Cardiorespiratory Fitness

Maximum Oxygen Uptake (VO2max)

Definition: Maximum Oxygen uptake defined as the greatest rate at which oxygen can be consumed during exercise or the maximal rate at which oxygen can be taken up, distributed, and used by the body during physical activity.

Contributions to max VO2

a. b. c. respiratory system CV system Musculoskeletal system

Determination of true max Criteria

1. oxygen consumption plateaus during the last minutes of a graded exercise test (defined as a rise of less than 2 ml/kg/min between the final test stages 2. The respiratory exchange ratio increases to 1.15 or higher 3. Subjects HR increases to within 10 beats of age predicted max HR 4. Blood lactate levels > 8 mmol/liter

Measurement of max VO2

1. Laboratory measurement (Graded Exercise Test/ GXT) i. maximal lab tests expensive, time consuming requires highly trained personnel potentially higher risks not practical in most situations. ii. submaximal lab tests

2. 3.

nonexercise test VO2 max predictions field tests of CR endurance

Measurement of max VO2 (contd)

Before VO2max measurement are conducted the preliminary considerations, such as
medical/health screening questionnaire, consent form, physical exam by a physician if high risk a treadmill test possibly a blood lipid analysis.

Measurement of max VO2 (contd) Graded Exercise Test (GXT)

1. 2. 3. 4. 5. 6. 7. Purposes for GXT assess the safety in terms of starting or changing an exercise program aid in the diagnosis of heart disease prescribing an appropriate exercise program to follow the progress of known coronary or pulmonary disease to determine effectiveness of medical or surgical procedures involving medication to develop a rapport with an indiv. to assess the CV or Pulmonary capacity of both the apparently healthy and the diseased 8. To determine when to interfere put in a new valve What do GXT's do 1. Yield sig. data on the status of heart and lung functional capacities 2. detects myocardial ischemia - not CAD 3. Yield the cardiorespiratory capacities for exercise prescription purpose Purposes of GXT's 1. Functional 2. diagnostic 3. Prognostic

Measurement of max VO2 (contd) Graded Exercise Test (GXT)

1. 2. 3. 4. 5. 1. 2. 3. 4. Factors that determine the depth of GXT scan age health status type of test ( max ) exercise plan (vigorous or sedentary) Submaximal or maximal Test Importance of screening prior to exercise testing safety choosing appropriate exercise testing identification needs for more comprehensive medical evaluations prescribing appropriate exercise programs
nature of the exercise programs

Measurement of max VO2 (contd) Graded Exercise Test (GXT)

Three categories to undergo GXT 1. apparently healthy 2. high risk symptoms suggest CV, Pumonary or metabolic prob's; or al least one major coronary risk factor Major Coronary risk factors 1. High BP - 145 / 95 2. Total Cholesterol / HDL's > 5.0 3. Cig. smoking 4. Abnormal resting ECG is indirect evidence of an old myocardial infarct, l-ventricular hypertrophy, ischemia, conduction defects, or disrhythmias 5. Family history of coronary or other atherosclerosis prior to age 50 6. Diabetes Mellitus 3. Individual's with known diseases Metabolic Diseases 1. Diabetes 2. renal disease 3. thyroid disorder 4. liver disease 5. other smaller diseases

Measurement of max VO2 (contd) Graded Exercise Test (GXT)

1. 2. 1. Classify individuals Give a medical questionnaire Then put them in one of the above three categories Guidelines for GXT Apparently Healthy no major coronary risk factors i. If < age 45 Not compulsory to exercise test prior to beginning an exercise program ii. if 45 or older give a max exercise test before beginning or changing the exercise program all max exercise tests after age 35 should be done with a physician present a sub max test at any age will not require a physician it is valuable to giving a safe exercise prescription

Measurement of max VO2 (contd) Graded Exercise Test (GXT)

2. High risk 1. GXT max is desirable at any age esp. with symptoms physician should be there 2. without symptoms and less than 35 no physician necessary 3. Sub-max tests little diagnostic value lead to determination of heart disease functional test tests fitness 4. Symptomatic at any age need a physician supervised max test 3. Diseased Need a physician supervised max test Purpose 1. to determine the safety of the exercise 2. to determine functional capacity

Measurement of max VO2 (contd) Graded Exercise Test (GXT)

Complications and potential risks of GXT's 1. Extremely low risk of morbidity both max and sub-max deaths are not related to severity deaths are 1 / 10,000 2. the complication rate is 8 / 10,000 3. ventricle Arrhythmia or myocardial Infarction (MI) = 4 / 10,000 The risks appear acceptable each case is evaluated separately as to the benefits vs. the risk ( exp. with the old and diseased )

The PAR-Q is used as a bare minimum will identify those to whom exercise may be harmful contains 6 questions if answer yes, then should not exercise until cleared by a physician

Measurement of max VO2 (contd) Graded Exercise Test (GXT)

Depth of the evaluation
in addition to the others ( age, health status, type of test, and exercise plan ) Other complications evaluated prior to exercise testing
(1) medical history is the most important (2) physical exam. 3) lab tests

Measurement of max VO2 (contd) Graded Exercise Test (GXT)

Conditions for a GXT 1. Continuous or non-continuous children use non-cont a ramp protocol is a continuous one 2. Single load or multi-staged 3. supine or upright 4. modality 5. max or a sub-max 6. nature of recovery cool down (1) not needed with cardiac patients if looking at recovery (2) if not enough time (over 10 min.) have them lie down and elevate the feet 7. Type of protocol a. diseased status b. activity status c. age more likely to get a false positive than a true positive myocardium irritability increases with age 8. orthopedic considerations

Measurement of max VO2 (contd) Graded Exercise Test (GXT)

GXT preparations 1. Patient preparation food, clothing, etc. 2. Complete medical history and any lab tests 3. Consider the indications and the contraindications to testing recent MI is a definite contraindication recent illness is also will get a false positive 4. consideration of the factors leading to a false positive or negative sub-max tests => false negatives because of 1. did not get high enough intensity 2. more likely in the females (big breasted ones esp., and the old) 5. consideration of drug effects and electrolyte imbalance are they on drugs diuretics effect the electrolyte imbalance 6. obtain the informed consent

Measurement of max VO2 (contd) Graded Exercise Test (GXT)

Subject preparation 1. Avoid strenuous activity on the day of the test, esp. 2-4 hr before if testing athletes, have them rest the day before 2. have an overnight fast, or four hours past a heavy meal or 2 hours past a light meal 3. avoid caffeine 2-4 hrs before they increase the PVC's and HR 4. no alcohol or cigs 2-4 hrs before, esp. just before alcohol can both increase and decrease HR 5. free of any illness or discomfort 6. dressed comfortable with light shoes 7. 68-74 deg. F., with a 40 - 60 % humidity 8. rest comfortable in a supine position 10 min. prior

Measurement of max VO2 (contd) Graded Exercise Test (GXT)

1. 2. 3. Informed consent (would not hold up in court) absolute necessity- though not universally recognized ACSM - states they should sign prior to exercise the exact value of the medical viewpoint is not clear people cannot waive their right to sue 4. PURPOSE - to make certain the participant is aware of the risk if a subject asks excessive questions, this person is likely to sue if something goes wrong Specifics of an informed consent 1. Immediately prior to exercise, the participant must receive 2. Should contain a) explanation of the procedures, purpose, risks, discomfort, and benefits b) offer to fully answer any questions c) both the person and the test administrator should sign should sign if a minor, then both parents and the minor should sign d) a brief demonstration of the test procedures

Graded Exercise Test (GXT) Maximal Exercise Test

Maximal Tests should Involve large muscle groups Allow for measurable and reproducible workload Be tolerated by a variety of people Mechanical efficiency should be as uniform as possible in the population study people should be equally efficient

Difficulties in Maximal Test 1. Motivation i. subject ii. administrator relates to experience 2. Increased risk of bringing on a cardiac abnormality especially in the middle aged 3. Values depend on the accurate calibration of the ergometer and the measuring device should allow for constant efficiency 4. All subjects should be able to tolerate a similar accumulation of anaerobic metabolites (need to keep anaerob. part constant) Especially in the bike, as it requires more anaerobic capacity

Graded Exercise Test (GXT) Maximal Exercise Test Protocols

1. Types
i. ii. iii. iv. Naughton - good for the average person, has steady increases Ellestat - bigger jumps Catis Balke - he is the father of treadmill protocols
3-4 MPH walking

v. Bruce - is a standard (considered useless by many)

STAGE 1 2 3 4 5 6 7

MPH 1.7 2.5 3.4 4.2 5.0 5.5 6.0

% GRADE 10 12 14 16 18 20 22

MINUTES / STAGE 3 " " " " " "

METS 4 6-7 8-9 15-16 21

NEED TO MEMORIZE STAGES

Graded Exercise Test (GXT) Maximal Exercise Test Protocols

2. Reasons to stop the test i. Absolute a) visual disturbances b) confusion c) Three or more premature ventricular contractions d) malfunctioning equipment ii. Relative a) Less serious symptoms dizziness leg pain b) SBP increases less than 20 mm / Hg

Graded Exercise Test (GXT)

SUBMAXIMAL LAB TESTS (contd)

Why test using submax testing? 1. larger numbers can be tested quickly 2. not as much skill needed to administer the test 3. not as much equipment required 4. the subject tested does not have to perform an all out effort 5. max testing requires a high level of motivation to get to max 6. submax testing can give an adequate assessment of fitness status without risk, expense, and hard effort. 7. to avoid potential risk of maximal testing safer (by 3 times) for cardiac emergencies difficult to arrange for medical coverage 8. require no specific skill 9. do not require the subject to stress till max some measure VO2, while most measure HR Sub - Max tests should not be used for 1. Research 2. comparisons between individuals

Graded Exercise Test (GXT)

SUBMAXIMAL LAB TESTS

Three assumptions for submax exercise testing: 1. A linear relationship exists between heart rate, oxygen uptake and workload throughout the entire range this depends on the steady increasing CO and A-VO2 difference. the deviation from this in healthy young adults is small in the older, the dev. is more as the SV may not be sustained, causing too much increase in HR i. if intensity too low, SV may not max and the HR may fluxate ii. if too high, VO2 will plateau, HR will continue to increase, and the VO2 will be underestimated because the HR will be disproportionately high 2. The maximum heart rate at a given age is uniform. That an individuals HR varies little from the mean 220 - age has a std.dev. of +/- 12 beats / min. the mechanical efficiency (oxygen uptake at a given workload) is the same for everyone. it actually varies more on the bike than on the t-mill solution: instead of testing them right away on the exercise, why not let them come into the program and let them get used to the equipment, then test them. This may eliminate much of the mech. eff. difference

3.

Graded Exercise Test (GXT)

SUBMAXIMAL LAB TESTS (contd)

These assumptions are not entirely accurate and can result in 10-20% error due to
1. in most submaximal tests, HRs at submaximal workloads are plotted, then extrapolated to an estimated maximum heart rate level, and then further extrapolated to an average oxygen consumption. 2. These extrapolations can result in substantial error.
a. max HR using the equation 220-age varies considerably among individuals of the same age. One SD of 12 beats b. oxygen uptake at the same workload can vary 15% among different people. Some are more efficient than others. c. VO2max estimates from submax tests tend to overestimate those who are highly trained (they respond with a low HR at a given workload) and underestimate the untrained.

Graded Exercise Test (GXT)

SUBMAXIMAL LAB TESTS (contd)

Choice of Equipment 1. Treadmill There are some tests available, but due to cost restraints, this is not the method of choice. Normally used for maximal tests 2. Bicycle 1. Cost Much less $ 10 bikes = 1 t-mill 2. Less space 3. t-mill is seen as ominous 4. bike has a measurable - reproducible workload 5. Used for assessing work capacity except for bicyclers, it is hard to test for maximal values on the bike 6. Mechanical efficiency is independent of weight except in the very obese 7. Efficiency varies with RPM (for any given workload) unless you have a RPM independent bike 8. 50 RPM is the optimal efficiency for sub-max tests at > 200 watts, RPM need to progressively increase past 60 RPM ( 90 RPM is the optimal pedaling rate for elite cyclists) if the test requires a change if the wattage, one needs to also change the rpm to keep the efficiency from dropping too much

Graded Exercise Test (GXT)

SUBMAXIMAL LAB TESTS (contd)

ACSM sub max test HRmax = 220 - age has some variance
some people may stop at 70 or even 100 % HRmax

The ACSM test has different endpoints

1. 85 % of HR max 2. pre determined exercise intensity 3. achieve a certain RPE

VO2 max is an unreliable measure Not is good for diagnosis, as need to go a high intensity used best for intraindividual differences

Graded Exercise Test (GXT)

SUBMAXIMAL LAB TESTS (contd)

ACSM sub max test measured in ml/min and is non-weight bearing bigger (muscled or resistant trained) people have an advantage may therefore overestimate their VO2max Considerations for the protocol 1. weight 2. activity status questionnaire works for both the test and the prescription Monitor HR during the test the last 15 sec of each.stage for 2-3 stages Test termination 70 %HRmax is okay for older population (35-40 yrs old), but may not be a high enough intensity for younger people Calculation of VO2 1. use the axis derivation 2. or use 2 KGM + 300 used for non-weight bearing activities that only have one point ex: if the max is 200 watts, then 200 W = 1200 kgm., 2*(1200) + 300 = 2700 ml/min

* read for the cycle max protocol

Graded Exercise Test (GXT)

SUBMAXIMAL LAB TESTS (contd)

Legal and procedural considerations 1. Standard of care The AMA, American Heart Assoc.,the ACSM, the American PT assoc. all publish standards forprofessional standards of care should be familiar with all of them 2. Providing a safe test what constitutes a safe test for the participant 3. Legal risks associated with tests what risks from the test are for the participant

Graded Exercise Test (GXT)

SUBMAXIMAL LAB TESTS (contd)

What constitutes Liability 1. Negligence i. failure to conform ones conduct to a generally accepted std. of duty ii. failure to give due care to protect the patient if you are supposed to do so iii. the failure to protect proximally caused the injury in general (1) must have to protect (2) must have the responsibility to protect (3) prove proximal cause from the failure to protect 2. Other parameters (if omitted) i. monitoring ECG, HR, BP, RPE, etc. ii. pre-screening (risk factor ass.) or medical screening iii. with more education, are held more responsibility. iv. still held accountable for std. of care if have just a little knowledge v. cannot practice medicine without a license (or will be in violation of a civil and a criminal law) cannot diagnose and prescribe ECG's

Graded Exercise Test (GXT)

SUBMAXIMAL LAB TESTS (contd)

To minimize risks 1. Exercise due care consistent with common professional standards not avail for medical exer. testing 2. Execute a consent form it is an assumption of some of the risks by the subject Conducting an Informed Consent Subject must be legally capable of giving consent (adult) must know and fully understand risks consenting to must know all facts and related dangers in order to make an informed decision must give the consent voluntarily, under no duress

Graded Exercise Test (GXT)

SUBMAXIMAL LAB TESTS (contd)

Further considerations Be aware of organizations that publish standards Ask questions regarding activity habits know of local medical practices and national standard's add knowledge of risks to consent form (adapt it to population) have a legal council and a medical director MUST have liability insurance If you suggest your program is a preventative program, then it is a medical program See the state statutes on informed consent Have a physician answer questions from participants obtain consent by audio/video tape keep copies of records (questions and responses) Document the emergency procedures Inspect the physical site (w/ written records) Institute people how to use equipment keep records on personal certifications evaluate employees periodically, check out references

Field tests for CR fitness

A. Running Endurance tests 1. 1 mile run prediction test VO2 max (ml/kg/min) = (-8.41 X MRT) + (0.34 X MRT2) + (0.21 X age X sex) (0.84 X BMI) + 108.94

Sex = 0 for females, 1 for males; BMI = body mass index in kg/m2

Example: 15 year old male ran the mile in 6.5 minutes, a BMI of 21
VO2max = (-8.41 X 6.5) +(0.34 X 6.52) + (0.21 X 15 X 1) (0.84 X 21) + 108.94 = 54.2 ml/kg/min

2.

1.5 mile run for college students VO2max = 88.02 + (3.716 X gender) (0.1656 X kg) (2.767 X time) Gender = 0 for females; 1 for males; time = total time in minutes

Example: a 70 kg male ran 1.5 miles in 9 minutes VO2 max = (88.02)+(3.716 X 1) (0.1656 X 70) (2.767 X 9) = 55.3 ml/kg/min

Estimation of VO2 max from average running speed

An order should be followed for a testing battery.

1. It should take about 1 hour. 2. Precise instructions are given to the participants before they come for testing 3. Should dress in the proper exercise attire, and bring a swim suit if necessary 4. Avoid eating or drinking for 3 hours prior to the test. 5. Avoid exercising on the day of the test 6. Try to get a good nights sleep 7. Bring the medical/health questionnaire

An order should be followed for a testing battery.

8. If blood is to be analyzed avoid alcohol and vigorous exercise for 24 hour prior to the test, and a 12 hour fast; diabetics should be allowed to keep their dietary habits and injections of insulin as regular as possible, and patients should continue their medication regimen on their usual schedule so that the exercise test responses will be consistent with responses expected during exercise training. Testing session should begin with quiet, resting tests (HR, blood pressure, blood drawing, all after a 5 minute rest) Body composition measures Graded exercise testing for cardiorespiratory endurance Musculoskeletal tests; if done before the CR tests the HR & BP could be elevated Immediate feedback and counseling should follow the testing.

9. 10. 11. 12. 13.

Examples: YMCA
1. 2. 3. 4. 5. standing height weight resting HR and BP skinfold tests submaximal cycle test for CR endurance; or 3 minute step test for mass testing 6. sit and reach test 7. Bench press test (35 # for women; 80 pounds for men at a rate of 30 times per minute for muscular endurance and strength) 8. Timed (1 minute) situps for abdominal muscular endurance or abdominal curlups

Examples: Canadian
1. resting HR 2. BP 3. standing height 4. weight 5. waist girth 6. skinfolds (triceps, biceps, subscapular, iliac crest, medial calf) 7. Canadian aerobic fitness step test 8. Grip strength 9. Pushups 10. Trunk forward flexion 11. Partial curlups 12. Vertical jump

Blood pressure measurement

For best results 1. mercury stand sphygnomanometer, a recently calibrated aneroid manometer, or validated electronic device. 2. 2 or more readings should be taken 30-60seconds apart, and averaged; if differ by more than 5 mmHg, and additional reading is taken 3. take measurement in a quiet room with temperature approx. 70-74 deg F, or 21-23 deg. C 4. having upper arm bare makes it easier to adject the cuff 5. with older people, because of potential arterial obstructions, it is best to take readings on both arms. If the pressures differ by more than 10 mmHg obtain simultaneous readings in the two arms and thereafter use the arm with the high pressure.

6.

7.

8.
9.

Use the proper size cuff. The rubber bladder should encircle 80% of the arm. If the persons arm is large the adult normal size cuff will be too small making the reading larger than it actually should be Between determinations allow 30 seconds for normal circulation to return to the arm. Subject should be comfortably seated with the arm straight, palm up, and the whole forearm supported at heart level on a smooth surface. Anxiety, emotional turmoil, food in stomach, bladder distension, climate variation, exertion and pain all may influence the BP and should be avoided or controlled. Smoking or ingested caffeine should be avoided for at least 30-60 minutes prior to measurement. Note the time when the person took any medication for BP and the name of the medication.