Mod 8: Endurance Training & Testing
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Transcript Mod 8: Endurance Training & Testing
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 1971
518,448 GXT at 1375 medical centers
mortality rate 0.0005% per 10,000
morbidity rate 0.09% per 10,000
Stuart & Ellestad Chest 1980
6 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
Risk Factors
Risk Factors
Risk Factors
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 70-75 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 VO2 with equations or graphs
Functional Assessment
HR
BP
SaO2
ECG
RPE
Supine
70
110/70
97
NSR
6/20
Sit
80
112/70
97
NSR
8/20
Stand
90
115/68
96
NSR
11/20
Ambulate
100
120/68
96
NSR
13/20
Exercise Guidelines
No Exercise
Light
Exercise
Moderate
Exercise
Unrestricted
Exercise
Hematocrit ♀
♂
<25%
25%
25-37%
25-40%
37-47%
Hemoglobin ♀
♂
<8 g/dl.
10-12 g/dl.
10-14 g/dl.
12-16 g/dl.
14-18 g/dl.
WBC
<5000/mm3
with fever
Platelets
<20,000/mm3
8-10 g/dl.
40-50%
5,00010,000/mm3
20,00030,00030,000mm3 50,000mm3
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 +
0.60 (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
VO2 max incorporates age, gender, mass, time & HR
Cooper 12 minute & 1.5 mile Walk Tests
VO2 max = 3.5 + 483/ 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
SaO2 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 VO2 fail to rise with in workload
RPE = 19+
Respiratory Exchange Ratio (R) > 1.15 (CO2 /O2)
HLa Levels