European Journal of Applied Physiology

Verification testing to confirm VO2max attainment in persons with spinal cord injury
--Manuscript Draft--

Manuscript Number:

Full Title: Verification testing to confirm VO2max attainment in persons with spinal cord injury

Article Type: Original Article

Keywords: VO2max incidence; paralysis; arm ergometry; oxygen uptake; blood lactate
concentration

Corresponding Author: Todd Anthony Astorino, Ph.D

CSU--San Marcos
San Marcos, CA UNITED STATES

Corresponding Author Secondary

Information:

Corresponding Author's Institution: CSU--San Marcos

Corresponding Author's Secondary

Institution:

First Author: Todd Anthony Astorino, Ph.D

First Author Secondary Information:

Order of Authors: Todd Anthony Astorino, Ph.D

Gabrielle Phillips, BS

Noelle Bediamol, BS

Sarah Cotoia, BS

Natasha Menard, BS

Brianna Nyugen, BS

Cassandra Olivo, BS

Gabriela Velasco Cruz, BS

Kenneth Ines, BS

Ardreen Tirados, BS

Nicolas Koeu, BS

Order of Authors Secondary Information:

Funding Information:

Abstract: Maximal oxygen uptake (VO2max) is a widely used measure of cardiorespiratory

fitness and long-term health risk. Although VO2max has been measured for almost
100 yr, there are no standard criteria used to verify VO2max attainment. Many studies
document that incidence of 'true' VO2max obtained from incremental exercise (INC)
can be confirmed using a subsequent verification test (VER). The aim of this study was
to examine efficacy of verification testing in persons with spinal cord injury (SCI). Ten
men and women (age and injury duration = 33.3 10.5 yr and 6.8 6.2 yr) with SCI
underwent determination of peak oxygen uptake (VO2peak) via INC on an arm
ergometer followed by VER at 105 percent of peak power output (% PPO). Their
responses were compared to 10 able-bodied (AB) men and women (age = 24.1 7.4
yr). Gas exchange data, heart rate (HR), and blood lactate concentration (BLa) were
measured during each session. Across all participants, VO2peak was highly related
between protocols (ICC = 0.98) although there was a significant interaction (p = 0.01).
Compared to INC, VO2peak from VER was similar in SCI (1.30 0.45 L/min vs. 1.31
0.43 L/min) but higher in AB (1.63 0.40 L/min vs. 1.76 0.40 L/min). In persons with
SCI, the verification test leads to similar VO2peak estimates, which suggests that it

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 confirms VO2peak attainment in this population. However, in AB participants
completing arm ergometry, VER may be warranted to verify 'true' VO2peak.

Suggested Reviewers: Adrian W Midgley, Ph.D

Senior Lecturer, Edge Hill University
Midglead@edgehill.ac.uk
Dr. Midgley published some of the seminal papers concerning utility of verification
testing in various individuals.

Friederike Scharhag-Rosenberger, Ph.D

Researcher, Nationales Centrum fur Tumorerkrankungen Heidelberg
friederike.scharhag-rosenberger@nct-heidelberg.de
Dr. Scharhag-Rosenberger published a seminal paper concerning timing of verification
testing

Lance C Dalleck, Ph.D

Associate Professor, Western State Colorado University
ldalleck@western.edu
Dr. Dalleck has published many papers concerning efficacy of verification testing in
various populations.

Harry Rossiter, Ph.D

Associate Professor, University of California Los Angeles David Geffen School of
Medicine
hrossiter@ucla.edu
Previously, Dr. Rossiter published some seminal studies regarding VO2max attainment
using various verification protocols.

Brandon J Sawyer, Ph.D

Associate Professor, Point Loma Nazarene University
bsawyer@pointloma.edu
Dr. Sawyer has published recent studies concerning verification testing in clinical
populations.

Victoria L Goosey-Tolfrey, Ph.D

Professor, Loughborough University
v.l.tolfrey@lboro.ac.uk
Dr. Goosey-Tolfrey has published widely in sports performance of wheelchair bound
persons and published the only study regarding verification testing in SCI.

Opposed Reviewers: David Poole, Ph.D

Professor, Kansas State University
poole@vet.k-state.edu
Dr. Poole published a study in EJAP in 2008 concerning inadequacy of VO2max
criteria, yet has not published in this area since then, other than a recent commentary
in J Physiology which emphasized the use of verification testing.

Andrew Jones, Ph.D

Professor, University of Exeter
A.M.Jones@exeter.ac.uk
Dr. Jones has published widely in cardiorespiratory physiology, although like Dr. Poole,
his focus is not really in use of the verification testing.

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Cover Letter Click here to download Cover Letter Cletter.docx

College of Education Health and Human Services

Todd A. Astorino, Ph.D.

Professor, Kinesiology
California State University San Marcos, San Marcos, California 92096-0001 USA
Email: astorino@csusm.edu Tel: 760-750-7351 Fax: 760-750-3190

Dr. Hakan Westerblad and Dr. Klaas R. Westerterp

Editors-in-Chief, European Journal of Applied Physiology

Dear Drs. Westerblad and Westerterp:

We are submitting this new original manuscript for potential publication in European Journal
of Applied Physiology and are confident that its findings will interest your readership. Data from
this novel study demonstrate the efficacy of verification testing to confirm VO2max incidence in
persons with spinal cord injury (SCI). Only one study to our knowledge has employed this
approach in persons with SCI (Leicht et al. 2013 in EJAP), but their participants were athletes
and they used wheelchair ergometry rather than upper body ergometry, which is more accessible
in this population. Our data show that verification testing completed at a supramaximal work
rate confirms VO2max obtained from incremental exercise in this particular population, which
supports Leicht et al.s findings, but did not verify VO2max attainment in able-bodied men and
women completing the identical protocol. These data have application to fitness and health
assessment using tests of VO2max in populations completing arm ergometry exercise.

As you are aware, VO2max is a widely-used assessment of cardiorespiratory fitness and

future health risk in various populations. Despite its widespread use, scientists have yet to
develop standardized approaches to confirm VO2max attainment, and VO2max criteria adopted
by many scientists are highly flawed (Poole et al. 2008). The verification test has been
repeatedly employed in the last decade to verify VO2max attainment (Midgley et al. 2006;
Astorino et al. 2009; Scharhag-Rosenberger et al. 2011; Sawyer et al. 2015, etc.), and the
majority of data show similar estimates of VO2max between this test and the previously-
determined incremental value. However, it has not been widely tested in persons with SCI who
maintain a low VO2max, which merits further study of its utility.

Please note that these results will not be submitted for publication in another journal until a
decision is rendered as to its suitability for EJAP. Preliminary data from this submission will be
presented at the Southwest ACSM meeting in Costa Mesa, CA in October 2017. Also please
note that these data stem from a previous project examining feasibility of high intensity interval
training in persons with SCI, and data documenting changes in oxygen uptake, heart rate, blood
lactate concentration, and perceptual responses were published in J Spinal Cord Med and Disabil
Rehabil, yet we promise that European Journal of Applied Physiology is the only forum for this
particular set of data. In these two manuscripts, we described procedures of VO2max testing and
reported baseline VO2max values, yet did not present or interpret the verification testing results.
Moreover, data from the SCI population were obtained in summer 2016; whereas, testing of
able-bodied participants leading to the data reported in this submission transpired in summer
2017.

Thank you for considering our new submission and we look forward to hearing about the
status of our manuscript.

Todd A. Astorino Ph.D, Corresponding Author

Manuscript Click here to download Manuscript Paper.docx

Click here to view linked References

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4 1 Todd A. Astorino, Noelle Bediamol, Sarah Cotoia, Kenneth Ines, Nicolas Koeu, Natasha
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7 2 Menard, Brianna Nyugen, Cassandra Olivo, Gabrielle Phillips, Ardreen Tirados, Gabriela
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9 3 Velasco Cruz
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16 5 Verification testing to confirm VO2max attainment in persons with spinal cord injury
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7 Department of Kinesiology, CSUSan Marcos, San Marcos, CA USA
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26 8 Corresponding Author: Todd Anthony Astorino, Ph.D
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29 9 Professor, Department of Kinesiology
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10 California State University, San Marcos
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36 11 333. S. Twin Oaks Valley Road, UNIV 320
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39 12 San Marcos, CA 92096-0001
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13 Phone: (760) 750-7351
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46 14 Fax: (760) 750-3237
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49 15 Email: astorino@csusm.edu
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52 16 Running head: Verification testing in spinal cord injury
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56 17 Acknowledgements: The authors thank the participants for their dedication to the study as well
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58 18 as Jacob Thum for assistance with data collection.
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 1 2
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4 19 Abstract
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7 20 Maximal oxygen uptake (VO2max) is a widely used measure of cardiorespiratory fitness and
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9 21 long-term health risk. Although VO2max has been measured for almost 100 yr, there are no
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22 standard criteria used to verify VO2max attainment. Many studies document that incidence of
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14 23 true VO2max obtained from incremental exercise (INC) can be confirmed using a subsequent
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16 24 verification test (VER). The aim of this study was to examine efficacy of verification testing in
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19 25 persons with spinal cord injury (SCI). Ten men and women (age and injury duration = 33.3
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21 26 10.5 yr and 6.8 6.2 yr) with SCI underwent determination of peak oxygen uptake (VO2peak)
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24 27 via INC on an arm ergometer followed by VER at 105 percent of peak power output (% PPO).
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26 28 Their responses were compared to 10 able-bodied (AB) men and women (age = 24.1 7.4 yr).
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29 29 Gas exchange data, heart rate (HR), and blood lactate concentration (BLa) were measured during
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31 30 each session. Across all participants, VO2peak was highly related between protocols (ICC =
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31 0.98) although there was a significant interaction (p = 0.01). Compared to INC, VO2peak from
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36 32 VER was similar in SCI (1.30 0.45 L/min vs. 1.31 0.43 L/min) but higher in AB (1.63 0.40
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38 33 L/min vs. 1.76 0.40 L/min). In persons with SCI, the verification test leads to similar VO2peak
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41 34 estimates, which suggests that it confirms VO2peak attainment in this population. However, in
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43 35 AB participants completing arm ergometry, VER may be warranted to verify true VO2peak.
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49 37 Key words: VO2max incidence; paralysis; arm ergometry; oxygen uptake; blood lactate
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 1 3
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4 43 Abbreviations
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7 44 AB able-bodied
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9 45 ANOVA analysis of variance
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11 46 BLa blood lactate concentration
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47 BMI body mass index
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16 48 C cervical
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18 49 HRmax maximal heart rate
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20 50 ICC intraclass correlation coefficient
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23 51 INC incremental exercise
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25 52 MD minimum difference
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27 53 MICT moderate intensity continuous training
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54 PPO peak power output
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32 55 RER respiratory exchange ratio
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34 56 RPE rating of perceived exertion
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36 57 SCI spinal cord injury
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39 58 SEM standard error of the mean
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41 59 UBE upper body exercise
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43 60 VCO2peak peak carbon dioxide production
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61 VE ventilation
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48 62 VER verification testing
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50 63 VO2max maximal oxygen uptake
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52 64 VO2peak peak oxygen uptake
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55 65 W Watt
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59 67
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 1 4
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4 68 Introduction
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7 69 Maximal oxygen uptake (VO2max), the integration of cardiopulmonary oxygen transport and
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9 70 muscle utilization of oxygen, is the gold standard measure of cardiorespiratory fitness and
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71 recently has been identified as the best measure of long-term morbidity and mortality (Myers et
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14 72 al. 2002). The primary goal of most physical activity regimes is to improve VO2max, hence
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16 73 current Physical Activity guidelines espouse a minimum of 150 min/wk of moderate intensity
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19 74 continuous exercise training (MICT) (Garber et al. 2011). For example, in sedentary adults, data
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21 75 show that a higher volume and intensity of MICT elicit greater increases in VO2max than low-
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24 76 volume, lower intensity MICT (Duscha et al. 2005).
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27 77 Despite the the use of VO2max testing in the field of Exercise Physiology to assess
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78 cardiorespiratory fitness for almost 100 yr and documented efficacy of exercise training to
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32 79 enhance VO2max, there are no standardized criteria to confirm VO2max incidence (Poole et al.
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34 80 2008). Current approaches to confirm VO2max incidence including a levelling off or plateau in
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37 81 VO2, maximal HR within 10 b/min of age-predicted maximum (220-age), and respiratory
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39 82 exchange ratio (RER) > 1.10 (Midgley et al. 2006; Poole et al. 2008; Astorino 2009), yet these
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42 83 are flawed, as they do not differentiate between people who show a true VO2max and those
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44 84 who do not (Astorino 2009). Recently, use of a constant load test performed at an intensity
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85 below, equal to, or greater than that attained at VO2max (the verification test (VER)) has been
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49 86 used to confirm VO2max attainment in participants differing in age and fitness level (Midgley et
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51 87 al. 2006; Astorino et al. 2009; Scharhag-Rosenberger et al. 2011; Bhammar et al. 2017). This
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54 88 test is typically performed 5 - 10 min after the initial incremental VO2max test and yields similar
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56 89 estimates of VO2max, hence verifying VO2max attainment.
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 1 5
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4 90 One population with a VO2max on the low end of the fitness spectrum includes persons with
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7 91 spinal cord injury (SCI). It is apparent that onset of SCI leads to marked physical disability
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9 92 which diminishes participation in physical activity, leading to a low VO2max between 10 20
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12 93 mL/kg/min. Fortunately, chronic exercise training using modalities including arm ergometry
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14 94 (West et al. 2015) and circuit training (Nash et al. 2001) increases VO2max and physical function
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17 95 and potentially reduces health risks in this population; however, scientists have yet to develop
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19 96 criteria to confirm VO2max attainment in this population. For example, in these studies, no
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21 97 criteria were denoted to identify VO2max or verify its incidence. This lack of established criteria
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24 98 is problematic when VO2max is measured to assess cardiorespiratory fitness, or when scientists
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26 99 use VO2max testing to monitor adaptation to habitual physical activity. One study (Leicht et al.
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29 100 2013) in men with SCI showed similar estimates of VO2peak between INC and VER, but it was
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31 101 performed in international level athletes and used wheelchair ergometry, which is quite
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34 102 expensive, impractical, and inaccessible to most persons with SCI. In contrast, arm ergometry is
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36 103 a popular and more accessible exercise modality for persons with SCI as well as able-bodied
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104 (AB) individuals with impaired lower extremity function. To our knowledge, no study has
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41 105 utilized verification testing to verify VO2max attainment in persons with SCI during arm
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43 106 ergometry.
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47 107 The aim of the present study was to test the efficacy of VER in persons with SCI and compare
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49 108 their responses to AB. Use of VER to confirm VO2max attainment in AB is grounded in the
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52 109 concept that VO2 will not increase with increasing intensity, due to limitations in the delivery
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54 110 and utilization of oxygen (Wagner 2000). Nevertheless, upper-body exercise (UBE) including
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56 111 arm ergometry as typically performed by persons with SCI is not limited by oxygen delivery, but
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59 112 local muscle fatigue due to the smaller exercising muscle mass (Sawka 1986). Hence, findings
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 1 6
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4 113 showing efficacy of VER obtained from whole-body exercise including cycling (Astorino et al.
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7 114 2009; Scharhag-Rosenberger et al. 2011) and running (Midgley et al. 2006; Hawkins et al. 2007)
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9 115 cannot necessarily be translated to small muscle mass exercise. It was hypothesized that VER
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12 116 will elicit similar estimates of peak oxygen uptake (VO2peak) during UBE in both populations,
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14 117 as previously shown (Astorino et al 2009; Scharhag-Rosenberger et al. 2011).
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118 Methods
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21 119 Participants: Habitually active men and women at least 12 mo post-SCI (injury duration = 6.8
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23 120 6.2 yr) were recruited from a local SCI rehabilitation facility as well as through word-of-mouth.
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26 121 They consisted of two tetraplegics and eight paraplegics who regularly completed wheeling,
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28 122 resistance training, locomotor training, surfing, stretching, and assisted/unassisted walking. Four
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123 had complete SCI; whereas, six had incomplete SCI. Prospective participants were free of
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33 124 disease and musculoskeletal ailments including shoulder weakness or pain preventing them from
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35 125 completing the study. Inclusion criteria were injury lower than C2 and non-ventilator dependent,
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38 126 physician permission to engage in intense exercise, lack of medication use which may affect
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40 127 study outcomes, and age equal to 18 - 60 yr. Participants initially completed a health-history
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43 128 questionnaire and physical activity survey (National Cancer Institute) to verify their eligibility.
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45 129 Able-bodied participants included four men and six women who were physically active yet
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48 130 lacked previous experience with arm ergometry. They were healthy and non-obese and did not
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50 131 have any upper-extremity issues preventing completion of arm ergometry. Physical
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52 132 characteristics of all participants are demonstrated in Table 1. Data show that compared to SCI,
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55 133 AB were younger (p = 0.03), yet no differences were shown in body mass index, physical
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57 134 activity, or peak power output.
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 1 7
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4 135 Experimental design: Participants came to the lab well-rested and hydrated and completed a
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7 136 single exercise session, which was preceded by a 2 h fast and abstention from exercise for 24 h.
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9 137 Peak oxygen uptake (VO2peak) was determined during progressive arm ergometry to exhaustion
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12 138 followed by VER. During each trial, gas exchange data, heart rate (HR), blood lactate
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14 139 concentration (BLa), and perceptual responses were measured. Participants provided their
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17 140 written informed consent prior to study participation, and the research protocol was approved by
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19 141 the University Institutional Review Board. Data from participants with SCI were acquired from
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142 June October 2016; whereas, data from AB were obtained in June 2017.
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25 143 Assessment of VO2peak: Participants were dressed in exercise attire for the VO2peak assessment.
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27 144 After recording of height and body mass and 2 min of seated rest, BLa was obtained from a
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30 145 fingertip blood sample (Nova Biomedical, Waltham, MA) using a sterile 23 g lancet (Owen
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32 146 Mumford Inc., Marietta, GA). Subsequently, a 5 min warmup at 7 W was completed, and then
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147 all participants performed arm cranking on a wall-mounted ergometer (Lode Angio, Groningen,
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37 148 the Netherlands) at a self-selected cadence until volitional exhaustion, which was identified as
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39 149 cadence less than 30 rev/min. For each participant, the height of the arm ergometer was
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42 150 modified to properly align with the shoulder joint. During exercise, power output was increased
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44 151 in a ramp-like manner by 3 W/min for tetraplegics and 13 W/min for paraplegics; whereas, for
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47 152 AB, power output was increased from 8 20 W/min depending upon size and gender of each
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49 153 participant, resulting in test duration ranging from 6 10 min (Midgley et al. 2008). Pulmonary
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52 154 gas exchange data were obtained every 15 s using a metabolic cart (ParvoMedics True One,
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54 155 Sandy, UT) which was calibrated pre-exercise according to manufacturer specifications. Three
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56 156 minutes following this bout, peak BLa was determined. After a 10 min active recovery at 7 W,
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 1 8
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4 157 participants cranked at 105 % of their peak power output (PPO) until exhaustion. Strong verbal
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7 158 encouragement was provided during exercise.
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10 159 From each trial, VO2peak was identified as the mean of the two highest VO2 values during the
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13 160 last 45 s of exercise. Peak values of HR, ventilation (VE), respiratory exchange ratio (RER), and
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15 161 carbon dioxide production (VCO2) were identified using the same technique. Duration of INC
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17 162 and VER was also recorded. Preliminary testing in our lab showed that in 5 AB men and women
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20 163 repeating INC and VER between 3 and 10 d apart, absolute VO2peak was not different (1.86
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22 164 0.36 L/min and 1.88 0.42 L/min, p = 0.83, and 2.02 0.37 L/min and 1.95 0.37 L/min, p =
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25 165 0.25) and highly related (ICC = 0.96 and 0.97). We also used a peak HR criterion < 2 b/min
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27 166 versus INC, as previously used (Midgley et al. 2006).
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167 Rating of perceived exertion (RPE) was also acquired pre-exercise and immediately at end of
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33 168 INC using the 0 - 10 category ratio scale (CR-10) (Borg 1998). The meaning of this scale was
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35 169 communicated before exercise by instructing participants to report perceptions of exertion in
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38 170 terms of their breathing, heart rate, and level of fatigue. Participants were asked to respond to
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40 171 this scale in terms of how they felt at that moment.
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44 172 Statistical analyses: Data are reported as mean standard deviation (SD) and were analyzed
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46 173 with SPSS version 20.0 (Chicago, IL). The Shapiro-Wilk test was used to determine if data were
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174 normally distributed. Two-way ANOVA with repeated measures was used to examine
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51 175 differences in peak variables as well as BLa and RPE. If a significant F ratio was obtained,
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53 176 Tukeys post hoc test was used to identify differences between means. The Greenhouse-Geisser
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56 177 correction was used to account for the sphericity assumption of unequal variances across groups.
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58 178 Independent t-test was used to examine baseline differences between SCI and AB. Effect size
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 1 9
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4 179 was determined using Cohens d. Intraclass correlation coefficient, standard error of the mean,
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7 180 and minimum difference were calculated for VO2peak between INC and VER. BlandAltman
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9 181 plots were used to examine agreement between VO2peak determined from INC and VER. Our
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12 182 sample size mirrored that of two studies demonstrating efficacy of VER in sedentary men and
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14 183 women (Astorino et al. 2009) and children (Bhammar et al. 2017). Statistical significance was
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17 184 equal to p < 0.05.
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20 185 Results
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23 186 Gas exchange data: Table 2 shows differences in all peak gas exchange and related variables in
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26 187 response to INC and VER. Results showed a significant main effect and interaction (p = 0.01)
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28 188 for relative and absolute VO2peak. Post hoc analyses showed that in AB, VER-derived absolute
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189 and relative VO2peak was significantly higher (~ 8 %, p = 0.001 and 0.003, d = 0.37 0.49) than
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33 190 INC, yet in SCI, these values were not different. Respiratory exchange ratio was lower (p =
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35 191 0.005, d = 0.84 1.0) in VER versus INC in both groups of participants. Ventilation was higher
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38 192 in VER compared to INC (p = 0.001, d = 0.40 - 0.61), yet there was no protocol X group
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40 193 interaction (p = 0.43). Able-bodied participants showed higher VE than SCI (p = 0.014, d =
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43 194 1.21). There was no difference in HRpeak (p = 0.72) or VCO2 (p = 0.12) between INC and
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45 195 VER, with no protocol X group interaction (p > 0.05).
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196 Comparing responses between INC and VER: Figures 1 and 2 show the difference in VO2peak
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51 197 between protocols in both SCI and AB. Across all 20 participants, the ICC was equal to 0.98
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53 198 between protocols and the mean difference in VO2peak was equal to 0.08 0.11 L/min. There
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56 199 was no association (r = 0.11, p = 0.65) between the difference in VO2peak between protocols and
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58 200 baseline VO2peak. The standard error of the mean and minimum difference were equal to 0.02
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 1 10
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4 201 L/min and 0.04 L/min, respectively. In SCI, the mean difference in VO2peak between protocols
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7 202 was equal to 0.02 L/min. Between VER and INC, eight participants showed small differences in
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9 203 VO2peak (-0.06 L/min 0.04 L/min), although two participants showed large increases in
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12 204 VO2peak (0.11 and 0.12 L/min = 8 %). In AB, five subjects exhibited small differences (0.02
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14 205 0.06 L/min) in VO2peak between protocols; whereas, the other five participants showed
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17 206 differences ranging from 0.08 to 0.38 L/min (mean difference = 0.23 L/min = 13 %).
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20 207 Changes in BLa and RPE: During INC, blood lactate concentration increased (p < 0.001) from
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22 208 baseline in both SCI (1.52 0.60 mM to 7.43 2.80 mM) and AB (1.56 0.47 mM to 8.49
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25 209 2.87 mM), yet there was no time X group interaction (p = 0.44). A similar pattern was shown for
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27 210 RPE, which increased during exercise (p < 0.001) and peaked at values equal to 8.8 0.3 and 8.9
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30 211 0.3 in SCI and AB, respectively, with no difference between groups (p = 0.91).
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33 212 Discussion
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36 213 This study tested the utility of verification testing to determine incidence of true VO2peak in
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39 214 men and women with SCI, whose data were compared to AB participants of similar body mass
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41 215 index and physical activity. Our data in SCI show similar VO2peak values between protocols,
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44 216 which would suggest that this bout is useful to verify VO2peak attainment in this particular
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46 217 population. However, AB demonstrated higher VO2peak in response to VER, which suggests
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218 that they can potentially surpass their incremental-derived value obtained from UBE.during
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51 219 verification testing.
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54 220 In the present study, we used VER to confirm incidence of VO2peak obtained from graded
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57 221 arm ergometry rather than primary (VO2 plateau) or secondary criteria. Although the VO2
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59 222 plateau criterion has been used for several decades, its incidence widely varies across studies
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 1 11
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4 223 (Duncan et al. 1997; Astorino et al. 2000; Day et al. 2003), partially due to methodological
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7 224 differences including participant characteristics as well as alterations in the specific sampling
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9 225 interval (Myers et al 1990; Astorino et al. 2000) and work rate increment (Robergs et al. 2010)
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12 226 used during the exercise test. Moreover, a plateau in VO2 infrequently occurs in response to
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14 227 UBE (Glaser et al. 1980). Various criteria for RERmax (> 1.10. 1.15, etc.) exist to confirm
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17 228 VO2max attainment, and 18 of 20 participants in the present study surpassed these threshold
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19 229 values. Moreover, peak BLa values surpassing 8 mM (Robergs and Roberts, 1997) have been
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21 230 identified as representing a maximal effort. However, Poole et al. (2008) demonstrated in AB
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24 231 men performing INC that peak values of RER occurred at submaximal intensities and in
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26 232 addition, that most participants did not achieve this BLa criterion, which led them to recommend
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29 233 that neither criterion be used to confirm VO2max attainment. Although peak HR during UBE
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31 234 can approach values seen during whole-body exercise (Sawka et al. 1983), the values seen in AB
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34 235 (Table 2) are not within 10 b/min of age-predicted HRpeak equal to 220 age. In addition,
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36 236 many participants with SCI have altered sympathetic input which blunts the HR response to
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237 exercise, leaving the HRpeak criterion as relatively impractical in this clientele. Although these
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41 238 criteria are widely used, they do not seem adequate to verify VO2max attainment in SCI, and
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43 239 since none was specifically developed for this population as has been recommended (Midgley et
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46 240 al. 2006), it is cautioned to apply them to incremental UBE as performed in the present study.
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49 241 Our data showing no difference in VO2peak between INC and VER in individuals with SCI
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52 242 support previous results. In a study by Leicht et al. (2013), wheelchair athletes consisting of
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54 243 tetraplegics, paraplegics, and AB completed INC and VER on two separate days. In contrast to
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56 244 our study, they used wheelchair ergometry as the exercise mode rather than UBE, and VER
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59 245 consisted of a slightly higher gradient than that attained at the end of the incremental test rather
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 1 12
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4 246 than a 5 % higher power output as used in the current study. They reported similar VO2peak in
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7 247 response to both protocols and high reliability for these measures across days. In addition, they
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9 248 stated that a 6 % difference in VO2peak between protocols is acceptable, which is what 80 % of
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12 249 our SCI participants exhibited.
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15 250 Nevertheless, in AB, mean VO2peak obtained from VER was higher than INC, and five AB
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17 251 participants showed higher VO2peak (~ 13 %) in VER versus INC, which can be explained by
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20 252 the following factors. First, it is possible that the INC trial served to familiarize some subjects
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22 253 with intense UBE, during which they may have terminated exercise prematurely due to local
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25 254 muscle discomfort and fatigue due to the small muscle mass engaged. They then used this
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27 255 experience to exercise maximally during VER and attain a higher value of VO2peak. Although
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30 256 data for all participants showed no relationship between baseline VO2peak and the difference in
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32 257 VO2 between protocols, the three AB participants with the lowest VO2peak equal to 20
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258 mL/kg/min showed substantial differences in VO2 between protocols, which suggests that
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37 259 baseline fitness in AB may modify the magnitude of difference in VO2peak between INC and
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39 260 VER. Second, excessive bodily movement due to torso stabilization may lead to increased VO2
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42 261 during UBE (Sawka 1986). We noted that many participants attempted to engage their hips and
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44 262 trunk to tolerate the supramaximal intensity of VER, which may have led to elevations in VO2.
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47 263 This additional torso movement may be minimal in individuals with SCI, partially explaining
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49 264 why VO2peak did not differ between INC and VER. Third, fatigue of higher threshold fast
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52 265 twitch motor units recruited during supramaximal exercise (Wood et al. 2016) as well as removal
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54 266 and oxidation of BLa (Brooks and Gaesser 1980) in response to INC may enhance VO2
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267 contributing to the greater VO2peak observed in this protocol.
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 1 13
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4 268 Results from Rossiter et al. (2006) suggest that a 2 min VER duration is adequate to elicit
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7 269 VO2max. This duration is supported by recent data (Scharhag-Rosenberger et al. 2011) in men
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9 270 and women (VO2max = 50 mL/kg/min) which demonstrated a VER duration ranging from 2.0
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12 271 2.7 min in response to running at 115 % of the peak velocity at VO2max. In obese adults
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14 272 performing VER at 100 %PPO, Sawyer et al. (2015) reported VER duration equal to 1.9 min,
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17 273 and their data showed no difference in mean VO2max between INC and VER. They also
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19 274 concluded that constant load supramaximal exercise as brief as 1.25 min can elicit VO2max in
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21 275 young men (Sawyer et al. 2012). Whole-body exercise such as cycling and running should elicit
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24 276 greater time to exhaustion than UBE which is limited by peripheral fatigue. Our data showed
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26 277 VER duration < 2 min which was similar across groups (Table 2), and there was similar disparity
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29 278 in VER duration in AB (1.2 2.3 min) and SCI (1.1 2.1 min). In addition, no relationship was
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31 279 shown between this duration and INC (p = 0.09) or VER-derived VO2peak (p = 0.21), PPO (p =
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34 280 0.19), BMI (p = 0.61), or the difference in VO2peak between protocols (p = 0.20), which
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36 281 suggests that performance on the incremental test does not seem to modify time to exhaustion
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282 during VER. We encourage other scientists to conduct further studies manipulating the intensity
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41 283 of VER, especially in persons with SCI, to identify optimal protocol characteristics to confirm
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43 284 VO2peak attainment in this population.
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47 285 Although our participants had similar BMI, PPO, and physical activity, relative VO2peak was
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49 286 higher in AB compared to SCI. Whether a greater fitness level modifies efficacy of the VER test
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52 287 to confirm VO2max attainment is unlikely, considering that similar VO2max values have been
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54 288 reported between INC and VER in runners (Midgley et al. 2006), active men and women (Foster
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56 289 et al. 2007; Kirkeberg et al. 2011), sedentary men and women (Astorino et al. 2009), paraplegics
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59 290 and tetraplegics (Leicht et al. 2013), and older adults (Dalleck et al. 2011). The disparity of men
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4 291 and women differed across the two populations, although any effect of this discrepancy on our
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7 292 outcomes is likely small as no data show a unique effect of gender on VO2max estimates from
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9 293 VER. During exercise, cadence was not standardized across participants, which may be a
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12 294 limitation considering that cadence equal to 70 rev/min elicits higher VO2max compared to
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14 295 lower cadences (30 and 50 rev/min, Sawka et al. 1983). Nevertheless, all participants typically
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17 296 maintained cadence above 60 rev/min during INC, and a common strategy during VER was to
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19 297 increase cadence above 80 rev/min upon application of the supramaximal workload. Unlike
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21 298 another study (Nolan et al. 2014), we only used a single supramaximal intensity in VER equal to
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24 299 105 %PPO, so we cannot say for certain that this work rate is optimal for eliciting true VO2max
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26 300 during UBE. In fact, constant load exercise at 90 %PPO elicits VO2max in AB (Day et al. 2003),
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29 301 and may be superior to verify incidence of VO2max during UBE, especially in persons with low
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31 302 fitness such as SCI.
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303 Conclusions
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38 304 Persons with SCI exhibit significantly higher rates of obesity, diabetes, and heart disease than
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40 305 able-bodied individuals (Myers et al. 2007) which is partially attributed to their high level of
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43 306 inactivity and low VO2peak. Testing of VO2peak is performed in this population to establish
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45 307 fitness level and monitor adaptations to exercise training. Nevertheless, there are no
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48 308 standardized methods to confirm VO2peak attainment in this population. Our results show that
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50 309 verification testing elicits similar VO2peak values compared to incremental exercise, thus may be
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52 310 effective to establish true VO2peak. These results; however, refute findings from able-bodied
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55 311 men and women who showed significantly higher VO2peak with verification testing versus
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57 312 incremental exercise.
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4 313
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8 314 References
9
10
11 315 Astorino TA, Robergs RA, Ghiasvand F, Marks D, Burns S (2000) Incidence of the VO2 plateau
12
13
316 during exercise testing to volitional fatigue. J Exerc Physiol 8:112.
14
15
16
17 317 Astorino TA (2009) Alterations in VO2max and the VO2 plateau with manipulation of sampling
18
19 318 interval. Clin Physiol Funct Imaging 29:60-67.
20
21
22
23
319 Astorino TA, White AC, Dalleck LC (2009) Supramaximal testing to confirm attainment of
24
25 320 VO2max in sedentary men and women. Int J Sports Med 30:279284.
26
27
28 321 Bhammar DM, Stickford JL, Bernhardt V, Babb TG (2017) Verification of maximal oxygen
29
30
31 322 uptake in obese and nonobese children. Med Sci Sports Exerc 49:702-710.
32
33
34 323 Borg G (1998) Borgs perceived exertion and pain scales. Human Kinetics; Champaign, IL.
35
36
37 324 Brooks GA, Gaesser GA (1980) End points of lactate and glucose metabolism after exhausting
38
39
40 325 exercise. J Appl Physiol 49:1057-1069.
41
42
43 326 Dalleck LC, Astorino TA, Erickson RM, McCarthy RM, Beadell AA, Botten BH (2012)
44
45
46
327 Suitability of verification testing to confirm attainment of VO2max in middle-aged and older
47
48 328 adults. Res Sports Med 20:118-128.
49
50
51 329 Day JR, Rossiter HB, Coats EM, Skasick A, Whipp BJ (2003) The maximally attainable VO2
52
53
54 330 during exercise in humans: the peak vs. maximum issue. J Appl Physiol 95:19011907.
55
56
57 331 Duncan GE, Howley ET, Johnson BT (1997) Applicability of VO2max criteria: discontinuous
58
59
60
332 versus continuous protocols. Med Sci Sports Exerc 29:273278.
61
62
63
64
65
 1 16
2
3
4 333 Duscha BD, Slentz CA, Johnson JL, Houmard JA, Bensimhon DR, Knetzger KJ, Kraus WE
5
6
7 334 (2005) Effects of exercise training amount and intensity on peak oxygen consumption in middle-
8
9 335 age men and women at risk for cardiovascular disease. Chest 128(4):2788-2793.
10
11
12
13 336 Foster C, Kuffel E, Bradley N, Battista RA, Wright G, Porcari JP, Lucia A, deKoning JJ (2007)
14
15 337 VO2max during successive maximal efforts. Eur J Appl Physiol 102:67-72.
16
17
18 338 Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain
19
20
21 339 DP, Med ACS (2011) Quantity and quality of exercise for developing and maintaining
22
23 340 cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults:
24
25
26 341 Guidance for prescribing exercise. Med Sci Sport Exerc 43:13341359.
27
28
29 342 Glaser RM, Sawka MN, Brune MF, Wilde SW (1980) Physiological responses to maximal effort
30
31 343 wheelchair and arm crank ergometry. J Appl Physiol 48:1060-1064.
32
33
34
35 344 Hawkins MN, Raven PB, Snell PG, Stray-Gundersen J, Levine BD (2007) Maximal oxygen
36
37 345 uptake as a parametric measure of cardiorespiratory capacity. Med Sci Sports Exerc 39:103107.
38
39
40
346 Kirkeberg JM, Dalleck LC, Kamphoff CS, Pettitt RW (2011) Validity of protocols for verifying
41
42
43 347 VO2max. Int J Sports Med 32:266-270.
44
45
46 348 Midgley AW, McNaughton LR, Carroll S (2006) Verification phase as a useful tool in the
47
48
49 349 determination of the maximal oxygen uptake of distance runners. Appl Physiol Nutr Metab 31:
50
51 350 541548.
52
53
54 351 Midgley AW, Bentley DJ, Luttikholt H, McNaughton LR, Millet GP (2008) Challenging a
55
56
57 352 dogma of exercise physiology: does an incremental exercise test for valid VO2max determination
58
59 353 really need to last between 8 and 12 minutes? Sports Med 38:441-447.
60
61
62
63
64
65
 1 17
2
3
4 354 Myers J, Walsh D, Sullivan M, Froelicher V (1990) Effect of sampling on variability and plateau
5
6
7 355 in oxygen uptake. J Appl Physiol 68:404-410.
8
9
10 356 Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE (2002) Exercise capacity and
11
12
13 357 mortality among men referred for exercise testing. New Engl J Med 346:793-801.
14
15
16 358 Myers J, Lee M, Kiratli J (2007) Cardiovascular disease in spinal cord injury: an overview of
17
18 359 prevalence, risk, evaluation, and management. Am J Phys Med Rehabil 86:142-152.
19
20
21
22 360 Nash MS, Jacobs PL, Mendez AJ, Goldberg RB (2001) Circuit resistance training improves the
23
24 361 atherogenic lipid profiles of persons with chronic paraplegia. J Spinal Cord Med 24(1):2-9.
25
26
27 362 National Cancer Institute, Past year total physical activity questionnaire, National Institutes of
28
29
30 363 Health, Bethesda, MD.
31
32
33 364 Nolan PB, Beaven ML, Dalleck L (2014) Comparison of intensities and rest periods for VO2max
34
35
36 365 verification testing procedures. Int J Sports Med 35:1024-1029.
37
38
39 366 Poole DC, Wilkerson AM, Jones AM (2008) Validity of criteria for establishing maximal O2
40
41 367 uptake during ramp exercise tests. Eur J Appl Physiol 102:403-410.
42
43
44
45 368 Robergs RA, Roberts SO (1997) Exercise physiology: exercise, performance and clinical
46
47 369 applications. Mosby, London.
48
49
50 370 Robergs RA, Dwyer D, Astorino T (2010) Recommendations for improved data processing from
51
52
53 371 expired gas analysis indirect calorimetry. Sports Med 40(2):95-111.
54
55
56 372 Rossiter HB, Kowalchuk JM, Whipp BJ (2006) A test to establish maximum O2 uptake despite
57
58
59 373 no plateau in the O2 uptake response to ramp incremental exercise. J Appl Physiol 100:764-770.
60
61
62
63
64
65
 1 18
2
3
4 374 Sawka MN, Foley ME, Pimental NA, Toner MM, Pandolf KB (1983) Determination of maximal
5
6
7 375 aerobic power during upper-body exercise. J Appl Physiol 54(1):113-117.
8
9
10 376 Sawyer BJ, Morton RH, Womack CJ, Gaesser GA (2012) VO2max may not be reached during
11
12
13 377 exercise to exhaustion above critical power. Med Sci Sports Exerc 44:1533-1538.
14
15
16 378 Sawyer BJ, Tucker WJ, Bhammar DM, Gaesser GA (2015) Using a verification test for
17
18 379 determination of VO2max in sedentary adults with obesity. J Str Cond Res 29:3432-3438.
19
20
21
22 380 Sawka MN (1986) Physiology of upper-body exercise. 175-211.
23
24
25 381 Scharhag-Rosenberger F, Carlsohn A, Cassel M, Mayer F, Scharhag J (2011) How to test
26
27 382 maximal oxygen uptake: a study on timing and testing procedure of a supramaximal verification
28
29
30 383 test. Appl Physiol Nutr Metab 36:153-160.
31
32
33 384 Wagner PD (2000) New ideas on limitations to VO2max. Exerc Sports Sci Rev 28(1):10-14.
34
35
36
385 West CR, Currie KD, Gee C, Krassioukov AV, Borisoff J (2015) Active-arm passive-leg
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39 386 exercise improves cardiovascular function in spinal cord injury. Am J Phys Med Rehabil
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41 387 94:e102-e106.
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45 388 Wood KM, LaValle K, Greer K, Bales B, Thompson H, Astorino TA (2016) Effects of two
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47 389 regimens of high intensity interval training (HIIT) on acute physiological and perceptual
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50 390 responses. J Str Cond Res 30(1):244-250.
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53 391
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56 392 Figure legends
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 1 19
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4 393 1. VO2peak attained on the incremental (x-axis) and verification (y-axis) test in all 20
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7 394 participants. Open circles () equal AB and dark circles () equal participants with SCI. The
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9 395 line represents the line of identity (y = x).
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13 396 2. Bland-Altman plot for VO2peak from both protocols. Open circles () equal AB and dark
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15 397 circles () equal participants with SCI. Solid line equal mean difference between verification
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18 398 and incremental VO2peak; dashed line equal mean 1.96 X SD
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Figure 1 Click here to download Figure Fig1.jpg
Figure 2 Click here to download Figure Fig2.jpg
Table 1

Table 1: Participant physical characteristics (mean SD).

Parameter SCI Range AB Range p value

Age (yr) 33.3 10.5 25 - 57 24.1 7.4* 21 - 45 0.03
Gender 9 M/1 W NA 4 M/6 W NA NA
Body mass index 22.6 3.1 19.0 22.9 24.1 3.4 20.2 27.4 0.33
2
(kg/m )
Physical activity 8.1 4.4 3 - 18 5.4 2.7 2.5 - 10 0.11
(h/wk)
VO2peak 1.30 0.45 0.66 1.94 1.63 0.41 1.15 2.50 0.10
(L/min)
PPO (W) 96.3 35.0 32 - 146 108.9 25.9 75 - 163 0.37
SCI = participants with spinal cord injury; AB = able-bodied participants; * = p < 0.05 between
groups at baseline; M = men; W = women; NA = non applicable; PPO = peak power output
Table 2

Table 2: Gas exchange data in response to incremental and verification testing (mean SD).

Parameter SCI AB
Incremental test

VO2peak (L/min) 1.30 0.45 1.63 0.40

VO2peak 17.4 4.7 24.0 4.7
(mL/kg/min)
VCO2peak (L/min) 1.69 0.41 1.99 0.61
RER 1.29 0.12 1.23 0.12
VE (L/min) 54.9 17.5 76.0 16.9
HRpeak (b/min) 160.6 29.1 176.4 17.8
Time (min) 7.9 1.6 6.9 1.3

Verification test

VO2peak (L/min) 1.31 0.43 1.76 0.40*

VO2peak 17.6 4.5 26.0 4.3*
(mL/kg/min)
VCO2peak (L/min) 1.69 0.41 1.98 0.62
RER 1.21 0.10 1.12 0.11*
VE (L/min) 62.3 21.4* 86.8 20.9*
HRpeak (b/min) 160.2 26.4 178.1 12.8
*
Time (min) 1.8 0.3 1.7 0.4*
SCI = participants with spinal cord injury; AB = able-bodied participants; * = p < 0.05 versus
incremental test within group