Laboratory Manual Guidelines for Exercise

Rehabilitation
1st Edition

Rahmat Adnan
1.0 Pre-participant Health Screening

Purpose

1) Identification and exclusion of individuals with medical contraindications to

exercise
2) Identification of individuals at increased risk for disease of age, symptoms, and/or
risk factors who should undergo a medical evaluation and exercise test before
starting an exercise program
3) Identification of persons with clinically significant disease who should participate
in a medically supervised exercise program
4) Identification of individuals with other special needs.
 Table 1.1 ACSM Pre participation Screening Algorithm

Screening Recommended Prior to Self- Screening Recommended Prior to Professionally-Guided. Exercise Testing/Prescription
Guided Physical Activity
1. Complete ACSM/AHA 1. Identify presence of major CAD risk factors and major sign/symptoms of cardiovascular,
Questionnaire or PAR-Q pulmonary or metabolic disease. This process could include the use of the ASM/AHA
Risk Stratification &
Medical Clearance

2. Determine need for medical Questionnaire. This process may also include a more elaborate facility-specific medical/health
LEVEL-1

clearance and obtain if history questionnaire.

(chapter 2)

recommended 2. Determine ACSM risk category from table 2.4 for use in level 2 and 3.
3. Proceed to Level 2 3. Determine need for medical clearance prior to testing and/or participation and obtain if
recommended
4. Proceed to level 2 and follow recommendations based on ACSM risk category.
 Initiate general physical activity Low Risk Moderate Risk High Risk
recommendation as outlined by the
Additional Pre-Participation

United States Surgeon General Perform informed consent for testing and/or
Assessment (chapter 3-4)

 For a specific self-guide exercise  Perform informed consent training.

assessment and examples of both for testing and/or training.
LEVEL-2

aerobic and resistance training  Complete appropriate

regimens see Chapter 4-6 of the assessment procedures
ACSM Fitness Book Both the depth and breath of pre-exercise test
outline in Chapter 3-4
 Individuals identification as needing assessment should increase as a function of risk
medical clearance in Level 1 may  Medical history, physical
category. Refer to chapter 2 and 4 for advance
benefit from participation in a examination, laboratory
assessment procedures
professionally-guide pre-exercise tests, body composition
assessment and prescription.
 Further medical examination  Medical examination and  Medical examination and
and exercise testing not exercise testing exercise testing recommended
necessary prior to initiation of recommended prior to prior to initiation of moderate
LEVEL-3

exercise training initiation of vigorous or vigorous exercise training

considerations

  Medical
(chapter 4-5)

exercise training
Exercise Test

Medical supervision for supervision

submaximal or maximal  Medical supervision recommended for maximal or
exercise testing not necessary recommended for maximal submaximal exercise testing
exercise testing
Table 1.2 ACSM Risk Stratification Categories

 Low Risk

Men < 45 years of age and women 55 years of age who are asymptomatic and meet no
more than one risk factor thresholf from table 2-2.

 Moderate Risk

Men ≥45 years and women ≥55 years or those who meet the threshold for two or more risk
factors from Table 2-2

 High Risk

Individuals with one or more sign and symptoms list in Table 2-3 or known cardiovascular,
pulmonary, or metabolic disease
Figure 1.1
Figure 1.2
Figure 1.3
Figure 1.4
Table 1.3

Table 1.4
Table 1.5

Table 1.6
Table 1.7

Table 1.8
Table 1.9
SUMMARY

KEY MESSAGES

 Assessment of absolute cardiovascular risk is the starting point for all discussions with
people who have cardiovascular risk factors measured. Reduction in cardiovascular risk
is the goal of treatment.
 Risk assessment for most asymptomatic men is recommended from the age of 45 (or
from the age 35 if they have risk factors). Risk assessment for most asymptomatic
women is recommended from the age of 55 (or from the age of 45 if they have risk
factors)
 A fasting lipid profile, fasting plasma glucose and two blood pressure measurements
are recommended investigations for comprehensive risk assessment.
 People with known cardiovascular disease and those at high risk because of diabetes
with renal disease intervention.
 Cardiovascular mortality is high in people with impaired glucose tolerance (IGT) or
diabetes and most will require intensive intervention.
 Lifestyle change and drug intervention should be considered together. The intensity of
intervention recommended depends on the level of cardiovascular risk:
- a life free from cigarette smoke, eating a heart healthy diet and taking every
opportunity to be physically active is recommended for people at less than
10% 5 years CV risk
- lifestyle intervention for people at more than 10% 5 year CV risk are strongly
recommended and his group should receive individualized advice using
motivational interviewing techniques relating to smoking cessation if relevant,
a cardio protective diet and regular physical activity.
- Cardiovascular risk should be reduced in people at greater than 15% 5-year
CV risk by lifestyle interventions, aspirin, blood pressure lowering medication
and lipid modifying therapy (statins). There should be greater intensity of
treatment for higher risk people (more than 20-30%)
- After myocardial infarction, comprehensive programmers that promote life
style change for people are best delivered by a cardiac rehabilitation team.
Most people with angina or after myocardial infarction will be taking at least
four standard drugs, low-dose aspirin (75-150mg), a beta-blocker, a statin
and an ACE-inhibitor
- Virtually all ischemic stroke and transient ischemic attack survivors should be
taking low dose aspirin, a combination of two blood pressure drugs and a
statin.
2.0 Measuring Heart Rate (Palpation Method)

Heart rate may be palpated from a number of arteries, however, the three major sites of choice
are:

1. Radial artery : at the base of the thumb on the anterolateral side of the wrist ( figure 2.1)

2. Brachial artery: behind the biceps branchii and the below of the axilla on the inside of the
arm. (figure 2.2)

3. Carotid artery; on the neck lateral to the larynx. ( figure 2.3)

Figure 2.1 Figure 2.2

Figure 2.3
Specific Instructions:

For the accuracy of the reading, you should first try to obtain the heart rate from the radial
artery, if this is unsuccessful then try at the brachial artery. You should try to avoid taking the
heart rate at the carotid artery as can excessive pressure which may block blood flow to the
brain. Massaging this are (as you trying to locate this artery) may stimulate baroreceptors in the
artery in blood pressure fluctuations, which may lead to fainting.

The first step in palpating the radial artery is to locate the correct position on the wrist. After
rolling the wrist and forearm so that the palm is facing upwards, the correct location will be 3 -5
centimeters proximal to the wrist on the lateral side of the arm. Apply light to moderate pressure
with the tips of the middle and index fingers from the opposite hand, and try to feel the
rhythmical pulsing. If you do feel the pulse, count for ten seconds and multiply by the 6 to get
the heart rate per minute. Alternatively you may count for fifteen seconds and multiply by 4. It is
important to count the first pulse as “0”. You should not use your thumb to palpate as it has an
artery near the surface and you may feel your own pulse.

During the exercise the pulse will generally be easier to palpate since the heart will be
contracting more forcefully. During exercise on a cycle ergometer, have the individual take their
hand off the handlebars when you are trying to palpate the heart rate to minimize vibration and
excessive noise from the bike.

If the heart rate is difficult to obtain from an artery, a direct measure at the heart can be made by
using a stethoscope. Place the diaphragm of stethoscope either below the left clavicle close to
the sternum of below of the nipple.

Below are normal values and terms associated with slow and fasting heart rates:

 < 60 bpm = bradycardia (slow rate)

 60 – 100 bpm = normal rate

 > 100 bpm = tachycardia ( fast rate )

2.1 Measuring Heart Rate (Heart Rate Monitor)

Specific Instructions

 Firstly, Run the heart rate monitor under the tap water (warn the client that it may feel
cold).

 Attach the strap to one side of the monitor.

 Stand beside the client and attach the heart rate monitor below the chest level and then
either move in into position yourself or ask you client to move the transmitter so that it
just below the pectoral fold.

 Ask the client to hold the watch up to the transmitter for approximately 5-10 seconds or
until the client heart rate is displayed on the screen.

2.2 Activity

Palpate radial HR on the individual who is wearing a HR monitor and compare your result. To
obtain the percentage error, divide the radial HR on the monitor, multiply this result by 100, and
then find the difference between this value and 100. This will be your percentage error.

Radial HR : __________bpm

HR Monitor :___________bpm

Percentage error :____________%

3.0 Blood Pressure

3.1 Measuring Resting Blood Pressure

Resting BP is regularly measured to detect hypertension (high blood pressure). Given that
hypertension is a primary risk factor for cardiovascular disease, exercise scientists have a
professional responsibility to screen this condition prior to an exercise test. The blood pressure
response to exercise is also a strong predictor of cardiovascular outcome, therefore it is also
important to measure BP during exercise.

The equipment used to measure BP is a sphygomomanometer (sphygmo) and stethoscope.

The manometer on the sphygmo may be either aneroid (dial) or a mercury column. At
present, mercury column manometers are more common and easier to calibrate. In addition,
there automated devices that are useful for RBP but many are unsuitable and not validated for
use during exercise due to noise interference. Millimeters of mercury (mmHg) are the standard
international unit for BP.

BP, for the purpose of laboratory testing, may define as the force distending the arterial walls.
The brachial artery at the antecubital fossa (elbow crease) is usually the site for this
measurement, due to its position at approximately heart level.

The measurement of BP relies on vibration made by blood against the arterial wall. These are
referred to as KOROTKOFF sounds and due to turbulent blood flow when a cuff is inflated so
that it partially occludes the artery. When pressure within the cuffs exceeds blood pressure
within the artery, there is total occlusion (no blood flow) and therefore no sound can be heard
when the stethoscope is place over the brachial artery. As the cuff deflated, pressure within the
artery exceeds the occluding pressure off the cuff allowing the blood flow resume and beat of
the heart to be heard. The FIRST audible heart beat corresponds to systolic blood pressure
(SBP) and indicates the contraction of the heart (primarily the left ventricle) which propels
quantity of blood into the aorta and through arterial system. As the cuff is continued to deflate,
diastolic blood pressure (DBP) corresponds to the point at which the sound cease and
indicates the lowest (or baseline) pressure within arterial system. When the cuff is completely
deflated, blood flow is laminar and unimpeded; therefore no sound can be heard.

Two further terms are relevant:

1. Pulse Pressure is the difference between the systolic and diastolic pressure, and
theoretically provides an approximately of stroke volume (proportional) and can be
considered inversely proportional to the compliance of the aorta. With exercise, pulse
pressure should increase as SBP rises and DBP is remains relatively stable.

Pulse Pressure : SBP – DBP

2. Mean Arterial Pressure is the average blood pressure against the arterial walls. Because
diastole is longer than systole, mean arterial pressure can be calculated as follows:

Mean Arterial Pressure (MAP) : (SBP – DBP) + DBP

3
3.2 Procedures

Precaution

The mercury contained with the columns of sphygmomanometers is highly toxic. It can be
absorbed through the skin or inhaled. For these reasons much care need to be shown when
dealing with the sphygmomanometers. Please ensure that you tilt the sphygmomanometer until
the mercury disappears and switch the mercury locking level at the base to OFF (move the
switch right). Please report any spilt mercury immediately.

Introduction

Systolic blood pressure is the pressure against the arteries during contraction (systole) of heart
and diastolic blood pressure is the pressure against the arteries while the heart is in between
contractions (i.e., diastole). A blood pressure cuff, gauge (sphygmomanometer) and
stethoscope is used.

The following procedure is recommended for blood pressure measurement:

Procedures for assessment of Resting Blood Pressure:

1. Patients should be seated quietly for at least 5 minutes in a chair with back support
(rather than on an examination table) with their feet on the floor and their arm supported
at heart level. Patients should refrain from smoking cigarettes or ingesting caffeine
during the 30 minutes preceding the measurement.

2. Measuring spine and standing values may be indicated under special circumstances.

3. Wrap cuff firmly around upper arm at heart level; align cuff with brachial artery.

4. The appropriate cuff size must be used to ensure measurement. The bladder within the
cuff should circle at least 80% of the upper arm. Many adults require a large adult cuff.

5. Place stethoscope bell below the antecubital space over the brachial artery

6. Quickly inflate cuff pressure to 20 mm Hg above first Korotkoff sound.

7. Slowly release pressure at rate equal to 2 to 5 mmHg per second;

8. Systolic BP is the point at which the first of two or more Korotkoff sounds is hear (phase
1) and diastolic Bp is the point before the disappearance of Korotkoff sounds *phase 5)

9. At least two measurements should be made (minimum of 1 minute apart)

10. Provide to patients, verbally and in writing, their specific BP numbers and BP goals.

*modified from National Blood Pressure Education Program. The Seventh Report of the Joint
National Committee on Prevention, Direction, Evaluation and Treatment of High Blood Pressure
(JNC7). 2003. 03-5233
Table 3.1 Activity

Have your blood pressure measured by three students. (All measurements are measured in
mmHg.)

SBP DBP Pulse Pressure Mean Arterial

pressure
Tester 1
Tester 2
Tester 3

3.3 BLOOD PRESSURE RESPONSE

The normal blood pressure response to dynamic upright exercise consists of a progressive
increase in SBP, no change or a slight decrease in DBP, and a widening of the pulse pressure.
The following are key point concerning interpretation of the blood pressure. The following are
key points concerning interpretation of the blood pressure response to progressive dynamic
exercise:

 A drop in SBP (>10mm Hg from baseline SBP despite an increase in workload, or failure
of SBP to increase with increased workload is considered an abnormal test response.
Exercise-induced decreases in SBP (exertional hypotension) may occur in patients with
CAD, valvular heart disease, cardiomyopathies and serious dysrhythmias. Occasionally,
patients without clinically significant heart disease demonstrate exertional hypotension
caused by antihypertensive therapy, prolonged strenuous exercise and vasovagal
responses. However, exertional hypotension has been shown to correlate with
myocardial ischemia, left ventricular dysfunction, and an increased risk of subsequent
cardiac events. In the same cases this response is improve after coronary bypass
surgery.
 The normal post exercise response is progressive decline in SBP. During passive
recovery in an upright posture, SBP may decrease abruptly because of peripheral
pooling (and usually normalizes on resuming the supine position). SBP may remain
below pre testing values for several hours after the test. DBP also may drop during the
post exercise period.
 In patients on vasodilators, calcium channel blockers, angiotensin-converting enzyme
inhibitors, and α- and β-adrenergic blockers, the blood pressure response to exercise is
variably attenuated and cannot be accurately predicted in the absence of clinical test
data.
 Although maximal heart rates are comparable for men and women, men generally have
higher systolic blood pressure (~20 ±5 mm Hg) during maximal treadmill testing.
However, the gender difference is no longer apparent after 70 years of age. A systolic
blood pressure >250 mm Hg or a diastolic blood pressure >115 mm Hg should result in
test termination.
 The rate-pressure product or double product (SBP X HR) is an indicator of myocardial
oxygen demand. Signs and symptoms of ischemia generally occur at a reproducible
double product.
Table 3.2 Example template for measuring Blood Pressure

PERSON 1 PERSON 2

Trial Systolic Diastolic Trial Systolic Diastolic

1. S 1. S
Seated Seated
Standing Standing
2. S 2. S
Seated Seated
Standing Standing

3.4 Measuring Exercise Blood Pressure

The method for measuring blood pressure during exercise is similar to that at rest; however the
weight of the arm should be supported to reduce the influence of muscular tension on the
brachial artery. Remember that during exercise (and in some individuals at rest), phase V sound
can often be hard down to, or close to zero mmHg (e.g. 30-40mmHg). Under these conditions a
more accurate estimation of diastolic blood pressure would be the onset of the phase IV
Korotkoff sound (attenuated, muffled sound).

With an increase in exercise intensity, systolic blood pressure normally rises progressively
reaching a maximum level at the point of maximum exercise intensity (~160-200mmHg).

With an increase in exercise intensity, diastolic blood pressure tends to remain at resting levels
or rise or fall slightly.

An abnormal blood pressure response to exercise is when the systolic blood pressure

1. fails to increase with increasing intensity

2. decreases by >10 mmHg from one stage on the next
3. increases to >220mmHg (men) or >190mmHg (women)

or when the diastolic blood pressure increases to greater than 115 mm Hg.

See indications for terminating exercise test on previous page. A relative indication
(according to ACSM) occurs when blood pressure rises above 250mmHg systolic and/or
115 mmHg diastolic. These increases in blood pressure will be regarded as absolute
indications for terminating testing for the exercise tests you conduct.
3.5 Activity – Measuring Exercise Blood Pressure

You will be required to measure exercise blood pressure on a partner.

1. Have the client complete the SMA screening assessment form

2. Have the client wear a HR monitor
3. Position the client on the Monark cycle ergometer and adjust the seat (leg should be
slightly bent at the bottom of the crank) and handle bars (such that the client is
comfortable)
4. Use a stand to place the sphygmomanometer on.
5. Place the blood pressure cuff on the client, support the weight of the arm and measure
resting blood pressure
6. Start the client exercising at a workrate of 300kpm.min-1 or 50 W (i.e. 1.0kp @ 50 rpm)
for 3 minutes
7. Measure blood pressure during the 3rd minute. You should start inflating the cuff after 2
minutes. (This will give you adequate time (1 minute) to take blood pressure). Record
heart rate at the end of the 3 minutes.
8. After the 3rd minute increase the workrate into 600 kpm.min-1 (100 W). This will depend
on the estimated aerobic capacity of the person.
9. Measure blood pressure during the 6th minute. Record heart rate at the 6th minute

Client: ____________________

Time systolic BP Diastolic BP Heart rate

Resting _________ __________ __________

3rd minute _________ __________ __________

6th minute _________ __________ __________

Table 3.3 Classification of Blood Pressure (BP) for Adults Aged 18 Years and Older
∗
Category Systolic BP (mmHg) Diastolic BP (mmHg)

Optimal <120 And <80

Normal 120-129 And 80-84
High normal 130-139 Or 85-89
Hypertension
Stage 1 140-159 Or 90-99
Stage 2 160-179 Or 100-109
Stage 3 ≥ 180 Or ≥ 110

* Reprinted with permission from Sixth Report of the Joint Committee on Prevention, Detection, evaluation, and Treatment of High
Blood Pressure (JNCVI), Public Health Service, National Institutes of Health, National Heart, Lung and Blood Institute, NH
Publication No. 98-4080, November 1987.
† Not taking antihypertensive medication and not acutely ill. When systolic and diastolic BPs fall
into different categories, the higher category should be selected to classify the individual‟s BP
status. For example, 190/92 mmHg should be classified as stage 2 hypertension and 174/120
mmHg should be classified as stage 3 hypertension. Isolated systolic hypertension is defined as
BP ≥ 140 mmHg and diastolic BP < 90 and staged appropriately (e.g, 170/82 mmHg is defined
as stage 2 isolated systolic hypertension). In addition to classifying stages of hypertension on
the basis of average BP levels, clinicians should specify presence or absence of target organ
disease and additional risk factors. This specificity is important for risk classification and
treatment.

± Optimal BP with respect to cardiovascular risk is below 120/80 mmHg. However, unusually low readings should be
evaluated for clinical significance.

¥ Based on the average of two or more readings taken at each of two or more visits after an initial screening.

Source: American College of Sports Medicine (2005) ACSM‟s guidelines for exercise testing and prescription.
Baltimore : Lippincott Williams & Wilkins.
4.0 Body Composition

4.1 Body Mass Index

Body Mass Index (BMI) is used to assess weight relative to height and is calculated by dividing
weight in kilograms by height in meters squared (kg/m2).

4.1.1To measure standing height (stature)

Ask the client to remove his/her shoes. The client then stands
directly under the stadiometer with their feet together and their
heels, buttock, and upper part of their back touching the wall or
the stadiometer. The client‟s head should be positioned in the
Frankfort plane. The Frankfort plane is achieved when the
orbitale (lower edge of the eye socket) is in the same horizontal
plane as the tragion (the notch superior to the tragus of the ear).
When these points are aligned, the vertex is the highest point on
the skull. The client should then be instructed to take and hold a
deep breath and while keeping the head in a Frankfort plane.
The measurer then brings the stadiometer tape down until it is
placed firmly on the vertex, crushing the client‟s hair as much as
possible. Depending on the stadiometer, it may be helpful to
stand on an anthropometry box so the reading is at eye level.
The measurement is taken at the end of a deep inward breath.

4.1.2 To measure body mass

Position the scales where you will be able to read the dial clearly and directly from the front
(reading the dial upside down). Check that the scales are reading zero before beginning. Ensure
the client remains with the shoes off and ask the client to empty his/her pockets. Ask the subject
to stand on the center of the scales without support and with the weight distributed evenly on
both feet. Ask the client to hold his/her head up and look directly ahead.
4.1.3 Activity – Measuring BMI

Measure BMI of a partner

Client: _________________

Height: _________________m

Weight: _________________kg

BMI: ___________________ kg/m2

The following table can be used to classify an individual‟s BMI score. This table also allows for a
classification of risk of developing chronic disease/s (i.e. using sex differences and/or an
additional measure of waist circumference – this measure is described later in this section)

Classification (according to Table 4.1) _____________

Table 4.1 Classification of Disease Risk Based on Body Mass Index (BMI) and Waist
1
Circumference
2
Disease Risk Relative to Normal Weight and Waist
3
Circumference
Men, >102cm Men, >102cm
2
BMI, kg/m Women, >88cm Women, >88cm
Underweight <18.5 … …
4
Normal 18.5-24.9 … …
Overweight 25.0-29.9 Increased High
Obesity, class
I 30.0-34.9 High Very high
II 35.0-39.9 Very high Very high
III >40 Extremely high Extremely high
1. Modified from Expert Panel. Executive summary of the clinical guidelines on the identification,
evaluation, and treatment of overweight and obesity in adults. Arch Intern Med 1988; 1855-1867
2. Disease risk for type 2 diabetes, hypertension, and cardiovascular disease. Ellipses indicate that
no additional risk at these levels of BMI was assigned.
3. A gender neutral value for waist circumference (>100 cm) has also been suggested as an index
of obesity (see Table 2.1)
4. Increased waist circumference can also be a marker for increased risk even in persons of normal
weight

Source: American College of Sports Medicine (2005) ACSM‟s guidelines for exercise testing and prescription.
Baltimore : Lippincott William & Wilkins
4.2. Location of Landmarks
(All description assume that the body is in anatomical position)

Landmarks identify the exact location of the measurement site. All landmarks are found by
palpation and the measurer should trim his/her fingernails. The landmark is identified with the
thumb and index finger and dermographic pen or eyebrow pencil. The site is marked with an „X‟
so that a specific point can be located. All landmarks are marked before measurements are
made. The order of their identification is as listed below (note: an ISAK guideline for order of
landmark location has been modified). All landmarks are identified on the right side of the
body unless otherwise indicated.

Activity – Locating Landmarks

On a partner locate and mark the following Landmarks

1. Ilioocristale
The point on the most lateral aspect of the iliac tubercle. Stand behind the client and with the
client‟s arm placed horizontally in a lateral position; locate the most lateral superior edge of the
ilium using the right hand. The left hand is used to stabilize the body by providing resistance on
the left side of the pelvis. The landmark is made at the identified edge of the ilium, which is
interested by the imaginary vertical line from the mix-axilla (directly under the centre of the
armpit).

2. Lower border of costal rib

Mark the lower costal rib on the lateral aspect of the body intersected by the imaginary vertical
line from the mid-axilla (directly under the centre of the armpit).

3. Midpoint between iliocristale and lower rib border

Locate the point equidistant between the iliocristale and the lower costal rib border. Measure the
linear distance between the iliocristal and lower rib border with the arm relaxed and extended by
the side. Place a small horizontal mark at the level of the mid-point between these two
landmarks. This will be the level of the waist girth measure.

4. Acromiale (at curve of bone)

Mark the point at the superior and lateral border of the acromion process, midway between the
anterior and posterior border of the deltoid muscle when viewed from the side. To locate – stand
behind and on the right side of the client and palpate along the spine of the scapula to the
corner of the acromion. This represents the start of the lateral border, which usually runs
anteriorly, slightly superiorly and medially. Apply the straight edge of a pencil to the lateral
aspect of acromion to confirm the location of the border. The landmark is a point on the most
lateral and superior part of the border which is adjudged to be in the mid-deltoid position when
viewed from the side.
5. Radiale
Mark the point at the proximal and lateral border of the head of the radius. Palpate downward
into the lateral dimple of the right elbow. It should be possible to feel the space between the
capitulum of the humerus and the head of the radius. The head of the radius can be palpated
with the slight rotation of the forearm.

6. Mid-acromiale-radiale
The point equidistant between the acromiale and radiale. Measure the linear distance between
the acromiale and radiale with the arm relaxed and extended by the side. Place a small
horizontal mark at the level of the mid-point between these two landmarks. Project this mark
around to the posterior and anterior surfaces of the arm as a horizontal line. This is required for
locating the triceps and biceps skinfol sites.

7. Biceps landmark
The biceps skinfold is taken over the most anterior part of the biceps when viewed from the side
(at the marked mid-acromiale-radiale level).

8. Triceps landmark
The triceps skinfold is taken over the most posterior part of the triceps when viewed fron the
side (at the marked mid-acromiale-radiale level).

9. Stylion
Using a thumb nail the anthropometrist palpates in the triangular space identified by themuscle
tendons of the wrist immediately above the thumb. This site is also called the anatomical „‟snuff
box‟‟. Once the snuff box has been identified, palpate in the space between the distal radius and
the most proximal aspect of the first metacarpal in order to correctly identify the styloid process.
Mark the most distal point on the lateral margin of the inferior head of the radius (i.e the styloid
process of the radius).

10. Midstylion
The midpoint, on the anterior surface of the wrist, of the horizontal line at the level of the stylion.
The tape is aligned with the stylion landmark and a horizontal line is drawn close to the mid-
point of the wrist. The mid-point is equidistant between the medial and lateral edges of the wrist
and is located by measuring the linear distance between these point and marking the point
between them by drawing a vertical line that intersects the horizontal line.

11. Dactylion
The tip of the middle (third) finger when the arm is hanging down and the fingers are stretched
downward. No marks are required for this site since it is the point on the end of the third finger.
The other fingers are designated the second (index finger), fourth and fifth dactylia (digits).
Finger nails should not be used as landmarks for the end of fingers.

12. Subscapulare
The undermost tip of the inferior angle of the scapula. Palpate the inferior angle of the scapula
with the left thumb. If there is difficulty locating the inferior angle of the scapula, the client should
slowly reach behind the back with the right arm. The inferior angle of the scapula should be felt
continuously as the hand is again placed by the side of the body. A final check of this landmark
should be made with the hand by the side in the functional position. Mark this point.
13. Subscapulare skinfold site
Mark the point 2cm away from the inferior angle of the scapula, at a 45 degree angle running
laterally and obliquely downwards. (Ask female clients to take bra out of the way with other
arm.)

14. Mesosternale
This landmark is located by palpation beginning from the top of the clavicles. Using the thumb
the anthropometrist should roll down from the clavicle to the first costal space (i.e between the
first and second ribs.) the thumb is then replaced by the index finger and the procedure is then
repeated down to the second, third and fourth intercostals spaces. The fourth rib is between the
last two spaces. Mark the midpoint of the sternum at the level of the centre of the articulation of
the fourth rib with the sternum (chondrosternal articulation).

15. Xiphoidale
The xiphoidale is found at the lower extremity of the sternum. Mark the inferior tip of the xiphion.
It is located by palpation in the medial direction of the left or right costal arch toward the
sternum. These arches (which from the infrasternal angle) articulate at the xiphi-sternal junction.
Then follow down to the inferior tip of the xiphion. This is the Xiphioidale.

16. Xiphoidale skinfold site

The ilio-axilla line is the imaginary vertical line joining the observed mid-point of the armpit with
the iliac crest. Mark the point along this line that is level with the xiphoidale.

17. Abdominal skinfold site

The abdominal skinfold is measured 5cm to the right of the navel. Using a tape measure, this
site is measured horizontally across from the midpoint of the navel.

18. Iliospinale
To locate the iliospinale, palpate the superior aspect of the ilium and follow anteriorly and
inferiorly along the crest until the prominence of the ilium runs posteriorly. The landmark is the
lower margin or edge where the bone can just be felt. Difficulty in appraising the landmark can
be assisted by the client lifting the heel of the right foot and rotating the femur outward. Because
the sartorius muscle originates at the site of the iliospinale, this movement of the femur enables
palpation of the muscle and tracing to its source. Mark the most inferior or undermost tip of the
superior iliac spine.

19. Supraspinale skinfold site

Using a tape measure, locate the line that runs from the anterior axillary border (i.e the front of
the armpit) to the iliospinale. Mark the point that intersects with this line at the level of the iliac
crest.

20. Midpoint between inguinal fold and superior border of patella

Position a tape measure from the inguinal fold to the superior border of the patella. Mark the
point that is equidistant between these two landmarks. This mark will be where the thigh skinfold
will be measured.

21. Medial calf site

Using a tape measure, find the maximum circumference of the calf. Mark the most medial
aspect of the calf at this maximal girth level.

22. Trochanterion
This site is identified by palpating the lateral aspect of the gluteal muscle while standing behind
the client. It is advisable to support the left side of the client‟s pelvis with the left hand while
applying pressure with the heel of the right hand. Once the greater trochanter has been
identified the measurer should palpate upwards to locate the most superior aspect of this body
landmark. (Note: This site is difficult to locate in persons with thick adipose tissue over the
greater trochanter.) Mark the most superior point on the greater trochanter of the femur, not the
most lateral point.

23. Tibiale laterale

This is often a difficult landmark to correctly locate due to thick lateral ligaments that run across
the knee joint. Palpate the site using a thumb nail using the following guidelines. Locate the
area bounded by the lateralcondyle of the femur and the anterolateral portion of the head of the
tibia. Press inwards firmly in order to locate the superior and lateral border of the head of the
tibia. It is often useful to have the client sitting on a box while flexing and extending the knee
several times to ensure that the correct position has been located. Mark the most superior point
on the lateral border of the head of the tibia. The mark should be made approximately one-third
of the distance along the border moving in an anterior-postrior direction.

24. Midpoint between trochanterion and tibiale laterale

Mark the point equidistant between the trochanterion and the tibiale laterale. This will be the site
of the mid-thigh girth measurement.

25. Tibiale mediale

The tibiale mediale is approximately in the same tranverse plane as the tibiale laterale. It is
marked with the client seated on the box with the right leg rested over the left knee so that the
medial aspect of the lower leg can be marked. Palpate the site bounded by the medial femoral
condyle and the internal tibial tuberosity. Mark the most superior point on the medial border of
the head of the tibia.

26. Sphyrion tibiale

This landmark may be located most easily by palpation with the thumb nail from beneath and
dorsally. It is the distal tip, not the outermost point, of the medial malleolus of the tibia. It is
marked with the client seated on the box with the right leg rested over the left knee so that the
medial aspect of the lower leg can be marked. Mark the most distal tip of the mediale of the
tibia.
4.3 Measuring girth and reliability

Activity – Measuring Girth and Reliability

Working in pairs, ensure you measure the same person twice (with one week between
measures), and have measures taken on you by two different people (with one week between
measures).

Carry out the measures for 2 rotations (trial 1 and trial 2) around the two girths. If there is less
than a 1% difference between the two measures, record the mean (average) of these
measures. If there is >1% difference, make a third measure and record the median. To
calculate whether your measures are less than 1% divide the larger measure by the smaller
measure, multiply the result by 100, then subtract 100 (see below – calculating accuracy
example).

You need to be measured by two different testers. This is to calculate inter-tester reliability
(i.e. the reliability of two different testers).

You need to measure the first person that you measured again. This is to calculate intra-tester
reliability (i.e. the reliability of one tester making the same measures).

Calculating Accuracy Example:

Trial 1 Trial 2 Trial 3 Mean of 2 or

(if needed) median of 3
Waist (minimum) 81.5 80.3
gluteal (hips) 101.7 102.1

To calculate whether the waist and hip measures are less than 1%:
Waist: [(81.5/80.3) x 100] – 100% = 1.47%
This indicates that the two waist circumferences taken differ by 1.47% (which is >1%), therefore
a third waist measure must be taken. When a third measure is taken the median of all three
measures is recorded.

Hip: [(102.1/101.7) x 100] – 100% = 0.39%

This indicates that the two hip circumference are within 0.39% (which is smaller than 1%)
therefore a third measure will not be required and the mean of the first two measures is
recorded.

Trial 1 Trial 2 Trial 3 Mean of 2 or

(if needed) median of 3
Waist (minimum) 81.5 80.3 80.4 80.4 (median)
gluteal (hips) 101.7 102.1 101.9 (average)
Using the tape measure

The tape measure is positioned at right angles to the limb or body segment that is being
measured. The tension of the tape must be held constant. To position the tape, hold the case in
the right hand and the stub in the left. Facing the body part being measured, pass the stub end
around the back of the limb and take hold of the stub with the right hand which then holds both
the stub and the casing. At this point the left hand is free to manipulate the tape to the correct
level. Apply sufficient tension to the tape with the right hand to hold it at that position while the
left hand reaches underneath the casing to take hold of the stub again. The middle fingers of
both hands are free to exactly locate the tape at the landmark for measurement and to orientate
the tape so that the zero is easily read. When reading the tape, the measurer‟s eyes must be at
the same level as the tape to avoid error of parallax.
Activity – Measuring waist-to-hip ratio

Waist-to-hip ratio is another measure of body fat distribution. This ratio uses measures of waist
girth and gluteal (hip) girth. To calculate a value of your client‟s waist-to-hip ratio, simply divide
the waist girth by the hip girth. Precise locations of these sites are described below. Waist-to-hip
ratios above 0.95 for males and above 0.8 for females are associated with an increased risk of
coronary heart disease. However, these values may vary depending on the literature source.
Table 4.2 can be used to classify waist-to-hip ratios.

Measuring waist circumference

ISAK guidelines state that this measure is taken at the level of the
narrowest point between the lower costal (rib) border and the
iliocristale. However for novices it is easy to confuse the
narrowest point with the lower rib cage border) Therefore, the
waist measurement will be taken at the mid-point between the
lower costal border and the iliocristale. The measurer stands in
front of the client and to ensure that the tape measure is
horizontal you should always ask the person writing down the
result to check this. The measurement is taken at the end of a
normal expiration with the arms relaxed at the site.

Measuring gluteal (hip) circumference

This is taken at the level of the greatest posterior protuberance

of the buttocks, which usually corresponds anteriorly to about
the level of the symphysis pubis. The measurer stands at the
side of the client and to ensure that the tape measure is
horizontal you should always ask the person writing down the
result to check this. The client stands with feet together and
should not tense the gluteal muscle. The client‟s hands rest on
his/her opposite shoulders. Ensure you pull the tape measure
tightly to compress any clothing
Inter-tester Reliability

This is your data from two different testers (tester 1 and tester 2)
Tester 1

Trial 1 Trial 2 Trial 3 Mean of 2 or

(if needed) median of 3
Waist (minimum)
Gluteal (hips)

WHR from tester 1

Tester 2

Trial 1 Trial 2 Trial 3 Mean of 2 or

(if needed) median of 3
Waist
(minimum)
Gluteus (hips)

WHR from tester 2

Intra-test Reliability

This is data collected by you on the same person (client). You should allow sufficient time
between measures (take measures on at least two other people in between).

Client

Trial 1 Trial 2

Trial Trial Trial 3 Mean

Trial Trial Trial 3 Mean
1 2 (if of 2 or
1 2 (if of 2 or
needed) median
needed media
of 3
) n of 3
Waist
Waist
(minimum)
(minimum
Gluteal
)
(hips)
Gluteal
(hips)
WHR from trial 1 WHR from trial 2 _________________
The following can be used to classify waist-to-hip rations

Table 4.2 Waist to Hip Circumference Ratio (WHR) Norms

Males Female
Age <60 >60 <60 >60
Low risk* <0.90 <0.95 <0.80 <0.85
Moderate risk* 0.90 – 0.95 0.95 – 1.03 0.80 – 0.86 0.85 – 0.90
High risk* >0.95 >1.03 >0.86 >0.90

*Risk of obesity related diseases such as Cardiovascular disease, type 2 diabetes and Cancer.
Adopted From Sport Medicine Australia Screening Questionnaire and Human Movement
Studies, University of Queensland

Pre Screening Questionnaire - Gymnasium Faculty of Sport Science and Recreation UiTM

Participant Responsibility:
 We have a responsibility towards your health and safety during this test.
 If you have information about your health status or previous experience of unusual
feeling with physical effort, your responsibility is to truthfully disclose such information on
accompanying sheets or when requested by testing staffs.
 You must also disclose any unusual feeling or discomfort during the test. We will take all
reasonable precaution to ensure the safety and values of your test but we cannot be
held responsible in the event that you fail to disclose important information to us.
PERSONAL INFORMATION

Name: DOB:

Phone: Mobile: Gender: M /F

Email: Staff/ student No:

Address

EMERGENCY CONTACT DETAILS

Name Relationship:

Phone: Mobile: Work:

MEDICAL CONDITION

No Condition No Yes Details

1 Have you ever had a heart attack, coronary

revascularization surgery or a stroke

2 Has your doctor ever told you that you have heart
trouble or vascular disease

3 Has your doctor ever told that you have heart murmur

4 Do you suffer from pains in your chest especially with

exercise

5 Do you ever get pains in your calves, buttock or at the

back of your legs during exercise which are not due to
soreness or stiffness.
6 Do you ever feel faint or have spells of severe dizziness,
particularly with exercise?

7 Do you experience swelling or accumulation of fluid

about the ankles?

8 Do you ever get feeling that your heart is suddenly

beating faster, racing or skipping beats, either at rest or
during exercise.

9 Do you have chronic obstructive pulmonary disease,

interstitial lung disease or cystic fibrosis?

10 Have you ever had an attack of shortness of breath that

developed after you were not doing anything strenuous,
at any time in the last 12 month?

11 Have you ever had an attack of shortness breath that

developed after you stopped exercising, at any time in
the last 12 month?

12 Have you ever been woken at night by an attack of

shortness of breath at any time in the last 12 month?

13 Do you have diabetes? If so do you have trouble

controlling diabetes?

14 Do you have any ulcerated wound or cuts on your feet

that do not seem to heal?

15 Do you have any liver, kidney or thyroid disorder?

16 Do you experience unusual fatigue or shortness of

breath with usual activities

17 Is there any other physical reason or medical condition,

or are you taking any medication which could prevent
you from undertaking an exercise program?

QUESTION REGARDING RISK FACTORS

18 Do you have smoke cigarettes regularly or have you quit

smoking in the last 6 month?

19 Do you have a family history of cardiovascular disease?

(This refers to a primary relative i.e parent, child or
sibling who has had a myocardial infarction, coronary
revascularization or died suddenly due to heart attack
before age of 55 years (male) or 65 years (Female).
20 Have you been told you have a systolic blood pressure
measure at greater 140mmHg on two separate occasion
OR a diastolic blood pressure measure at greater than
90 mmHg? Or you are taking anti-hypertensive
medication?

21 Have you been told you have impaired fasting glucose?

(Fasting glucose less than 6.1 mmol/L on two separate
occasions).

22 Have you ever been told that you have a total serum
cholesterol concentration of greater than 5.2mmol/L or
ahigh density lipoprotein concentration of less than
0.9mmol/L? or you on lipid lowering medication?

23 Do you have an occupation where you are seated for

long periods of time AND do no regular exercise?
(Regular exercise defined as more than 150 minutes of
moderate intensity physical activity per week).

SECTION FILL UP BY EXERCISE PHYSIOLOGIST / PERSONAL TRAINER

Does the client have a BMI greater than 30 kg/m2 or a

waist girth greater than 100cm?

I have read the Participant Responsibility Statement on the previous page and believe, to the
best of my ability that all the answer and information supplied is accurate.

Signature_____________________

LOW RISK MODERATE RISK HIGH RISK

5.0 INTRODUCTION

The most widely accepted measure of cardiorespiratory fitness or aerobic capacity is maximal
oxygen uptake or VO2 max. VO2 max is defined as the body‟s maximum capacity to take in
oxygen from the environment, transport it to the working tissues, and for those working tissues
to use oxygen.

Measuring VO2 max requires expensive and sophisticated equipment, technical expertise,
maximal efforts by clients and a small degree of medical risk. Thus, tests have been developed
to predict VO2 max from submaximal efforts. Apparatus is less complex, less expensive, easier
to use, useful in field, and the tests require less intense exercise and therefore have a lower
medical risk.

The physiological basis for the prediction of VO2 max from submaximal efforts is based on a
number of assumptions. The major assumptions are that relationships between oxygen
consumption (VO2) and exercise intensity, and heart rate to exercise intensity are linearly
related. Thus, based on these assumptions, valid and reliable tests have been developed that
involve exercise intensity and heart rates. From these values oxygen consumption can be
determined and maximal oxygen consumption predicted.

All predictive tests should be interpreted with caution, especially if the original data from the test
were from a different type of client population to the client being tested. Age and fitness
characteristics may also influence test results. The Astrand Bicycle Ergometer test and Astrand
Step test involves age correction factors to account for age-related declines in maximal heart
rates (220-age).

Untrained persons are more likely to be under estimated by submaximal tests, whereas highly
trained individuals are more likely to be overestimated in their maximal oxygen capacities. A
selection of tests widely used in the sports/fitness industry is given here with the concept for
each predictive test the same: a prediction of maximal oxygen consumption based on the
client‟s heart rate response at a given workload or exercise intensity.
General Methods for Submaximal Test

Conditions for Testing

1. No exercise four hours prior to testing.

2. No stimulants (cigarettes, coffee, tea, coke) or depressants (alcohol) four hour prior to
testing.
3. No heavy meals four hours prior to testing.
4. Client well hydrated.
5. Client wears lightweight/loose clothing and sandshoes/track shoes.
6. If comparing to previous or future test, standardize temperature and humidity.
7. Orientate client: explanation of procedures/purpose of test.
8. For bicycle ergometer tests: - establish seat height (when client‟s leg is stretched
vertically, with the ball of the foot on the pedal, the leg should be slightly bent at about 5º
flexion. Seat height can affect mechanical efficiency. Quality ergometers have numbered
holes on the seat posts. Record these for retest purposes.
9. ACSM recommends that a resting blood pressure greater than 250mm Hg systolic
and/or 115mm Hg diastolic is a relative contraindication for exercise. For the purposes of
exercise testing, this will be seen as an absolute contraindication.
10. Although ACSM recommends a warm-up before all submaximal exercise tests, the
submaximal tests selected for this course all include an initial workload, or are at a
workload of relatively low intensity, so you will not be required to give your client a warm-
up.
11. It is important to continually monitor cadence on the Monark bike tests. Clients have a
tendency to cycle faster than the requested cadence (usually 50 rpm). This invalidates
the test as they are cycling at a higher power output.
12. If you are using a Monark bike to determine power it may be necessary to use the
following table if this information is not ready provided on the bike.
Force (F) And Power (P) On A Mechanically Cycle Ergometer

FORCE POWER

Kg/kp N Kgm.min or W

Kpm.min

0.5 5 150 25

1.0 10 300 50

1.5 15 450 75

2.0 20 600 100

2.5 25 750 125

3.0 30 900 150

FORCE POWER

Kg/kp N Kgm.min or W

Kpm.min

3.5 35 1050 175

4.0 40 1200 200

4.5 45 1350 225

5.0 50 1500 250

5.5 55 1650 275

6.0 60 1800 300

Where Kg = Kilogram, Kp = Kilopound, N = Newtons, W = Watts, Kgm.min = Kilogram meters

per minute, Kpm.min = Kilopound meters per minute

Based on 50 revolutions per minute

Note: kgm = kpm

Kgm/min = kpm/min

(For our purposes, kpm and kgm can be used interchangeably. Be aware that texts/tutors may

alternate between them.)

5.1 Detail Exercise Testing

A skill that separates an Exercise Scientist from any other therapy or discipline is the ability to
carry out an exercise test. Although some health and fitness centers carry out detailed exercise
testing, these tests are performed more commonly in clinical laboratories. The ability of an
Exercise Scientist to carry out these tests opens career paths in the area of cardiac
investigation.

Exercise testing can be either with or without the goal of determining cardiorespiratory fitness.
For example in a cardiac investigation setting the major goal of the exercise test is usually to
see the ECG pattern changes with exercise.

Below is the common sequence for detailed exercise testing:

Table 5.1 Sequence of Measures for Heart Rate, Blood Pressure,

Rating of Perceived Exertion (RPE), and
Electrocardiogram (ECG) During Exercise Testing

Pretest
1. 12-lead ECG in supine and exercise postures
2. Blood pressure measurements in the supine position and exercise posture

Exercise*
1. 12-lead ECG recorded during last 15 seconds of every stage and at peak exercise (3-lead ECG
observed/recorded every minute on monitor)
2. Blood pressure measurements should be obtained during the last minute of each stage#
3. Rating scales: RPE at the end of each stage, other scales if applicable.

Post test
1. 12-lead ECG immediately after exercise, then every 1 to 2 minutes for at least 5 minutes to allow
any exercise-induced changes to return to baseline.
2. Blood pressure measurements should be obtained immediately after exercise, then every 1 to 2
minutes until stabilised near baseline level.
3. Symptomatic ratings should be obtained using appropriated scales as long as symptoms persist
after exercise.
* In addition, these referenced variables should be assessed and recorded whenever adverse
symptoms or abnormal ECG changes occur.

# Note: An unchanged or decreasing systolic blood pressure with increasing workloads should
be retaken (i.e. verified immediately).

Source: American College of Sports Medicine (2005) ACSM‟s guidelines for exercise testing
and prescription. Baltimore : Lippincott Williams & Wilkins.
 Table 5.2 Contraindications to Exercise Testing*

Absolute
 A recent significant change in the resting ECG suggesting significant ischemia, recent myocardial
infarction (within 2 days) or other acute cardiac event.
 Unstable angina.
 Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise.
 Severe symptomatic aortic stenosis.
 Uncontrolled symptomatic heart failure.
 Acute pulmonary embolus or pulmonary infarction.
 Acute myocarditis or pericarditis.
 Suspected or known dissecting aneurysm.
 Acute infections.

Relative#
 Left main coronary stenosis.
 Moderate stenosis valvular heart disease.
 Electrolyte abnormalities (e.g. hypokalemia, hypomagnesemia).
 Severe arterial hypertension (i.e. systolic BP of >200mg Hg and/or a diastolic BP of >110 mm Hg)
at rest.
 Tachyarrhythmias or bradyarrhythmias.
 Hypertrophic cardiomyopathy and other forms of outflow tract obstruction.
 Neuromuscular, musculoskeletal, or rheumatoid disorders than are exacerbated by exercise.
 High-degree atrioventricular block.
 Ventricular aneurysm.
 Uncontrolled metabolic disease (e.g. diabetes, thyrotoxicosis, or myxedema).
 Chronic infectious disease (e.g. mononucleosis, hepatitis, AIDS)

* Modified from Gibbons RA, Balady GJ, Beasely JW, et al. ACC/AHA guidelines for exercise testing. J AM Coll Cardiol

1997;30;260-315
# Relative contraindications can be superseded if benefits outweigh risks of execise. In some instances, these individuals can be
exercised with caution and/or using low-level end points, especially if they asymptomatic at rest.
Source: American College of Sports Medicine (2005) ACSM‟s guidelines for exercise testing and prescription. Baltimore : Lippincott
Williams & Wilkins.
5.3 YMCA protocol

Unlike the Astrand bicycle test, which can be single stage, the YMCA test involves multiple
stages (see Table 5.3)

1. Asses the client`s risk using the SMA Screening Assessment From
2. Attach a heart rate monitor to the client.
3. Collect the client`s resting data; blood pressure, heart rate and body weight
4. Calculate 85% of the client`s age-predicted maximum heart rate. (85% x (220-age))
5. Adjust seat height and record his value (client`s leg bent slightly (5 degree flexion))
6. Set first workrate at 0.5 kp at 50 rpm for 30 minutes.
7. Record heart rate and RPE at the end of each minutes.
8. Blood pressure should be taken at the end of each workrate, between the 2nd and 2nd
minutes (and again between 3rd and 4th minutes, if stage need to be continue for 4th
minutes) (NB. Start taking blood pressure 2 minutes after the workrate has started, after
collecting heart rate data)
9. After 3rd minutes compare the 2nd and 3rd minute‟s heart rates. If they differ by no more
than 6 bpm, consult figure 5.1 to select the 2nd work rate base on the client`s heart rate
after the 3rd minute. If the 2nd and 3rd heart rate differs by more than 6 bpm continue on
that workrate until two successive heart rate differ by no more than 6 bpm, then use the
last heart rate to select the 2nd workrate from figure 5.1.
10. The 3rd and (if required) 4th workrate are obtained from the same pre-selected vertical
column from figure 5.1.
11. As the first workrate, records heart rate and RPE at the end of each minute.
12. As the first workrate, move to the next workrate after 3 minutes if the last two successive
heart rates differ by no more than 6 bpm. If the last two successive heart rate at any
workrate differ by more than 6bpm continues on the same workrate until this is achieved.
13. A minimum of three workrate must be complete.
14. Continue the test until you have at least two heart workrates with corresponding steady
state heart rates > 110 bpm and less than 85% of the client`s age predicted maximum
heart rate. The test should not exceed 16 minutes and should be stopped if the HR
exceeds 85% of age-predicted maximum heart rate or SBP rises above 250 mm Hg
and/or DBP rises above 115 mm Hg or if other test termination criteria are met.
15. After the last minute the client cools down at any cadence with 0.5 kp resistance.
16. Use figure 5.4 to calculate predicted VO2MAX in L/Mi (plotting instruction are write
above the graph).
17. Multiply this value by 1000 and divide by client`s body weight in order to obtain a
VO2MAX in ml/kg/min.
18. Refer to table 5.4 to obtain percentile value for the client`s VO2Max.
19. Ensure all equipment (heart rate monitor, ear pieces) is cleaned.
 Figure 5.1

0.5 kp

(150 km/min)

(25 W)

HR< 80 HR 80-89 HR 90-99 HR > 99

2.5 kp 2 kp 1.5 kp 1 kp

(750 km/min) (600 km/min) (450 km/min) (3000 km/min)

(125 W) (100 W) (75 W) (50 W)

3 kp 1.5 kp
2.5 kp 2 kp
(900 km/min) (450 km/min)
(750 km/min) (600 km/min)
(150 W) (75 W)
(125 W) (100 W)

3.5 kp 3 kp 2.5 kp 2 kp

(1050 km/min) (900 km/min) (750 km/min) (600 km/min)

(175 W) (150 W) (125 W) (100 W)

Modified guide to setting workrates for the YMCA Test ( Adopted From ACSM Exercise
Testing & Prescription 8th Edition).
Table 5.3

Data for YMCA Bicycle Ergometer Test

Subject Name :______________ Age:____ Weight:__________

Resting HR:________________ Resting BP:____________ 85% HRmax:______________

Seat Height:___________

STAGE MINUTES KP HEART RPE BP

RATE
1 1
2
3
4 (if necessary)
2 1
2
3
4 (if necessary)
3 1
2
3
4 (if necessary)
4 1
(if necessary) 2
3
4 (if necessary)
5.4 Calculating predicted VO2max and Predicted Maximal work rate values from YMCA
test

Subject Name : ______________

2nd last workrate and HR: ______________ Final workrate and HR: ___________

Predicted absolute VO2Max: _________L/min Predicted Relative

V02max:________ml/kg/min.

1. On the graph, draw a horizontal line intersecting with the client age-predicted maximum
heart rate (220-age).

2. Plot the heart rates recorded in the last minute of each of the last two workrates (heart
rate should be >110 bpm and <85% of age predicted maximum) against the
corresponding workrates.

3. Draw a straight line joining the two plotted points and extend this up to the client age
predicted maximum heart rate line. Drop a vertical line from this intersection point to the
workrate and VO2 scales below the horizontal axis. Read off the predicted VO2max in
L/min to the nearest 0.1L. Convert this score to relative value by dividing by body weight,
and then multiply the result by 1000 to obtain a VO2max score in ml/kg/min.
Table 5.4 Percentile Values for Maximal Aerobic Power (mL/kg-1/min-1)

Men Age
Percentile 20-29 30-39 40-49 50-59 60+
90 51.4 50.4 48.2 45.3 42.5
80 48.2 46.8 44.1 41.0 38.1
70 46.8 44.6 41.8 38.5 35.3
60 44.2 42.4 39.9 36.7 33.6
50 42.5 41.0 38.1 35.2 31.8
40 41.0 38.9 36.7 33.8 30.2
30 39.5 37.4 35.1 32.3 28.7
20 37.1 35.4 33.0 30.2 26.5
10 34.5 32.5 30.9 28.0 23.1

Women Age
Percentile 20-29 30-39 40-49 50-59 60+
90 44.2 41.0 39.5 35.2 35.2
80 41.0 38.6 36.3 32.3 31.2
70 38.1 36.7 33.8 30.9 29.4
60 36.7 34.6 32.3 29.4 27.2
50 35.2 33.8 30.9 28.2 25.8
40 33.8 32.3 29.5 26.9 24.5
30 32.3 30.5 28.3 25.5 23.8
20 30.6 28.7 26.5 24.3 22.8
10 28.4 26.5 25.1 22.3 20.8

The following may be used as descriptors for the percentile rankings: well above average (90),
above average (70), average (50), below average (30 and well below average (10).

Source
The Physical Fitness Specialist Certification Manual, The Cooper Institute, Dallas, TX, reprinted
with permission.
Figure 5.4

BORG’S RATING OF PERCEIVE EXERTION (RPE Scale)

BORG’S RATING OF PERCEIVED EXERTION

7 VERY, VERY LIGHT

9 VERY LIGHT

10

11 FAIRY LIGHT

12

13 SOMEWHAT HARD

14

15 HARD

16

17 VERY HARD

18

19 VERY, VERY HARD

20
6.0 6-minute walk test (50 meters)

The purpose of this test is to assess aerobic endurance. Please note that as it assesses
endurance, it should be administered after all the other tests have been completed. More than
one person can be tested at a time, just stagger starting and stopping times.

Mark out a rectangle that is 20 m by 4 m. Place cones inside each corner of the rectangle. Place
additional markers at each 5m intervals along the length of the rectangle. (There should be 10
intervals all together). See figure below.

On the signal „go‟ the client walks as fast as possible (not running) around course covering as
much distance as possible in the 6 minute time limit. To keep track of the distance walked, the
tester keeps a record sheet to monitor each time the client completes a lap. The remaining time
should be announced to the client at halfway (3 minutes), at 2 minutes to go and 1 minute to go.
Clients can stop and rest on the chairs provided however the time continues running. Testers
should verbally encourage clients during the walk. When 6 minutes has elapsed, tell the client to
slow down a walked distance from the last marker that the client passed. Administer this test
once only.

Note: when the test was first designed the distances were allocated in yards, and have been
converted into metres for the purpose of this laboratory. To provide feedback to your client,
convert the distance to yards by dividing the number by 0.914. (eg. 45.7 m/ 0.914 = 50 yards).

Distance covered in 6 minutes _______________________ metres ______________ yards.

7.0 Body Strength

Hand Grip Strength:

Protocol:

1. This test you may use either the spring-resistance or the hydraulic dynamometer

2. The client is in the standing position

3. Grip size adjusted (by turning the handle on the spring-resistance device) so that hand is
comfortable (not too cramped or too stretched)

4. testing upper arm by the side and elbow flexed at approximately 90 degree

5. client performs three maximal contractions with each hand with 10 seconds between
trials record result below and consult Table 4.1 for your rating (note: this table assumes
right hand dominance, if client is left hand dominant use the opposite norms)

6. If using the spring-resistance dynamometer you will need to multiply your value by the
correction factor found on the sticker on the back of the dynamometer.

YOUR RESULT:

Dominant Hand: _____________

Right Hand: 1. _____________ Left Hand: 1. ______________

2. _____________ 2.______________

3. _____________ 3.______________

Maximum:________ Maximum:_________

Rating:____________ Rating:____________
8.1 UPPER BODY FLEXIBILITY TESTS

Task 3: The over/under arm test

Testing procedure:

1. Client should perform a short warm-up prior to this test on a cycle ergometer, pedaling at
50 rpm, with a workload of 0.5 kpm for 5 mins. Also include some adequate stretches
(for shoulder) so that the client is achieving maximum range of motion for the reach. The
exercise scientist should guide the client through these stretches.

2. Mark the 7th cervical vertebra

3. Testing the left side of the body first, have the client reach over the left shoulder and
down the spine as far as possible

4. Measure (using a tape measure) the difference between the tip of the longest finger and
the mark; record the value as positive if the finger is below the mark and negative if the
finger is above the mark

5. Repeat the procedure after allowing the at least 5 seconds rest

6. Repeat this procedure twice using the right arm allowing the client at least 5 seconds
rest between trials.

7. Then have the client reach behind and up the back with the back of the left hand against
the spine

8. Measure the difference between the tip of the longest finger and the mark; record the
value as positive if the finger reaches higher than the mark and negative if the finger is
below the mark

9. Repeat steps 7 and 8 for the left hand after allowing the client at least 5 seconds rest

10. Repeat steps 7 and 8 switch for the right hand allowing the client at least 5 seconds rest
between trials

11. Add the best over and under scores for the left and right arm together (adding four
scores in total) and compare with norms (see table 8.1 )
For example

Left side – over: trial 1 : 2 cm Right side – over: trial 1: 7 cm

trial 2 : 4 cm trial 2 : 5 cm

Left side – under: trial 1 : 3 cm Right side – under: trial 1 : 1 cm

trial 2 : -1 cm trial 2 : 2 cm

Total score = 4 cm + 7 cm + -1 cm + 2 cm

= 12 cm

Table 8.1 Norms for the Arms Over/Under Test of Upper Body Flexibility

Rating Male Female

Superior 30.0 31.8
Good 16.8 25.0
Satisfactory 10.2 19.4
Fair 3.7 11.6
Poor -9.0 3.9
9.0 Activity: Guidelines to Skill Test

Introduction

1. Greet client
2. Introduce yourself
3. Give a brief overview of session
4. SMILE!!!

Heart Rate Monitor

1. Check that the monitor is working
2. It is a good idea to put the HR monitor on well before you want to take the measure, as
just the activity of attaching the monitor can ↑HR
3. Wet the electrodes on the HR monitor first
4. Client can position the monitor once attached

While waiting
1. Ensure equipment is organized
2. Calculate 85% of your client‟s Age-Predicted Heart Rate Maximum (APHRM) : (220-23)
x 0.85 = 167bpm
3. Record this value on your results sheet (Note: this value MUST be calculated and
recorded BEFORE your client starts the submax test!)

Screening
1. Explain purpose of screening to client
2. Give client the SMA questionnaire
3. If client has one or more signs or symptoms of disease, or a known disease, the client is
classified as „high risk‟ and cannot participate in exercise without medical clearance
4. If client is not classified as „high risk‟, record this before testing the client

Resting Heart Rate

1. Count for 15 seconds and multiply the value by 4
2. Tester will check your HR measure is correct using the HR monitor
3. Give brief feedback to your client regarding this value (e.g. “that‟s normal”)

Resting Blood Pressure

1. Place cuff on left arm
2. Palpate for brachial pulse
3. Inflate cuff 20mmHg higher than what you expect SBP to be
4. Deflate cuff at 2-3mmHg per second
5. Tester will listen with teaching stethoscope
6. Record value
7. If you know the values are normal give feedback (e.g. “that‟s normal”). If you are unsure
wait till you check it in the tables provided.

Body Composition
Briefly explain the purpose of body composition measures to client
1. Measuring Body Weight
a. Ensure client‟s shoes are off and pockets are empty
b. Client looks straight ahead with weight evenly distributed on both feet
 c. Ensure you are in a good position to clearly read the scales (i.e. avoid parallax
error)
2. Measuring Height
a. Ensure client‟s shoes are off
b. Ensure client‟s head is positioned in the Frankfort plane
c. Measure is taken at end of inspiration
d. Record the height and weight values
3. Measuring Waist Circumference
a. Mark lowest costal rib with a cross
b. Mark top of iliac crest with a cross
c. Make a horizontal mark equidistant between these two points
d. The measure is taken at the front of the client
e. The measure is taken at the end of expiration
f. Your tester will record these measures for you
g. and your tester will check whether the tape measure is straight if you ask him/her
too

4. Measuring Hip Circumference

a. Kneel or squat on the side of the client
b. Client‟s hands rest on his/her opposite shoulders
c. The measure is taken at the greatest posterior protuberance of the buttocks
d. Pull tape measure tightly to compress clothing
e. Your tester will record these measures for you and your tester will check whether
the tape measure is straight if you ask him/her too

YMCA Fitness Test…

1. Ensure…
Stethoscope, sphygmomometer, calculator, stopwatch, RPE scale, HR watch and ruler
are on the stand (note some bikes have RPE scale on them)
a. 85% APHRM has been calculated
b. Client‟s shoes are on
2. Briefly explain test
3. Set seat height
a. Approximately hip level
b. Once riding bike, knee should have approximately 5 degrees of flexion when
extended
c. Record this seat height
4. Record heart rate every minute
5. Take RPE every minute
6. Take blood pressure during the third and (if needed) fourth minute of each stage
7. After 3 minutes of a stage, compare the 2nd and 3rd minute heart rates. If they differ by
no more than 6bpm, progress to the next stage. If they differ by more than 6bpm,
continue the stage for an extra minute. Another BP will have to be taken if the stage
goes for 4 minutes.
8. Consult figure 3.2 to decide on workrate after the first stage
9. A minimum of three workrates must be completed
10. Continue the test until you have two final minute heart rates greater than 110bpm
11. Stop the test immediately if the client‟s heart rate rises above 85%APHRM or SBP rises
above 250mmHg or DBP rises above 115mmHg
Grip Strength
1. Check the right grip whether the subject is left or right handed

Data analysis
1. Calculate all result.
2. Put into percentile or table norms.
Appendix

FITNESS ASSESSMENT RESULT

Client Name: Date:

Assessor Name: Age:

Stratified to: 85% APHRM:

MEASURES READING PERCENTILES/RATING

Resting Heart Rate (bpm)
Resting Blood Pressure
(mmHg)
Height (m)
Weight (kg)
BMI (kg/m2)
1st 2nd 3rd Avg or
Waist Circumference (cm) Median

1st 2nd 3rd Avg or

Hip Circumference (cm) Median

Waist: Hip Ratio

Cardiovascular Fitness
Vo2 max (L/min)

Vo2 max (ml/kg/min)

1st 2nd 3rd Best
Grip Strength (kg) score
Data for YMCA Bicycle Ergometer Test

Subject Name :______________ Age:____ Weight:__________

Resting HR:________________ Resting BP:____________ 85% HRmax:______________

Seat Height:___________

STAGE MINUTES KP HEART RPE BP

RATE
1 1
2
3
4 (if necessary)
2 1
2
3
4 (if necessary)
3 1
2
3
4 (if necessary)
4 1
(if necessary) 2
3
4 (if necessary)
Subject Name :______________

2nd last workrate and HR:______________ Final workrate and HR:___________

Predicted absolute VO2Max : _________L/min Predicted Relative

V02max:________ml/kg/min.

1. On the graph, draw a horizontal line intersecting with the client age-predicted maximum
heart rate (220-age).

2. Plot the heart rates recorded in the last minute of each of the last two workrates (heart
rate should be >110 bpm and <85% of age predicted maximum) against the
corresponding workrates.

3. Draw a straight line joining the two plotted points and extend this up to the client age
predicted maximum heart rate line. Drop a vertical line from this intersection point to the
workrate and VO2 scales below the horizontal axis. Read off the predicted VO2max in
L/min to the nearest 0.1L. Convert this score to relative value by dividing by body weight,
and then multiply the result by 1000 to obtain a VO2max score in ml/kg/min.