International Journal of Cardiology 140 (2010) 236 257

www.elsevier.com/locate/ijcard

Letters to the Editor

What are we measuring? Considerations on subjective ratings of perceived
exertion in obese patients for exercise prescription in cardiac
rehabilitation programs
Luca Alessandro Gondoni , Ferruccio Nibbio, Giulia Caetani,
Giovanni Augello, Anna Maria Titon
Unit of Cardiac Rehabilitation Ospedale San Giuseppe, IRCCS Istituto Auxologico Italiano, Verbania, Italy
Received 7 November 2008; accepted 8 November 2008
Available online 6 December 2008

Abstract

We sought to describe the differences in exercise prescription in obese subjects using attained METs as compared to the subjective
perception of the effort using the Borg scale ratings of perceived exertion (Borg RPE). We studied 552 obese patients who underwent an
exercise stress test in the setting of a rehabilitation program. Exercise was prescribed at 70% of peak attained METS. This method was
compared to an exercise level prescription that induces a subjective perception of mild fatigue (13 on the 20 points Borg scale). Attained
METS were 6.2 2.5 and Borg RPE was 15.2 1.7. Borg RPE was negatively related to intensity and duration of exercise. Females, patient
with a lower level of education and patients on diuretics perceived higher efforts. Patients who stopped exercising because of dyspnea or
angina reached a lower level of METs (4.7 1.7 vs 6.3 2.7 METs; P b 0.001) but the perceived effort was similar (15.5 1.7 vs 15.2 1.7;
P = 0.252). The subjective method would have yielded a significantly higher training workload: 5.4 2.3 vs 4.3 1.8 (P b 0.001). In
conclusion, in obese patients, Borg RPE is not equivalent to attained METs in exercise prescription and it influenced by educational level.
2008 Elsevier Ireland Ltd. All rights reserved.

Keywords: Obesity; Exercise; Rehabilitation

1. Introduction Nevertheless current guidelines suggest to use 50 to 80% of

The efficacy of exercise training in patients with cardio-
vascular disease is well established [1]. Patients should be
trained at an intensity as close as possible to the ventilatory
threshold, but this parameter is not routinely measured prior to
exercise prescription. Using heart rate response to exercise
could be difficult in patients with ischemic heart disease who
are almost always treated with beta-blockers, particularly in
obese patients whose chronotropic response to exercise is
altered [2]. Subjective evaluation of effort has long since been
proposed as a method for exercise prescription [35].
Corresponding author. Tel.: +39 0323514359; fax: +39 0323514371.
E-mail address: gondoni@auxologico.it (L.A. Gondoni).
exercise capacity measured in an objective way [6] and Borg
RPE scale has been rarely used in obese patients [7,8].
We sought to describe the differences in the intensity of
exercise prescription for obese subjects with the use of attained
METs as compared to subjective RPE and to define the
relationships between Borg RPE value and other variables.
2. Methods
We studied 552 consecutive obese patients (body mass
index 30 kg/m2) who underwent a symptom limited exercise
test conducted on a motorized treadmill with an individualized
ramp protocol that has been described before [9]. The test was
terminated when limiting symptoms occurred. Shortly after the
completion of the test each patient was asked to describe his/
 Letters to the Editor 237

her subjective perception of effort utilizing the 20 points Borg

scale [10].
Exercise was prescribed with a target of 70% of peak
attained METs. As an alternative, since patients are supposed
to reach a training level that induces a subjective perception
of mild fatigue (set at the level of 13 on the 20 points Borg
scale) it was assumed that, if a patient rates his/her effort 13
or lower, the maximum attained level of METs was
coincident with the training workload; on the contrary, if
the patient rates the effort N 13, the training workload was
calculated by multiplying the peak attained METs times the
ratio between 13 and the perceived Borg value.
Educational status was coded as: low = no titleelemen-
tarymiddle school, or high = high schooluniversity degree.
t-test for unpaired data or for paired data were executed as
appropriate. Pearson's bivariate correlations and partial
correlations were calculated.

3. Results
The general characteristics of the study population are
described in Table 1.
Exercise test duration was 481 157 s (range 180973),
attained METs were 6.2 2.5 (range 2.016.9), while Borg
RPE was 15.2 1.7 (range 819).
Fig. 1 shows the distribution of the response to Borg RPE.
424 patients vs 128 used an uneven number of the scale.
RPE was negatively related to intensity and duration of
exercise (R = 0.114, P = 0.007 and R = 0.089, P = 0.036
respectively). It was also related to sex, level of education and
the use of diuretics (Table 2). Considered as a whole, less
educated patients rated their effort as higher and exercised less
than their more educated counterpart. In the less educated
patients the correlation between attained METs and subjec-
tively perceived effort was negative and stronger (R = 0.176;
P = 0.001) whereas in others the correlation tended to be
positive, but was not statistically significant (R = 0.043;
P = 0.057).
Borg index was not related to diagnosis, BMI, age, ejection
fraction, HR behavior during the test, the difference between
predicted and attained METs, use of drugs other than diuretics,
smoking habits.
Fig. 1 Distribution of the results of perceived effort.
Patients who stopped exercising because of dyspnea or
angina were more frequently women (51% vs 29%;
P = 0.008); moreover they had higher BMI (41.3 7.4 vs
38.5 5.0; P = 0.003), and exercised less (4.7 1.7 vs 6.3 2.7
METs; P b 0.001); however RPE was similar (15.5 1.7 vs
15.2 1.7; P = 0.252).
If we used the method based on the subjective perception
we would have prescribed a significantly higher training
workload: 5.4 2.3 vs 4.3 1.8 METs (P b 0.001).
4. Discussion
Our study demonstrates that objectively and subjectively
based methods for exercise prescription are not equivalent.
Two observations cast doubts on the utility of Borg RPE:
uneven values of the scale, which are the ones that are followed
by a definition, were by far the more commonly chosen and
patients who stopped their exercise because of angina or
dyspnea gave the same subjective rating compared to patients
who stopped because of muscular fatigue. The reason why the
vast majority of patients chose values that are associated with

Table 2
Table 1
BORG P METS P
Age (years) 60.1 9.6 (range 2584)
Males 365 (66%) Level of education
BMI (kg/m2) 38.8 4.9 (range 30.157.9) Low 15.3 1.6 0.029 5.9 2.4 b0.001
Current smokers 83 (15%) High 15.0 1.8 6.9 2.6
Ischemic heart disease 381 (69%)
Low ejection fraction 146 (26%) Sex
Hypertension 430 (78%) Males 15.1 1.7 0.006 6.8 2.6 b0.001
Diabetes 214 (39%) Females 15.5 1.7 5.0 1.9
Education level
High 186 (34%) Use of diuretics
Low 366 (66%) Yes 15.4 1.7 0.004 5.6 2.2 b0.001
No 15.0 1.6 7.2 2.8
BMI = body mass index.
238
an explicit description is unclear, but it could be related to the
low familiarity of the patients with subjective scales. Indeed
the possibility exists that less educated patients find it difficult
to understand the meaning of the scale or consider it useless
[11]. Possibly poorly educated patients experience embarrass-
ment in declaring that they are tired and tend to minimize the
effort they have actually perceived, being sometimes evidently
fatigued and tachipneic, but generally grading their effort
choosing an intermediate point of the scale.
Women perceived their effort as heavier probably because
they are less active than males. Other authors found similar
results, even if the difference between genders disappeared
after correction for heart rate and oxygen consumption [12].
Another determinant of Borg RPE is the use of diuretics:
patients on diuretic treatment also reached a lower level of
exercise, being the more functionally compromised.
The three variables taken together explain only a very modest
portion of RPE variability indicating that other parameters are
relevant [13]. Nevertheless blood lactate measurement as well as
the direct measure of oxygen consumption are not routinely
performed and it seems complicated and expensive to extend
their use in clinical practice.
Whatever the causes, using Borg RPE to define the training
program the mean level of exercise would have been higher by
20% and there would have been a relevant percentage (21%) of
patients that would have had to exercise at their maximal
achievable level.
In conclusion subjective perception of effort it is not a
useful tool to prescribe exercise in obese patients and it is not
equivalent to an objectively based method. Level of edu-
cation, sex and use of diuretics are the main variables, among
the available ones in everyday practice, that influence sub-
jective exercise perception.
Acknowledgement
The authors of this manuscript have certified that they
comply with the Principles of Ethical Publishing in the
International Journal of Cardiology [14].
0167-5273/$ - see front matter 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijcard.2008.11.068
Letters to the Editor
References
[1] Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K,
Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based
rehabilitation for patients with coronary heart disease: systematic
review and meta-analysis of randomized controlled trials. Am J Med
2004;116:68292.
[2] Gondoni LA, Titon AM, Nibbio F, Augello G, Caetani G, Liuzzi A. Heart
rate behavior during an exercise stress test in obese patients. Nutr Metab
Cardiovasc Dis 2009;19:1706.
[3] Dunbar CC, Robertson RJ, Baun R, Blandin MF, Metz K, Burdett R,
Goss FL. The validity of regulating exercise intensity by ratings of
perceived exertion. Med Sci Sports Exerc 1992;24:949.
[4] Dunbar CC, Goris C, Michielli DW, Kalinski MI. Accuracy and repro-
ducibility of an exercise prescription based on ratings of perceived
exertion for treadmill and cycle ergometer exercise. Percept Mot Skills
1994;78:133544.
[5] Tabet JY, Meurin P, Teboul F, Tartiere JM, Weber H, Renaud N, Massabie
R, Driss AB. Determination of exercise training level in coronary artery
disease patients on beta blockers. Eur J Cardiovasc Prev Rehabil
2008;15:6772.
[6] Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM,
Franklin B, Sanderson B, Southard D. Core components of cardiac
rehabilitation/secondary prevention programs: 2007 update. Circula-
tion 2007;115:267582.
[7] Ward DS, Bar-Or O. Use of the Borg scale in exercise prescription for
overweight youth. Can J Sport Sci 1990;15:1205.
[8] Ofir D, Laveneziana P, Webb KA, O'Donnel DE. Ventilatory and
perceptual responses to cycle exercise in obese women. J Appl Physiol
2007;102:221726.
[9] Gondoni LA, Liuzzi A, Titon AM, Taronna O, Nibbio F, Ferrari P,
Leonetti G. A simple tool to predict exercise capacity of obese patients
with ischaemic heart disease. Heart 2006;92:899904.
[10] Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports
Exerc 1982;14:37781.
[11] Hu L, McAuley E, Motl RW, Konopack JF. Influence of self-efficacy
on the functional relationship between ratings of perceived exertion
and exercise intensity. J Cardiopulm Rehabil Prev 2007;27:3038.
[12] Robertson JM, Moyna NM, Sward KL, Millich NB, Goss FL, Thompson
PD. Gender comparison of RPE at absolute and relative physiological
criteria. Med Sci Sport Exerc 2000;32:21209.
[13] Held T, Marti B. Substantial influence of level of endurance capacity
on the association of perceived exertion with blood lactate accumula-
tion. Int J Sports Med 1999;20:349.
[14] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:
14950.