Exercise Testing Test 2

How do I calculate % improvement of my client?

FOLLOW-UP TEST SCORE - INITIAL TEST SCORE / INITIAL TEST SCORE Example: Muffy walked 1015 feet on her cardiac rehab entry 6MWT and 1472 feet on her 3 month follow-up test. What was Muffy's percent improvement in functional capacity over her 3 months in the cardiac rehab program? 1. 1472 feet - 1015 feet = 457 feet 2. 457 feet / 1015 feet = 0.453 0.45 x 100 = 45% 4. Muffy increased her performance on the 6MWT by 45%

6MWT INSTRUCTIONS

INSTRUCT THE PATIENT AS FOLLOWS: "The object of this test is to walk as far as possible for 6 minutes. You will walk around the cones. Six minutes is a long time to walk, so you will be exerting yourself. You will probably get out of breath or become exhausted. You are permitted to slow down, to stop, and to rest as necessary. You may lean against the wall while resting, but resume walking as soon as you are able."

Pretest Standardizations for CRF Assessments

Instruct your client to: • Have plenty of fluids for the previous 24 hours • Avoid strenuous exercise for the previous 24 hours • Obtain an adequate amount of sleep the night before the test • Avoid alcohol, tobacco, and caffeine with 3 hours of the test • Refrain from eating a large meal 1 hour prior to the test • Wear comfortable exercise-type clothing • Wear proper exercise shoes! • Sign the Informed Consent form • Take the PAR-Q (Canvas ACSM 2020 version) with screening

METS calculation

METS = VO2 (ml/kg/min) / 3.5

Factors that may decrease 6MWT performance.

Shorter height (shorter legs) • Female gender • Walking on a shorter distance with turns • Older age • Having COPD or cardiovascular disease (e.g., stroke) • Having musculoskeletal disorders (e.g., arthritis) • Higher ambient temperature, humidity, pollen count and/or air pollution • Walking on a self-paced treadmill for testing • Number of rest periods and time spent during rest

cycle ergometry

WORK (kg/m or kp/m) = FORCE (cycle braking resistance in kilograms or Newtons) x DISTANCE (distance in m traveled by the flywheel rim per revolution) - The flywheel distance varies by the brand, but is constant for each cycle ergometer of that brand. - The Monark cycle has a 6 meter per revolution ratio. - The flywheel travels 6 meters for a complete revolution of the pedal (down--up--down). - The flywheel itself is 1.62 meters in circumference and thus travels 3.7 circuits per pedal revolution.- 3.7 X 1.62 meters = 5.994 ~ 6.0 meters -A metronome is typically set at 100 beats/minute to produce 50 rpm (100 downstrokes of pedal). - This assures that the workload is constant and the amount of work being performed is constant. - As this rate is standardized for the Monark cycle, the subject will always be covering 300 meters/minute or 50 rpm x 6 meters/revolution.

BMI calculation

Weight (kg) / Height (meters2) • Weight in lbs. x .4536 • Height in inches x .0254 • Example: Zed is 6'0" and weighs 184 lbs. What is his BMI? - 184 lbs. x .4536 = 83.46 kg (1 lb. = 0.4536 kg) - 72 inches x .0254 = 1.83 meters (1 inch = 0.0254 meters) - (1.83)2 = 3.35- 83.46 / 3.35 = 24.91 (Zed is normal weight, just by a hair)

queens college step test or mcardale step test

• Based on research showing linear relationship between graded exercise HR and VO2 • Higher the HR, the lower the estimated VO2max (and vice versa)• 3 minutes—work in partners • Men: Set metronome at 96 bpm (24 steps/minute) • Women: Set metronome at 88 bpm (22 steps/minute) • 16.25" bench height • Foot cadence: UP LEFT- UP RIGHT- DOWN LEFT- DOWN RIGHT • HR taken immediately post-exercise (standing) • Females: VO2max (ml/kg/min) = 65.81 - (0.1847 x immediate post HR)

fixed distance tests

• Completion of a fixed distance as fast as possible • Two main types: - Walk Tests—Subject is strictly limited to walking • A formula using time and HR estimates cardiorespiratory fitness level (CRF)- Typically 1 mile - Walk/Run Tests—subject may utilize either method • A formula using time estimates CRF • Typically 1.5 miles- Pacing is Key (consider test trials on different days) • Need to consider a learning or practice effect

NON-EXERCISE PREDICTION EQUATION

• Estimates VO2max from various demographic variables and one's subjective estimation of their current physical activity and fitness level. • The equation used estimates functional capacity with an equation that includes body mass index (BMI), gender, degree of physical activity and physical capacity. • On average, if the subject estimates their fitness level and level of activity correctly, this equation can predict VO2max to within ± 3.5 ml/kg/min.

step tests

• Fixed amount of work in a fixed amount of time• Stepping up and down a specified step at a particular cadence for a fixed period of time (typically 3 minutes) • Different cadences for men and women • After completion, heart rate (HR) is measured (immediately) and used to estimate VO2max • Queens College Step Test (also called the McArdle Step Test) probably the most common protocol

cycle ergometer proper seat height

• Knee flexed ~ 25 degrees with full leg extension or... • Seat should align with the hip (greater trochanter) if standing beside the cycle and... • Client should maintain a comfortable, upright posture without gripping the handlebars too tightly

sources of error for step tests

• Leg fatigue • Following metronome with time and cadence (off the beat)• Poor balance• Improper bench height • High bench height • Short vs. tall person • Cadence too fast for older populations • Balance issues with older populations • Some guidelines say to sit after the test—brings out the variation in protocols (should not sit with Queens test) • Learning effect of test if performed more than once

ASTRAND-RHYMING STEP TEST

- Step height 33 cm (female) and 40 cm (men) • Metronome is set for 90 bpm (22.5 steps/ minute) • RPE measured at the end of each minute • HR measured immediately post-exercise via pulse palpation or HR monitor • Use the subject's HR and body weight to predict VO2max from the Astrand-Rhyming Nomogram (next slide) 1. BW (Female) = 70 kg 2. Step Test HR = 150 bpm 3. Est. absolute VO2max = 3.0 L/min. 4. Est. relative VO2max = (3.0 L/min. x 1000)/ 70 kg = 42.9 ml/kg/min.

maximal vs. submaximal testing

- The decision to use a maximal or submaximal exercise test depends largely on the reasons for the test, the risk level of the individual, and the availability of appropriate equipment and personnel (see Chapter 4). • Maximal tests require individuals to exercise to the point of volitional fatigue, which may be inappropriate for some individuals and may require the need for emergency equipment. • Exercise professionals often rely on submaximal exercise tests to assess CRF because maximal exercise testing is not always feasible in the health/fitness setting.

Test environment

- The demeanor of personnel should be one of relaxed confidence to put the subject at ease. - Testing procedures should not be rushed - All test procedures must be explained clearly prior to initiating the testing process. - Maintain a testing room temperature between 68°F and 72°F (20°C and 22°C) and a humidity of < 60% - Test anxiety/emotional issues, food in the stomach, bladder distention, room temperature, noise, lighting and ventilation should be controlled as much as possible. - To minimize subject anxiety, the test procedures should be explained adequately, and the test environment should be quiet and private. - The room should be equipped with a comfortable seat and/or examination table to be used for resting BP, HR and/or ECG recordings.

SOURCES OF ERROR: 1-MILE WALK TEST

- Inaccurate HR count and finding pulse (cannot take for an entire minute due to fast decrease, being off a beat and multiplying x 6) - Performing more than 1 test at a time - Learning or Practice Effect (lack of practice results in greater walking time; more practice results in less walking time) - Subject's diet, level of resting fatigue - Older patients might not be able to complete these tests (could be maximal for them) - Personal injury - Walking and talking with friends!! DO NOT DO THIS

cycle calibration

- MUST be performed on each cycle used to assure that the subject is pedaling at an accurate workload - Usually performed with 2-4 kg weights that hang from the suspension hook at the front of the flywheel. -The kg weight will move the pendulum to the proper marker on the scale at the side of the cycle ergometer. - The cycle is then adjusted with a screw device if the pendulum is off and the cycle is out of calibration

Pre-test instructions

- Perform the informed consent process - Have the subject complete a questionnaire: (PAR-Q) or the ACSM/AHA screening form. - Perform the exercise preparticipation health screening - Complete the pre-exercise evaluation

predicting maximal heart rate

- Predicted by equations with standard error ranges between ±10 and 15 bpm - Most commonly used age based equations: 1. Age-predicted HRmax = 220 - age (years) 2. Age-predicted HRmax = 208 - 0.7 (age) - Other equations have been developed to predict maximal HR, but remain controversial as no formula does a very good job - Bottom line: Must do max GXT to find true HRmax

cycle ergometers disadvantages

- Premature muscle fatigue from the workload on the quadriceps (local muscle fatigue) can result in submaximal performance before VO2max is achieved. - The measured functional capacity is usually 10-15% lower than that achieved on a treadmill. - Many find the seat uncomfortable, particularly older and thin populations. - The belt can come off the flywheel easily! - Cycling is not a common mode of exercise, particularly for older adults in the U.S. - The client must maintain a constant pedaling rate for accurate workload assessment.

6MWT VERBAL INSTRUCTIONS

"Remember that the object is to walk AS FAR AS POSSIBLEfor 6 minutes, but don't run or jog. Start now, or whenever you are ready." 1. After the first minute, tell the patient the following (in even tones): "You are doing well. You have 5 minutes to go." 2. When the timer shows 4 minutes remaining, tell the patientthe following: "Keep up the good work. You have 4 minutes to go." 3. When the timer shows 3 minutes remaining, tell the patientthe following: "You are doing well. You are halfway done." 4. When the timer shows 2 minutes remaining, tell the patient the following: "Keep up the good work. You have only 2 minutes left." 5. When the timer shows only 1 minute remaining, tell the patient: "You are doing well. You have only 1 minute to go." Do not use other words of encouragement (or body language to speed them up).

Estimates of VO2max from HR response to submaximal exercise tests are based on the following assumptions:

- A steady state HR is established for each work rate. - A linear relationship exists between HR and work rate. - The difference between predicted and actual MHR is small. - Mechanical efficiency is the same for everyone. - The individual is not on any HR altering medications (see Appendix A) or OTC products.

What is a submaximal exercise test?

- A test to measure the HR response and predict VO2max, which is a measure of functional capacity. - A client performs a fixed amount of work per unit of time that can be a single-stage or multi-stage test.- Examples: meters/min, miles/hour, etc. - Submaximal tests include: - YMCA cycle ergometer test - Astrand-Rhyming step test - 3 minute step test - Cooper 12-min test - 1.5 mile run - Rockport One-Mile Walk Test - 6 minute walk test****considered submaximal, this test may be somewhat maximal for the population it is used on (e.g., pulmonary rehab patients)

What information can we get from the submaximal exercise test?

- Estimated VO2max - What type of exercise your client likes - Normative data - How your client compares to people of their age and gender - Baseline fitness level data to compare to later and evaluate if a plan is working. - help set exercise goals. - help develop their exercise prescription (Ex Rx).

submaximal testing does this...

- Estimates VO2max - Includes most field tests - Heart rate is often the "deciding factor" - Affected by many different variables: Heat/Humidity, Caffeine, Anxiety, Smoking, Time of last meal, Medications

BASIC SUBMAXIMAL TESTING GUIDELINES

- Resting HR/BP in the exercise posture (on bike) - Client familiarized with the testing device - Exercise begins with 2-3 minute warm-up - 2-3 minute exercise stages - Consistent workload increments - HR monitored at least 2X each stage - BP last minute of each stage- RPE/Dyspnea/Angina scale last minute of each stage

cycle ergometer advantages

- The resistance is independent of body weight. - Upper body movement is minimal - other physiological measures such as heart rate, blood pressure and blood sampling can be taken more easily. - Power output can be measured directly. - Compared to a treadmill, cycle ergometers are relatively less expensive and there are no electrical requirements. - Cycle ergometers can be easily moved around on 2 rollers under the flywheel. - These type of ergometers are easily calibrated. - This is a "non-weight bearing" modality, making it a good choice for those with orthopedic injury, obesity, or chronic disease. - Cycles are relatively safe—less chance of falling off (as with the treadmill). - There is less extraneous noise and better stabilization for BP measurements on the arms. - Cycle ergometers require little space.

ACSM Leg Ergometry Equation

- VO2 (mL x kg-1 x min-1) = 1.8 (WR/BM) + 3.5 mL x kg-1 x min-1 + 3.5 mL x kg-1 x min-1 • BM= mass (weight) of subject in kg - WR= Work rate (power) in kg x meters x min-1, Convert when necessary - Power (Kgm x min-1) = R (kg) x D (m) x f (rev/minute) • R= resistance in kg (set by the tester) • D= distance of the fly wheel • 6m for Monark - 3m for Tunturi (we don't use this bike) • f = frequency in rpm (usually 50 or 60 rpm) NOTE: VO2 is reported as mL x kg-1 x min-1 • VO2 (mL x kg-1 x min-1) = 1.8 (work rate / body mass) + 3.5 mLkg-1 min-1 + 3.5 mLx kg-1 x min-1 (resting VO2) (unloaded cycling VO2) - Work rate (WR) = 4.0 kg x 6 m x 50 rpm- WR = 1200 kg x m x min-1 (1 kg resistance = 300 kg/m/min., 2 kg = 600 kg/m/min., etc.• VO2 (mL x kg-1 x min-1) = 1.8 (1200 / 70 kg) + 3.5 + 3.5 • VO2 = 30.85 + 7 • VO2 = 37.9 mL x kg-1 x min-1 • METS = 37.9 mL x kg-1 x min-1 / 3.5 = 10.83 METS

cardiorespiratory fitness

- a health-related component of fitness - low levels associated with increased risk of premature death from all causes, specifically cardiovascular disease. - Increases in CRF fitness are associated w/ a reduction in death from all causes. - High levels of CRF fitness are associated with higher levels of habitual PA, which in turn are associated with many health benefits. - The assessment of CRF fitness is an important part of a primary or secondary prevention and rehabilitation programs.

The Health-Related Components of Physical Fitness

- a strong relationship with good health - ability to perform daily activities with vigor - Are associated with a lower prevalence of chronic disease and health conditions and their risk factors

Purposes of Health-Related Physical Fitness Testing

- educating participants of their health status compared with the norms - helpful in the development of individualized exercise prescription - collecting data that allows for evaluation and outcome documentation - to motivate participants by establishing attainable fitness goals

ymca submaximal ergometer test: The error of this method is influenced by such factors as:

- variation in age-predicted HRmax. •mechanical efficiency. •one's physical condition (e.g., cyclist vs. runner). •one's physiologic status (e.g., effects of smoking, fatigue, caffeine, meds). •poor extrapolation techniques (must use grid on Canvas). - VO2max estimation may range from ~ 10% to 15% for trained and untrained individuals, respectively.

REVIEW FROM KNES 3281: ERGOMETRY

-Ergo = Work -Meter = Measure - Ergometry = The study of measuring work - EXTERNAL WORK: Work performed in the environment against a resistance to create energy - INTERNAL WORK: Work performed within the body to overcome inertia

What is kcal utilization over 20 minutes on a Monark cycle ergometer if a subject's VO2 = 1745 mL x min -1?

1) 1745 (mL x min-1) / 1000 = 1.75 L x min-1 2) 1.75 (L x min-1) x 5.05 (kcals x L-1) = 8.84 (kcals x min-1) 3) 8.84 (kcals x min-1) x 20 min = 176.8 ~ 177 kcals expended over 20 minutes

An ideal health-related physical fitness test is

1) Reliable 2) valid 3) relatively inexpensive 4) easy to administer

An ideal health-related physical fitness test should

1) yield results that are indicative of the current state of fitness 2) reflect positive changes in health status from participation in a physical activity or exercise intervention 3) be directly comparable to normative data.

Astrand-Rhyming ergometer Test

1. Subject warms up for 2-3 minutes at 0 resistance and 50 rpm. 2. Subject then pedals for 6 minutes at a workload chosen to try and elicit a steady-state HR between 125 and 170 bpm: - Unconditioned Men: 300 - 600 kg/m/min. - Conditioned Men: 600 - 900 kg/m/min. - Unconditioned Women: 300 - 450 kg/m/min. - Conditioned Women: 450 - 600 kg/m/min - Poorly conditioned or older individuals: 300 kg/m/min. 1. Record HR every minute. 2. If the HRs for minutes 5 and 6 are not within 5 beats of each other, pedal for an extra minute. 3. Goal is to reach a steady state HR between 125 and 170 bpm (if < 125 bpm, increase workload). 4. Plot a line on the nomogram that connects the steady state HR and the steady state workload. 5. Where the line crosses the VO2max line is the estimated VO2max (liters/minute). 6. Multiply estimated VO2max by a correction factor (0.65 to 1.1) depending upon the subject's age.

1 watt

6.12 kg-m/minute = 1 Joule/second

WHAT IS THE DIFFERENCE BETWEEN DETERMINING IF A TEST IS VALID VS. DETERMINING IF A TEST IS RELIABLE?

A valid test: is an accurate measure. A reliable test: consistently measures a similar result.

What is the VO2 and METS for a 72 kg woman pedaling on a Schwinn Airdyne cycle ergometer at 2 "Airdyne units"?

NOTE: One Airdyne unit = 300 ( kg x m x min-1) or 50 w - VO2 (mL x kg-1 x min-1) = 1.8 (work rate / body mass) + 3.5 (mL x kg-1 x min-1) + 3.5 (mL x kg-1 x min-1) ( (resting VO2), (unloaded cycling VO2) ) - VO2 = 1.8 x 600 (kg x m x min-1) / 72 kg + 7 (mL x kg-1 x min-1) - VO2 = 15.0 ( mL x kg-1 x min-1) + 7 mL x kg-1 x min-1) - VO2 = 22.0 (mL x kg-1 x min-1) METS = 22.0 (mL x kg-1 x min-1 ) / 3.5 = 6.3 METS

ACSM 6MWT EQUATION

Predicted VO2peak (ml/kg/min) = [0.02 x distance (m)] - [0.191 x age (yrs)] - [0.07 x weight (kg)] +[0.09 x height (cm)] + [0.026 x RPP] + 2.45 Where: m = distance in meters yrs = years kg = kilograms cm = centimeters RPP = rate pressure product (HR x systolic BP x 0.01)

Suppose Raven has a VO2 max test and peaks at 30 mL/kg/min...

Target VO2 =[(VO2max -VO2rest) x % intensity] + VO2rest Step 1: calculate vo2 reserve (vo2 R) VO2 R = VO2 max - VO2 rest VO2 R = 30 (ml x kg-1 x min-1) - 3.5 (ml x kg-1 x min-1) VO2 R= 26.5 (ml x kg -1 xmin-1) step 2: calculate exercise intensity as a % of VO2R convert the desired intensity (%VO2R) to a decimal % VO2 R = desired Intensity x % VO2 R Step 3: % VO2R = 0.6 x 26.5 (ml x kg-1 xmin-1) = 15.9 (ml x kg-1 xmin-1) Step 4: 15.9 (ml x kg-1 xmin-1) + 3.5 (ml x kg-1 xmin-1) = 19.4 (ml x kg-1 xmin-1) - ravens target VO2 range is 19.4 to 24.7 (ml x kg-1 xmin-1) or 5.5 to 7.1 METS

test organization

The following should be accomplished before the client/patient arrives at the test site - Ensure that all testing documents are organized and available for test administration. - Calibrate all equipment at least monthly, or more frequently based on use. - be familiar with the emergency response plan -Resting measurements should be obtained first (heart rate, blood pressure, height, weight, body composition). - Sufficient time should be allowed for HR and BP to return to baseline between tests conducted serially. - Organize all equipment so that each test can follow in sequence without stressing the same muscle group repeatedly. - Be sure to provide an informed consent form.

YMCA Cycle Ergometer Test "Steady State"

To assure that you have reached a "steady-state workload, the heart rate values must be within 5-6 beats of each other for each minute during the stage. Example: Frank is in Stage II of his YMCA test. His heart rates (bpm) for each minute are as follows: Minute 1: 112 Minute 2: 118 Minute 3: 127 Frank has NOT reached a steady state level of exercise during Stage II of the test because there is > than 5-6 bpm between the HRs of minute 2 and minute 3. How do you proceed? • Frank must pedal an additional minute and attempt to achieve a HR that is within 5-6 beats of 127 bpm (e.g., 130 bpm). • If he does, you would plot his HR for the 4th minute on the YMCA grid as your 2nd HR (130 bpm). • If he does not (e.g., his HR = 136 bpm) you cannot plot a 4th minute HR and the test is invalid.

estimating vo2 max

VO2 (ml/kg/min) = VO2 (L/min) x 1000 Body Weight (kg)

DOES THE SUBJECT WITH THE HIGHER IMMEDIATE POST-EXERCISE HR HAVE THE HIGHER OR LOWER FITNESS LEVEL?

lower fitness level

1 kilogram-meter

work in which the product of force (kg) acts against a kg weight through a distance = 1 kg-m = 1 kp-m (at sea level)

1 kilopond-meter

work in which the product of force (kp) acts against a kg mass through a distance = 1 kp-m = 9.81 joules = 0.00234 kilocalories (kcal)Note: Do not use this kcal equivalent in your lab calculations.

Why Measure Cardiorespiratory Fitness (CRF)?

• Low CRF is an independent risk factor for cardiovascular mortality—gigantic research finding • Individualization of exercise prescription • Tracking exercise progress (pre- and post-tests for outcomes assessment) • Clinical purposes with patients with chronic diseases• Motivation for the client or patient • To determine an estimated VO2max • To compare individual CRF values to normative values and percentiles • Overall health risk assessment • Determine MET levels for ADLs, vocational and recreational activities (e.g., snow shoveling, carrying groceries, swimming, golf) • Return to work assessment (occupational disability assessment—MET standards are in place) • Can provide diagnostic and prognostic information (e.g., orthopedic limitations, ECG changes for some tests, exercise oxygen saturation levels)

1.5 mile run/jog test

• Materials Needed: Stopwatches, calculators, marked area for walking (large gymnasium or outdoor track) • The time it takes to jog or run 1.5 miles • The formula used to calculate VO2max is: 3.5 + [483 ÷ Time (minutes)] • Factors that affect accuracy: - Proper pacing - Subject motivation - Amount of practice and training - How strictly the test is conducted (e.g., is the distance exactly 1.5 miles?) - Outside or inside temperature and humidity - Performing other fitness tests on the same day

What Is the Gold Standard Test?

• Maximal exercise test with collection of expired gases and ECG analysis using a treadmill • Highly involved regarding both time and expense • Many alternative approaches, falling into two categories: - Field tests: Take place in a variety of non-laboratory settings, typically by a group of people- Submaximal exercise tests: Tests with the level of effort limited to submaximal exertion, typically performed by an individual in a laboratory setting NOTE: Field fitness tests are also submaximal tests.

The Concept of Maximal Oxygen Uptake

• Maximal volume of oxygen consumed per unit of time (VO2max) is accepted as the criterion measure of CRF. • This variable can be expressed in relative (mL · kg−1 · min−1) or absolute (mL · min−1) values. Relative values allow for comparisons amongst individuals of different body sizes. • VO2max is the product of cardiac output (Q) and arterial venous oxygen difference (A-VO2 diff).

Incremental Shuttle Walk Test

• Measures symptom-limited walking distance over a marked, 10 meter (33 feet) course. • Walking distance correlates well with VO2peak .• Utilizes an audible pacing timer to incrementally increase the pacing frequency. • Patient walks at the pace until they are too tired; total distance walked to that point is measured. • Test should be performed twice due to learning effect with a patient rest of at least 30 minutes between tests (or on different days). • Test is both valid and reliable in pulmonary populations. • PRIMARY OUTCOME IS WALKING DISTANCE measured to the nearest 10 meters (33 feet). • Change of 78.7 m (258 feet) associated with feeling "slightly better" • MCID for the ISWT in PR = 47.5 m (156 feet) • 2 cones are set out 9 meters (29.5 feet) apart, but the distance walked around the cones is 10 m (33 feet) • NO encouragement given during test • Patient walks alone and rates dyspnea/RPE • End the test when the patient is more than 0.5 m (1.6 feet) away from the cone when the beep sounds (allow one lap to catch up) • Immediately record SpO2, HR, and dyspnea rating while the patient is sitting or standing (measurements taken before and after the test should be done with the patient in the same position). • Many reference equations for VO2peak

Estimation of VO2max (when using Queens College protocol)

• Men: VO2max (mL . kg-1 . min-1) = 111.33 - (0.42 × HR) • Women: VO2max (mL . kg-1 . min-1) = 65.81 - (0.1847 × HR)- HR = immediate recovery HR (bpm) Example: Male finishing with an HR of 144 bpm, then: • VO2max (mL . kg-1 . min-1) = 111.33 - (0.42 × 144 bpm) = 50.85 mL . kg-1 . min-1

6MWT

• Most popular submaximal test used in cardiac, pulmonary and cancer rehabilitation today • Determines how far a patient can walk around a track or in a hallway in a 6-minute time period • Blood pressure is measured pre- and immediate post-exercise • RPE and Dyspnea measured with Borg scales • SaO2 (arterial oxygen saturation) measured throughout test • Normative data available • Should NOT walk with the patient (can distance walked) • Easy to administer • Walking is familiar to most individuals • Multiple studies performed on multiple clinical populations • Strong correlation with functional capacity in many patient populations • Strong predictor of morbidity and mortality • Has been determined to be both a valid and reliable test from many studies

Field Tests for Prediction of Aerobic Capacity

• Origins in physical education (PE) curricula • Low cost, minimal equipment, lower level of training necessary (e.g., BS vs. MS) • Generally safe (partially due to young, low-risk groups in PE) • Screening procedures are necessary as different populations may perform differing levels of exertion to complete the activities (e.g., PAR-Q, overall health history, ACSM screening tools) • Designed to be administered at the level of the ACSM Certified Exercise Physiologist (ACSM-EP)

ymca submaximal cycle test graphing method #1:

• Plot the TWO HR's on the corresponding work output data points (x-axis) on your YMCA grid that are > 110 bpm .• Draw a horizontal line at the age-predicted maximal HR level across the top of the graph paper. • Connect the two data points (HR's) and extend this straight line to the horizontal age-predicted max HR line at the top .• Extend a perpendicular line down from this intersection point to the x-axis to determine the the estimated (predicted) maximal workload and VO2 level (in liters/minute). - OR, extend the line down to the predicted maximal workload in kg/m/min. - Then, use the ACSM cycle ergometer formula to predict VO2max (see Example Sophie (age 20 and 70 kg) has a HR of 100 bpm pedaling at 150 kg-m/min (stage I). She then increases her HR to 127 bpm pedaling at 450 kg/m/min during stage II of the YMCA cycle test and to a HR of 141 during stage III of the test at 600 kg/m/min. What is her estimated VO2max? 1. Line drawn down to x-axis bisects with 1200 kg/m/min or 2.8 Liters/min (from grid values) 2. VO2 (ml/kg/min) = VO2 (L/min) x 1000 Body Weight (kg) 3. VO2 (ml/kg/min) = 2.8 L/min x 1000 70 kg4. VO2 = 40 ml/kg/min

monitoring submaximal field tests

• Signs of fatigue or distress • Heart rate (required for assessment of CRF) • Blood pressure (optional, but more often in laboratory setting—needed for 6MWT equation) • RPE and Dyspnea (Borg scales, if applicable) • Usually no ECG, VO2 (except in lab setting or research) • SaO2 (think back to PFT lab in 3281) • NOTE: Monitoring is not nearly as extensive as in the clinical or laboratory setting!

Endurance shuttle walk test

• Standardized, externally controlled, constant-paced walking test for assessment of cardiorespiratory endurance capacity • ISWT is performed first; a paced walking speed is then set at 85% of the walking speed on the ISWT • ESWT is the field equivalent of a constant workload test • PRIMARY OUTCOME IS WALKING TIME • Increases in VO2peak more responsive to PR training effect than is ISWT • MCID for the ESWT in PR = 180 s (3 min.) • Test ends when the patient reaches 85% predicted of HR max

You want Raven to exercise at 60-80% of her stepping pace previously calculated. How do you determine this for her exercise prescription?

• Stepping VO2 = 16.8 mL x kg-1 x min-1 • 60% of 16.8 = .60 x 16.8 = 10.1 mL x kg-1 x min-1 • 80% of 16.8 = .80 x 16.8 = 13.4 mL x kg-1 x min-1 Therefore, you want your client to exercise at a level of 10.1 to 13.4 Therefore, you want your client to exercise at a level of 10.1 to 13.4 mL x kg-1 x min-1 or 2.9 to 3.8 METS.

fixed time tests

• Subject completes maximum distance in a fixed amount of time • 12 minutes is the most commonly used time • EXAMPLE: For the Cooper 12-Minute Run Test, CRF is estimated as follows: VO2max (mL . kg-1 . min-1) = (distance in meters - 504.9) /44.73

Factors that increase 6MWT performance

• Taller height (longer legs) • Male gender • Walking on an indoor oval track • Walking on a straight hallway (< 100 feet) • High motivation • Words or positive gestures of encouragement • Having performed the test (learning/practice effect) • Meds immediately prior to test (pulmonary inhalers) • Oxygen supplementation • Exercise training

important 6mwt considerations

• This is a reliable and valid measure of exercise capacity for those with chronic lung disease. • Definite learning effect (2nd test usually better than the 1st test). • MANY 6MWT prediction equations for VO2 out there! • Rare adverse events during testing; usually oxygen desaturation observed. • Walking aids (e.g., Rollators) and oxygen improve 6MWT performance .• Strong association between shorter 6MWT distances and increased mortality in COPD, pulmonary HTN, and those awaiting lung transplant. • Primary outcome measure is distance walked • Minimal important difference is between 25 and 33 meters (82—108 feet) with 30 meters (98 feet) most often cited in the literature today • Relationship between 6MWT distance and VO2peak during an incremental cardiopulmonary GXT is strong, with correlation coefficients ranging from 0.4 to 0.8 across patient groups • Relationship between 6MWT distance and peak work shows correlation coefficients ranging from 0.58 to 0.93 • This may be considered a "maximal" test for those who are low functioning with moderate to severe lung disease • Should NOT perform on a treadmill. WHY? mights be going either too fast or too slow • Longer distances walked on oval track vs. straight hallway (more than 13-19 meters or 43—62 feet) and on longer hallways than shorter hallways (probably due to number of turns) • Average increase of 30.5 meters (100 feet) if encouragement every 30 seconds 6MWT WORK = 6MWT Distance x Body Weight (kg)

Deciding Which Method to Use

• Time required • Expense • Personnel (who is licensed or certified to do test) • Equipment and facilities required and available • Risk level of subjects (e.g., disease, injuries, high risk) • Degree of medical supervision (rehab vs. HS track) • Environment • Purpose of the test for the subject

Calculation of Energy Expenditure: Stair Stepping

• VO2 (mL x kg-1 x min-1) = (0.2 x f) + (1.33 x 1.8 x H x f) + 3.5 mL x kg-1 x min-1 f = stepping frequency in minutes H = step height in meters • VO2 (mL x kg-1 x min-1) = 0.2 (steps x min-1) + [(1.33 mL x kg-1 x meter-1) x (1.8 mL x kg-1 x meter-1) x (step height in meters) x (steps x min-1)]+ 3.5 mL x kg-1 x min-1 Conversion: 1 inch = 0.0254 meters Most accurate for step rates from 12-30 steps x min-1 and step heights 0.04 to 40 m (1.6 to 15.7 inches VO2 is reported as mL x kg -1 x min -1 or METS

What is the oxygen consumption of Raven who performs step aerobics on a step 4 inches high at 30 steps/minute?

• VO2 (mL x kg-1 x min-1) = (0.2 x f) + (1.33 x 1.8 x H x f) + 3.5 mL x kg-1 x min-1 f = stepping frequency in minutes H = step height in meters • VO2 (mL x kg-1 x min-1) = 0.2 (steps x min-1) + [(1.33 mL x kg-1 x meter-1) x (1.8 mL x kg-1 x meter-1) x (step height in meters) x (steps x min-1)]+ 3.5 mL x kg-1 x min-1 • VO2 (mL x kg-1 x min-1) = 0.2 (30 steps x min-1) + [(1.33 mL x kg-1 x meter-1) x (1.8 mL x kg-1 meter-1) x (4 inches x 0.0254) x (30 steps x min-1)]+ 3.5 mL x kg-1 x min-1 • VO2 (mL x kg-1 x min-1) = 6 steps x min-1 + [(1.33 mL x kg-1 x meter-1) x (1.8 mL x kg-1 x meter-1) x (0.1016 m) x (30 steps x min-1)] + 3.5 mL x kg-1 x min-1 VO2 (mL x kg-1 x min-1) = 6 + [(1.33 mL x kg-1 x meter-1) x (1.8 mL x kg-1 x meter-1) x (0.1016 m) x (30 steps x min-1)]+ 3.5 mL x kg-1 x min-1 • VO2 (mL x kg-1 x min-1) = 6 + (7.3) + 3.5 mL x kg-1 x min-1 • VO2 (mL x kg-1 x min-1) = 16.8 mL x kg-1 x min-1

What is the energy cost (Kcal) of a 50 kg woman pedaling the Monark bike for 30 minutes at a VO2 level of 20 mL x kg-1 x min-1 (think back to kcal lab in KNES 3281)

• VO2 = 20 mL x kg-1 x min-1 • VO2 in L x min-1 = (VO2 in mL x kg-1 x min-1) (body mass) / 1000 • VO2 in L x min-1 = (20 mL x kg-1 x min-1) (50 kg) / 1000 • VO2 = 1.0 L x min-1 • Net caloric expenditure in Kcal x min-1 = 1.0 L x min-1 x 5.05 kcal/L ~ 5.1 Kcal x min-1 Net caloric expenditure for 30 minutes = 5.1 Kcal x min-1 x 30 minutes = 153 Kcal

ERGOMETRY

• WORK = FORCE (Kg or Newton) x DISTANCE (meter or ft.) • POWER = WORK (Kg/m) / TIME (min.) • Kelsey lifts a 5 kg weight 3 meters. She has done 15 kg/m of work. ( 5 x 3 = 15) If she does this over 2 minutes, her rate of power is 7.5 kg/m/min. (15/ 2 = 7.5)

BMI SOURCES OF ERROR: NON-EXERCISE PREDICTION EQUATION

• Wrong BMI calculation • Not measuring height and weight accurately • Under-estimation of one's fitness and/or physical activity level • Over-estimation of one's one's fitness and/or physical activity level • Actual subjective estimation from the PAR and PFA scales (rating things incorrectly)

the 1 mile walk test

•Materials Needed: Stopwatches, calculators, marked area for walking (large gymnasium, outdoor track or paved walkway), lap counters The formula used to calculate VO2max is: •Predicted VO2max (ml/kg/min) = 132.853 - (0.1692 × Weight in kg.) - (0.3877 × Age) + (6.315 × Gender) - (3.2649 × Time) - (0.1565 × Heart Rate) Where: •Weight is in kilograms (kg.) •Age is in years •Gender: Male = 1 and Female = 0 •Time is expressed in minutes and 100ths of minutes (e.g., 21:25 = 21 + 25/60 = 21.42) •Heart rate is in beats/minute (immediately post exercise)

YMCA submaximal cycle test

•THE PREMISE FOR THIS TEST IS THAT ONCE YOU ACHIEVE A STEADY-STATE HEART RATE, YOU CAN PREDICT VO2max FROM THE SUBJECT'S STEADY-STATE HEART RATES AT THE GIVEN WORKLOADS. Resistance—the force that the pendulum weight applies to the friction belt Cadence—revolutions per minute (usually 50-60) Flywheel distance—Distance the circumference of the flywheel travels per complete pedal revolution - Dependent on brand of cycle - Monark (most popular) = 6 m . rev-1 ratio - Monark Arm Ergometer = 3 m . rev-1 ratio • Work performed per unit of time • Work output (kp . m . min-1) =- Resistance (kg) × Revolutions per minute (rpm) × Flywheel distance traveled in 1 down-up-down pedal revolution (flywheel is 1.62 meters in circumference and travels 3.7 circuits per pedal revolution (m . rev-1) • Example: 2 kp x 50 rpm x 6 meters (1.62 x 3.7) = - 600 kg/m/min-1 (Watts = kg . m . min-1 / 6.12) • Work outputs are dependent on cycle ergometer settings • Used to estimate VO2, VO2peak, + VO2max • Establish a relationship between HR and work rate • Two to four 3-4 minute exercise stages- Total test time ranges from 6-16 minutes • Stage I has a set work rate (150 kg/m/min)with the subsequent stages being based on the stage I HR • This is a setting of 0.5 kp on the bike's force scale • You must obtain two separate workloads resulting in HR values between 110 and 150 bpm • Cadence is always kept at 50 rpm for this particular test