A BRIEF HISTORY (UPDATED December 2023)

The history of the Physical Activity Readiness Questionnaire (PAR-Q) and Physical Activity Readiness Medical Examination (PARmed-X) is quite an interesting story as documented eloquently by Dr. Roy Shephard (Shephard, 1988; Shephard, 1994, 2014, 2015). Readers are recommended to consult the informative articles by Dr. Shephard chronicling the history of the PAR-Q and its evolution from a concept to an evidence-based document (Shephard, 2014, 2015). Importantly, Dr. Roy Shephard played an important role in all versions of the PAR-Q.

Dr. Shephard passed away in February, 2023 at the age of 94. He was a key member of the PAR-Q+ Collaboration and the International Consensus committee responsible for updating the PAR-Q+. We are indebted to his tireless support and leadership. His legacy continues with the millions of people that make use of the PAR-Q and PAR-Q+.

The original PAR-Q emanated from the early pioneering work of leading Canadian researchers. The laboratory of Dr. Shephard (at the University of Toronto) was provided the opportunity to create and evaluate standardized screening tools in two surveys of population fitness in Canada (Shephard, 2014). The first survey was conducted in August 1966 at the Canadian National Exhibition in Toronto (Shephard & Pelzer, 1966) and the second survey was conducted in the summer of 1973 in Saskatoon as part of the Canadian Home Fitness Test (Bailey et al., 1974). Internationally renowned physical activity and exercise experts, Dr. Don Bailey (University of Saskatchewan), Dr. Shephard (University of Toronto), and Dr. George (Bert) McBride, played key roles in these studies and the resultant screening procedures.

Dr. Bailey (January 5, 1934 – June 3, 2023) passed away in June 2023. He was an internationally acclaimed scientist and visionary. For further information on Dr. Bailey please visit the following tribute: Don Bailey Lecture Series – College of Kinesiology | University of Saskatchewan (usask.ca)

In developing the screening procedures for these surveys, the research team conducted a review of the various reports on adverse exercise-related events (fatal and non-fatal) providing a summary of various warning signs (see Table 1).

Table 1: Factors increasing the risk of an exercise-related catastrophe.

• A history of fainting or chest pain during exercise
• A family history of cardiac death at an early age
• Undertaking a greater intensity and duration of activity than recently experienced
• Competition, publicity or pride encouraging continuation of exercise in the face of warning symptoms
• Exercising under pressures of time, or when facing business or social problems
• Engaging in activity that required heavy lifting or prolonged isometric effort
• Adverse weather conditions (either heat or cold)
• A viral infection, a sense of chest discomfort, cardiac irregularity, or a feeling of being “unwell.”

Table reproduced with permission from Shephard, R. J. (2014). A brief history of exercise and physical activity participation clearance and prescription: 2. Canadian contributions to the development of objective, evidence-based procedures. Health & Fitness Journal of Canada, 7(1), 36-68.

Based on these factors, the participants involved in both surveys were asked two simple questions upon initial contact:

• Have you ever had heart trouble?
• Have you ever had or do you now have persistent chest pains?

Individuals that answered “YES” to either question were excluded from participation. Following the initial screening, participants were then asked a six-item medical questionnaire by a registered nurse. The ultimate goal was to exclude individuals with responses that (suggested) were symptomatic of chronic disease (i.e., hypertension, heart disease, or angina), individuals that were taking prescribed medication on a regular basis, and anyone that had been hospitalized within the previous six months (Shephard, 2014). All participants were also monitored by electrocardiography before and during exercise with a physician (Dr. John Merriman)  (Shephard, 2014).

Drs. Shephard, Bailey, and McBride played key roles in the creation of the original questions. The original version consisted of eight items, and then was expanded to 19 items in British Columbia. Chisholm and colleagues (1975, 1978) working with the BC Ministry of Health evaluated critically the pre-participation screening form at a large agricultural fair at the Pacific National Exhibition in Vancouver, BC (Shephard, 2014). Dr. Chisholm and colleagues concluded that a seven item questionnaire was as effective as the longer version. This led to the development of the familiar seven question PAR-Q (as illustrated in the adjacent picture). The first version of the PAR-Q & YOU was released by Chisholm and colleagues (BC Med Assoc J) in the 1970s, was endorsed by Fitness Canada and the American College of Sports Medicine, and has been used extensively in Canada and internationally (Thomas et al. 1992). The PARmed-X was also created to assist physicians the in the clearance of clients that failed the PAR-Q test (Chisholm, et al., 1975; Chisholm, et al., 1978; Shephard, 2014).

In 1991, Dr. Roy Shephard and colleagues (1991) highlighted how the original PAR-Q screened out a significant proportion of participants (in particular older individuals). Therefore, an Expert Committee was commissioned by Fitness Canada to evaluate and revise the wording of the PAR-Q. In the early 1990s, Dr. Shephard and coworkers published recommended wording changes to the original PAR-Q questions in several articles. An analysis of the revised questions was conducted in 399 individuals (Shephard et al. 1990; Thomas et al. 1992). In this work, the original PAR-Q screened out approximately 17% of the participants in comparison to 12% for the revised PAR-Q. Further revisions to the wording were made and a 1994 version of the PAR-Q was released in Canada. Subsequent revisions to the PAR-Q were made including the 2002 version of the PAR-Q developed by an expert panel led by Dr. Norman Gledhill (York University). It should be highlighted that although the original PAR-Q has been revised, the original questions remain in extensive usage today by various individuals and organizations reflecting the impact the original work has had on pre-participation screening.

THE PAR-Q+ AND ePARmed-X+

The original PAR-Q & YOU remains in usage today including various peer reviewed publications, online websites, and in health screening batteries. Approximately 40 years of experience has demonstrated the remarkable ability of the PAR-Q to safely and effectively screen individuals who are interested in becoming more physically active. However, the various versions of the PAR-Q (including the latest 2002 version) were acknowledged to have limitations. Physicians, physical activity participants, fitness professionals, and various organizations acknowledged that the PAR-Q process and associated PARmed-X may create unnecessary barriers to physical activity/exercise participation. For instance, the purposely conservative nature of the PAR-Q led to many “false positives” leading to unnecessary medical referrals. The age restrictions (15-69 yr) also created an unnecessary barrier for children and the elderly. Also, the PAR-Q often resulted in barriers to physical activity participation for those living with chronic medical condition (who stand to benefit greatly from engaging in physical activity). Moreover, physicians often complain that the PARmed-X is too long, not user friendly, and not evidence-based. In fact, both the PAR-Q and PARmed-X were developed based on expert opinion. Both forms were challenged owing to the opinion-based nature and lack of evidence-based support.

Accordingly, in 2007 a group of researchers headed by Dr. Darren Warburton, Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Don McKenzie conducted a systematic, evidence-based consensus process to examine critically best practices in physical activity and risk stratification processes. The result of this process was the creation of a new pre-participation and risk stratification strategy (i.e., the new Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and the electronic Physical Activity Readiness Medical Evaluation (ePARmed-X+)). These forms were officially introduced on May 5-8, 2010 at the 3rd International Congress on Physical Activity and Public Health in Toronto, Ontario, Canada. Subsequent consensus panel approved versions of the PAR-Q+ were published in the Health & Fitness Journal of Canada.

This new strategy has been used with thousands of individuals from around the world demonstrating a remarkable ability to risk stratify participants and reduce the barriers to physical activity participation for individuals across the lifespan (including those living with a chronic medical condition) (Bredin et al., 2013; Warburton et al., 2011; Warburton et al., 2016).

INTERNATIONAL COLLABORATIONS

Various international authorities and organizations have been involved in the development of the new PAR-Q+ and ePARmed-X+. Current research trials are being conducted internationally allowing for the continual evaluation and update of the PAR-Q+ and ePARmed-X+. Recommendations for change to this strategy are vetted through an international consensus panel to ensure that the process adheres to evidence-based best practice. The forms are updated approximately every six (6) months to include new evidence-based information. This website contains the current consensus panel approved forms for the PAR-Q+ and ePARmed-X+.

Key References

Bailey, D. A., Shephard, R. J., Mirwald, R. L., & McBride, G. A. (1974). A current view of Canadian cardiorespiratory fitness. Can Med Assoc J, 111(1), 25-30.

Bredin, S. S., Gledhill, N., Jamnik, V. K., & Warburton, D. E. (2013). PAR-Q+ and ePARmed-X+: new risk stratification and physical activity clearance strategy for physicians and patients alike. Can Fam Physician, 59(3), 273-277.

Chisholm, D. M., Collis, M. L., Kulak, L. L., Davenport, W., & Gruber, N. (1975). Physical activity readiness. British Columbia Medical Journal, 17, 375-378.

Chisholm, D. M., Collis, M. L., Kulak, L. L., Davenport, W., Gruber, N., & Stewart, G. (1978). PAR-Q validation report: the evaluation of the self-administered pre-exercise screening questionnaire for adults. Victoria, BC: BC Ministry of Health and Health and Welfare Canada.

Shephard, R. J. (1988). PAR-Q, Canadian Home Fitness Test and exercise screening alternatives. Sports Med, 5(3), 185-195.

Shephard, R. J. (1994). Readiness for physical activity. President’s Council on Physical Fitness and Sports Research Digest, 1(5).

Shephard, R. J. (2014). A brief history of exercise and physical activity participation clearance and prescription: 2. Canadian contributions to the development of objective, evidence-based procedures. Health & Fitness Journal of Canada, 7(1), 36-68.

Shephard, R. J. (2015). Qualified Exercise and Fitness as Professionals and Exercise Prescription: Evolution of the PAR-Q and Canadian Aerobic Fitness Test. J Phys Act Health 12(4), 454-61.

Shephard, R. J., & Pelzer, A. M. (1966). The working capacity of subjects from an exhibition crowd. Can Med Assoc J, 94(4), 171-174.

Shephard, R. J., Thomas, S., & Weller, I. (1991). The Canadian Home Fitness Test. 1991 update. Sports Med, 11(6), 358-366.

Thomas S, Reading J, Shephard RJ. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Canadian Journal of Sport Science 1992;17:4 338-345.

Warburton, D. E. R., Jamnik, V. K., Bredin, S. S. D., & Gledhill, N. (2011). The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and electronic Physical Activity Readiness Medical Examination (ePARmed-X+). Health & Fitness Journal of Canada, 4(2), 3-23.

Warburton, D. E. R., Bredin, S. S. D., Jamnik, V., Shephard, R. J., & Gledhill, N. (2016). Consensus on Evidence-Based Preparticipation Screening and Risk Stratification Annual Review of Gerontology and Geriatrics (pp. 53-102): Springer Publishing Company.

NOTE: This article was written by Dr. Darren Warburton based on the personal recollections and peer-reviewed works of the key contributors/authors. The content contained in the original article was reviewed for accuracy and formally approved by Dr. Roy Shephard and Dr. Norman Gledhill.