Natalia Fernandez, PT, MS, MSc, CCS University of Michigan Health Care System Department of Physical Medicine and Rehabilitation.

Objectives Exercise Testing Choosing a Test (Indications & Contraindications) Administering a Test including 12 lead ECG during maximal graded exercise testing Interpreting the Test Results Why? outcome measure, baseline, determine limits Exercise Prescription Developing the Exercise Prescription Training Progression Re-evaluations

Why Exercise Test Determine the safety of exercise Develop Exercise Guidelines Monitor Progress Promote Patient Education/Motivation Research on treatment/training interventions

Risks of Exercise Testing Exercise Testing is Relatively Safe 170,000 GXT at 73 medical centers mortality rate 0.01% per 10,000 morbidity rate 0.03% per 10,000 Rochmis et al JAMA ,448 GXT at 1375 medical centers mortality rate % per 10,000 morbidity rate 0.09% per 10,000 Stuart & Ellestad Chest per 10,000 tests

Risks during Cardiac Rehabilitation In Cardiac Rehab Risks extremely low for supervised moderate activity Home & Clinic risk is equal Exception: Vigorous Exercise 100 x risk of healthy population

Minimizing Risks Pre-participation Screening/Health Risk Appraisal Identify individuals at risk for adverse events from exercise Exacerbation of conditions: Cardiovascular, Pulmonary, Metabolic Diseases ↑ Risk Factors requiring medical consult Require supervised exercise Special needs

Risk Factors

Minimizing Risks Assessment Determine who requires medical clearance, exercise testing, physician supervised testing ACSM Algorithm AHA/ACSM Questionnaire PAR-Q AACVPR & AHA Risk Stratification

Screening Risk Factors Low Younger asymptomatic With 1 or less risk factors Moderate Older or 2 + risk factors High 1+ signs/symptoms or known disease

Screening Major Signs & Symptoms Anginal Pain SOB Dizziness or Syncope Orthopnea or Nocturnal Dyspnea Intermittent Claudication Known heart murmur Unusual fatigue/SOB /w activity

Screening

Minimizing Risks Pre-Exercise Evaluations (con’t) Physical Examination Box (3-2) Body Comp Pulse rate and rhythm & Peripheral pulses BP; seated, supine & Standing Heart & Lung Auscultation Abdominal Evaluation Orthopedic/Neurological Function Skin & Lower Extremities

Minimizing Risks Pre-Exercise Evaluations (con’t) Laboratory Analysis (3-2) Lipid Profiles Glucose Thyroid Function Other (High Risk or known disease) Holter Monitor, ECG, angiography, Chest Radiograph, Ultrasound, PFT

Minimizing Risks

Contraindications to Testing Absolute Contraindications Recent significant ECG Change Unstable Angina Uncontrolled Arrythmias Severe Aortic Stenosis Uncontrolled Heart Failure PE or PI, Acute Myocarditis or pericarditis Dissecting aneurysm Acute Infections ACSM Ch. 3 p.50

Contraindications to Testing Relative Contraindications Left main coronary stenosis Moderate stenotic valve disease Electrolyte imbalance Severe HTN (200/110) Tachy-arrhythmias or brady-arrythmias Cardiomyopathy

Contraindications to Testing Other Relative Contraindications Neuro/Ortho disorders High Degree AV Block Ventricular aneurysm Uncontrolled metabolic disease Chronic infectious disease

Minimizing Risks Signed/Informed Consent (Fig 3-1) Be of lawful age Not be mentally incapacitated Know and comprehend risks Give voluntary consent Ambient Environment Temperature/humidity degrees F Organization, safety, privacy

Patient Pretest Instructions Wear comfortable shoes & clothing Drink plenty of water (See Fluid Guide Pyramid, Gatorade, Inc.) Avoid food, tobacco, alcohol & Caffeine 4 hrs prior to testing (or overnight) Avoid strenuous exercise the day of the test Get adequate sleep prior to the test

General Principles of exercise Testing

Minimizing Risks Monitoring HR and Rhythm [HR monitor or ECG], BP, RPE, SAO2 if h/o hypoxia (e.g. pulmonary disease, CHF, Renal Failure, etc.) Before, during and after Know in advance when to Stop the Test Be Prepared for an Emergency

RPE Scale

Choose the Exercise Tests Acute Care (Functional Assessment) Field Tests Submaximal Exercise Tests Symptom Limited GXT Maximal GXT Oxygen Analysis Tests Noonan & Dean ACSM

Submaximal Vs Maximal Tests Method Choose appropriate test protocol Bike test; treadmill test. Functional assessment Determine HR response to workloads Predict VO 2 with equations or graphs

Functional Assessment HRBPSaO2ECGRPE Supine70110/7097NSR6/20 Sit80112/7097NSR8/20 Stand90115/6896NSR11/20 Ambulate100120/6896NSR13/20

Exercise Guidelines No ExerciseLight Exercise Moderate Exercise Unrestricted Exercise Hematocrit ♀ ♂ <25%  25% 25-37% 25-40% 37-47% 40-50% Hemoglobin ♀ ♂ <8 g/dl.8-10 g/dl g/dl g/dl g/dl g/dl. WBC<5000/mm 3 with fever 5, ,000/mm 3 Platelets<20,000/mm 3 20, ,000mm 3 30, ,000mm3 From R.S. Sayre and B.C. Marcoux, 1992, L. Pfalzer 1988, Winningham, 1986

Clinical Exercise Testing Laboratory Testing Protocols (Fig 5-3) Screening/Diagnostic/Research Choose test protocol for individual Lasts ~ 9-12 minutes Types SLGXT Submaximal Maximal

Submaximal Vs Maximal Tests Accuracy Prediction Equations Assumptions Steady State HR achieved & measured HR increases linearly with workload HR & BMR are uniform for age/gender Mechanical Efficiency Submax is for functional interventions, to get target for EX percription. Maximal if for cardiac assessment.

Exercise Prescriptions Training HR Rate Range-Methods Age Adjusted Predicted Training Heart Rate Range [220- age] x (.50 to.70) HRR – Heart Rate Reserve/Karvonen Method HR threshold = HR rest (HR max - HR rest )

Submaximal Tests Astrand Bicycle Test 6 minute test Wattage: conditioning & gender Nomogram Correction Factor

Submaximal Tests YMCA Bicycle Test Start at 150 kg/m & 50 rpm Assess HR & determine next stage Use plot/graph to estimate max HR

Field Tests Walking/Running Tests Step Testing

Field Tests Walking/Running Tests 6 min & 12 min walk tests Rockport 1.0 Mile Test Cooper 12 minute & 1.5 mile Walk Tests Disadvantages Maximal tests & Little monitoring Assumes same mechanical efficiency Assumes similar Resting HR & HR response, BMR

Field Tests 6 min & 12 min walk tests Descriptive: Max distance Rockport 1.0 Mile VO 2 max incorporates age, gender, mass, time & HR Cooper 12 minute & 1.5 mile Walk Tests VO 2 max = / time in minutes

Field Tests Step Tests Benefits Used to assess large groups of subject Disadvantages Assesses Fitness Categories Similar Assumptions to other predictive equations

Test Guidelines Pre-Test Patient Instructions Screening/Risk Assessment (Par Q) Informed Consent Resting Vitals HR, BP, RR, ECG, SaO2; S & S

Test Guidelines Test Patient Instructions Warm-up Monitor & Record HR, BP RPE, ECG Determine Test Termination Cool Down

Test Termination Apparently Healthy Subject Reaches predetermined end point Subject requests to stop/marked fatigue Failure of Equipment Onset of angina > 20 mm Hg drop in BPs or failure to rise BPs > 260 mm Hg. or BPd >115 mm Hg S & S Failure of HR to  with workload increases Change in heart rhythm

Test Termination Apparently Healthy or Otherwise Subject Onset of angina > 20 mm Hg drop in BPs or failure to rise BPs > 260 mm Hg. or BPd >115 mm Hg Failure of HR to  with workload increases Change in heart rhythm S & S; confusion, dyspnea, leg cramps, etc.

Test Interpretation Parameters to Examine Reason test was terminated HR, BP, RR response MS response ECG Response SaO 2 response Signs & Symptoms: Angina, Dyspnea

Exercise Prescription Exercise prescription is based on - Test Interpretation --Person’s Initial Fitness Goal of training Intensity Duration Frequency Mode

Maximal Oxygen Uptake Aerobic Capacity Assessment: Gold Standard Treadmill or other protocol Parameters HR or VO 2 fail to rise with  in workload RPE = 19+ Respiratory Exchange Ratio (R) > 1.15 (CO 2 /O 2 ) HLa Levels