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
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mortality rate 0.01% per 10,000
morbidity rate 0.03% per 10,000
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Rochmis et al JAMA 1971
518,448 GXT at 1375 medical centers
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mortality rate 0.0005% per 10,000
morbidity rate 0.09% per 10,000
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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
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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
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ACSM Algorithm
AHA/ACSM Questionnaire
PAR-Q
AACVPR & AHA Risk Stratification
Screening
 Risk Factors
 Low
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Younger asymptomatic
With 1 or less risk factors
 Moderate
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Older or 2 + risk factors
 High
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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)
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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)
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Lipid Profiles
Glucose
Thyroid Function
 Other (High Risk or known disease)
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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
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Noonan & Dean
ACSM
Submaximal Vs Maximal Tests
 Method
 Choose appropriate test protocol
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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)
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Screening/Diagnostic/Research
Choose test protocol for individual
Lasts ~ 9-12 minutes
 Types
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SLGXT
Submaximal
Maximal
Submaximal Vs Maximal Tests
 Accuracy
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Prediction Equations
 Assumptions
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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
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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
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VO2 max = 3.5 + 483/ time in minutes
Field Tests
 Step Tests
 Benefits
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Used to assess large groups of subject
 Disadvantages
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Assesses Fitness Categories
Similar Assumptions to other predictive equations
Test Guidelines
 Pre-Test
 Patient Instructions
 Screening/Risk Assessment (Par Q)
 Informed Consent
 Resting Vitals
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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
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Intensity
Duration
Frequency
Mode
Maximal Oxygen Uptake
 Aerobic Capacity Assessment: Gold Standard
 Treadmill or other protocol
 Parameters
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HR or VO2 fail to rise with  in workload
RPE = 19+
Respiratory Exchange Ratio (R) > 1.15 (CO2 /O2)
HLa Levels