1. Aerobic Exercise Testing Maximal laboratory measurement & estimation protocols

2. Learning Objectives Discuss the importance of test characteristics: validity, reliability and applicability in normal populations and in clinical settings. Explain the components of fitness and performance with reference to basic principles of physics and physiology. Explain the rationale of named test protocols and discuss the acute physiological responses to testing. Explain and use fitness testing equipment and apply the principles of quality assurance.

3. Outline Introduction Terminology Common protocols Exclusion criteria Test termination criteria Interpretation of results Practical and DAI

4. Terminology Graded Exercise Test (GXT) Aerobic Power Aerobic Capacity - (VO 2max ) Aerobic Capacity - (VO 2peak )

5. Terminology Direct assessment: via pulmonary gas exchange –‘Measurement’ Indirect assessment –‘Estimation’ based on work ouput

6. What are we testing?

8. Protocols Bruce Modified Bruce Balke Naughton All incremental and continuous Discontinuous protocols used mainly in athletes

9. The Bruce Protocol (1973)

10. The Modified Bruce

11. Patient Preparation Par-Q Written Informed Consent Test Briefing –Protocol –RPE –Signals –What to do if things go wrong Practise treadmill walking

12. The Test Start –Position feedback –Hand position –Stride, gait and posture End of each stage –RPE –Signal –Encouragement

13. VO 2 max Achievement Criteria A plateau in your VO 2 with increased workload.

14. VO 2 peak Achievement Criteria HR within 10 beats of Max-est BLac of 8 – 10 mmol∙l R > 1.15 Failure of VO 2 to increase –Based on estimate from last stage (inappropriate)

15. Recovery Cool down –3 to 5 minutes or when heart rate and blood pressure has returned to recommended levels –keep subject moving and monitor condition –Be cautious, problems often occur during recovery Take rhythm strip at the end of each recovery minute Take blood pressure at 1, 3, 5 minutes into recovery –Note the condition of the patient and abnormalities on the EKG monitor

16. Recovery Verbally ensure the subject in doing well and has recovered from the test Disconnect the subject Advise subject –showering, –daily activity, –avoiding extreme temperatures

17. ACSM Absolute Indications Suspicion of a myocardial infarction or acute myocardial infarction (heart attack) Onset of moderate/severe angina (chest pain) Drop in SBP below standing resting pressure or with increasing workload accompanied by signs or symptoms Signs of poor perfusion

18. ACSM Absolute Indications Severe or unusual shortness of breath CNS (central nervous system) symptoms – ataxia, vertigo, visual or gait problems, confusion) Serious arrhythmias –second / third degree AV block, atrial fibrillation with fast ventricular response, increasing PVCs, sustained VT) Technical inability to monitor the ECG Patient's request (to stop)

19. ACSM Relative Indications Any chest pain that is increasing Physical/verbal manifestations of –shortness of breath –severe fatigue Wheezing Leg cramps or intermittent claudication (grade 3 on a 4-point scale) Hypertensive response –(SBP >260 mm Hg; DBP>115 mm Hg)

20. ACSM Relative Indications Pronounced ECG changes from baseline >2 mm of horizontal or down sloping ST- segment depression, or >2 mm of ST-segment elevation (except in aVR) Exercise-induced bundle branch block that cannot be distinguished from ventricular tachycardia Less serious arrhythmias (abnormal heart rhythms) such as supraventricular tachycardia

21. Interpretation and Exercise Prescription Calculate VO 2max and METS. Determine: exercise training intensity heart rate, RPE, or METs Have physician interpret ECG recordings Consult subject –review test results –exercise prescription –monitor outcome and behavioural changes

22. Measuring or Estimating VO 2 max Measurement - values Estimation Males & Male CHD –VO 2 max = 14.76 - 1.379 (T) + 0.451 (T^2) - 0.012 (T^3) SEE 3.35 ml.kg -1.min -1 With Handrail Support –VO 2 max = 2.282 (T) + 8.545 SEE 4.92 ml.kg -1.min -1

23. Estimating VO 2 max Women: –VO 2 max = 4.38 (T) - 3.90 ±2.7 ml.kg -1.min -1 Prediction equations –http://www.exrx.net/Calculators/Treadmill.htmlhttp://www.exrx.net/Calculators/Treadmill.html Full listings: –http://www.exrx.net/Testing/CardioTests.htmlhttp://www.exrx.net/Testing/CardioTests.html

24. Foster et al. MSSE, 28(6):752-756,1996.

26. Metabolic Equivalents (METs)

27. Calculating MET equivalents 1 MET = 3.5 ml.kg -1.min -1 Useful in exercise prescription and prognosis –http://www.exrx.net/Calculators/Treadmill.htmlhttp://www.exrx.net/Calculators/Treadmill.html

28. Summary Protocols Measurement –Direct, gold standard Estimation –Cost vs. accuracy Utilisation –Prescription, Assessment and Prognosis

29. References. Myers et al. The New England Journal of Medicine 346:14:11-16, 2002. Sui et al. J Am Geriatr Soc 55:1940–1947, 2007.