focuses on possible balance concerns and optimizing safety
of older individuals during their physical activities. Falls and fear of falling are
common problems in older adults (Howland et al., 2000; Lach, 2005; Li, Fisher,
Harmer, McAuley, & Wilson, 2003; Rubenstein & Josephson, 2002), and approxi-
mately one third of community-dwelling adults 65 years of age or older experience
one or more falls each year (Friedman, Munoz, West, Rubin, & Fried, 2002; Means,
Rodell, & O’Sullivan, 2005; Tinetti, 2003; Tromp et al., 2001). Clinical trials have
demonstrated that physical activity interventions result in decreased fear of falling
and prevent actual falls (Brouwer, Walker, Rydahl, & Culham, 2003; Day et al.,
2001; Liu-Ambrose et al., 2004; Lord et al., 2003; Schoenfelder & Rubenstein,
2004; Sherrington, Lord, & Herbert, 2004; Takeshima et al., 2002).
Although more research is needed to better understand the relationship
between the use of assistive devices and decreased falls and fear of falling, there
is some evidence to support the utility of these devices (Bateni & Maki, 2005). A
comprehensive review of over 1,000 studies exploring the use of canes and walkers
provided evidence to suggest that these devices improve balance and mobility in
many situations (Bateni & Maki; Steultjens et al., 2004). In addition, new tech-
nologies should be explored to encourage and ensure safe physical activity among
older individuals using assistive devices (Nelson et al., 2004). The EASY will link
older individuals who have a history of falls, feel unsteady when walking, or use an
assistive device to physical activity interventions that were developed for those with
balance problems, such as those provided by the Center for Neurological Studies
(www.cnsonline.org/www/archive/ parkins/park-03.html). As with the other EASY
questions, the individual will also be linked to the comprehensive list of safety tips
to use before, during, and after physical activity (Table 3).
Question 6: Is there a reason not mentioned why you would be concerned
about starting a physical activity program?
This question encourages individuals to report additional symptoms that might
influence their ability and willingness to increase their physical activity. For
example, some individuals might be concerned about participating in physical
activity because of urinary incontinence, and this should be addressed. Responses
to this question might provide important information for motivational interventions.
Concerns associated with increasing physical activity must be addressed so that
the individual feels confident in his or her ability to safely engage in a physical
activity program (Clark, 1999; Conn, Burks, Pomeroy, Ulbrich, & Cochran, 2003;
Damush, Perkins, Mikesky, Roberts, & O’Dea, 2004; Netz & Raviv, 2004). This
final question links to a variety of physical activity programs for older individu-
als that incorporate stretching and balance with aerobic and resistance activities
(www.nihseniorhealth.gov/exercise/toc.html). Likewise, the user will be encour-
aged to follow the comprehensive safety tips before, during, and after physical
activity (Table 3).
226 Resnick et al.
Use of the EASY
Figure 1 provides an example of one screen in the EASY. As previously described,
each of the EASY screening questions is followed by an algorithm that guides the
individual completing the measure through a variety of options. For example, the
first question differentiates whether the cardiac symptoms experienced are new or if
they had previously been evaluated. If an individual is experiencing a new symptom,
the individual is encouraged to check with his or her primary health care provider
to determine if there is any reason he or she cannot be physically active. If it is not
a new problem and the individual has previously had the problem evaluated and
been told that there is no reason that he or she cannot be physically active, then he
or she can begin exercising and will be linked to the recommended physical activ-
ity programs likely to benefit older adults with a history of cardiovascular disease
and the safety tips to use when exercising (Table 3).
Figure 1 — Example of a question from the Exercise Assessment and Screening for You
(EASY): Question 1.
A New Screening Tool 227
The questions in the EASY can be completed by older adults independently
or with the help of their primary health care provider, an exercise trainer, or group
exercise leader. The underlying message of the EASY is that physical activity is
good for people at all ages. Nearly all older adults can safely participate in moderate-
intensity physical activities such as a brisk walk or gardening for at least 30 min a
day, most days of the week. There is a new tool that helps individuals know when
to see a health care provider and how to choose activities for optimal benefit given
particular health conditions or situations. This changes the role of health care
provider from “gatekeeper” to “partner” in developing appropriate and effective
physical activity programs.
The EASY tool provides a resource to facilitate access to information about
physical activity for older adults, particularly with regard to specific exercise rec-
ommendations for individuals with certain common chronic medical problem. The
EASY has yet to be tested in randomly controlled trials to determine its effectiveness
in terms of increasing physical activity or preventing adverse events associated with
physical activity, although some practitioners are already beginning to employ this
tool in their activity programs with older adults, demonstrating the feasibility of
using the tool in community settings. The EASY philosophy, however, is supported
by research demonstrating the safety of physical activity at a low to moderate level
of intensity and incorporates the important ongoing safety tips to ensure safety
during all exercise activities. We encourage health care providers and older adults
to use the EASY (www.easyforyou.info) and provide us with feedback. The tool’s
overriding purpose is to promote a flexible, tailored approach to screening that
will better inform older adults and their health care providers about safe physical
activity programs with appropriate injury-management strategies. The identifica-
tion of a broader range of activities appropriate for different health circumstances
and situations will enable most older adults to engage in physical activity that will
improve their health and functioning.
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