Energy Cost of Rehabilitation Calisthenics

LOUIS R. AMUNDSEN, PhD,

MASAAKI TAKAHASHI, MA,

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CHARLES A. CARTER, PhD,
and DAVID H. NIELSEN, PhD

This study examined the relationship between total energy cost and cardiac
effort for a set of graded calisthenics that have been used in cardiac rehabilita­
tion programs. Cardiac effort was quantified by calculating myocardial oxygen
cost from the product of heart rate and systolic blood pressure. Total energy
cost was determined by measuring oxygen uptake during steady-state exercise.
Results indicate that total energy-cost values accurately reflect the cardiac
effort required during the performance of these calisthenic exercises by normal
subjects.

Key Words: Calisthenics, Cardiac, Exercise therapy, Heart rate,

Oxygen consumption.

CARDIAC CALISTHENICS STUDY
Good results have been achieved by including
graded calisthenic exercises in physical therapy pro­
grams for patients recovering from myocardial infarc­
tion. The intensity of these calisthenics used to be
expressed in kilocalories. Because body weight differ­
ences must be corrected for when using kilocalories,
energy cost is now commonly expressed as oxygen
uptake per unit of body weight (ml 02-Kg^1 • min1)
or as METs. One MET (metabolic equivalent) equals
the average oxygen cost at rest per kilogram of body
weight. One MET equals 3.5 ml 0 2 -kg '-min -1 . 1 The
average patient, four weeks after an uncomplicated
myocardial infarction, can exercise only at intensities
of 2 to 4 METs; therefore, to achieve good results
during exercise it is important to have a pool of
graded exercises that fall into this METs intensity
Dr. Amundsen and Dr. Nielsen are Assistant Professors, Physical
Therapy Educational Program, College of Medicine, SI 14 Westlawn,
University of Iowa, Iowa City, IA 52242.
Mr. Takahashi was a graduate student in Physical Therapy at the
University of Iowa when this study was conducted. He is now
Director, Physical Therapy Department, Fucho Rehabilitation
School, Tokyo, Japan.
Dr. Carter was a doctoral candidate in the Therapeutics Division
(Physical Therapy) of Physical Education at the University of Iowa
when this study was conducted. He is now Assistant Professor of
Physical Therapy at the University of Kentucky.
Adapted from a paper presented at the Fifty-third Annual Con­
ference of the American Physical Therapy Association, St. Louis,
MO, June 1977.
This was work supported in part by a grant from the Physical
Therapy Fund.
This article was submitted May 12, 1978, and accepted January 31,
1979.
range. When exercising these patients it is also nec­
essary to know how accurately the total energy cost
reflects the cardiac effort, which can be quantified as
myocardial oxygen cost. The purpose of this study
was to examine the relationship in normal subjects
between the total energy cost and the myocardial
oxygen cost of a set of graded calisthenics.
REVIEW OF LITERATURE
The relationship between total energy cost and
myocardial oxygen cost has been studied in normal
subjects performing upright exercise on a bicycle
ergometer. 2 In that study, Kitamura and associates
found that the correlation between total oxygen cost
and myocardial oxygen cost (MVo 2 ) was statistically
significant. This study demonstrated that the pres­
sure-rate product (peak systolic blood pressure X
heart rate) was the best predictor of MVO 2 . The
correlation between MVo 2 and the pressure-rate
product was higher than the correlations between
MVO 2 and total oxygen cost, heart rate (HR), or the
tension-time index (mean systolic blood pressure X
ejection time). The validity of the pressure-rate prod­
uct as a predictor of MVo 2 is also supported by
studies of isolated heart preparations and by clinical
studies demonstrating the reproducibility of angina
pectoris at established pressure-rate products. ! " 5
Total energy cost values may not accurately predict
MVO 2 when many different muscle groups (upper
extremity, trunk, and lower extremity) are exercised.
Applying the regression equation of Kitamura and

Volume 59 / Number 7, July 1979 855

 TABLE 1 neous recording of the ECG, arterial blood flow, and
Description of Subjects: Means and Standard Deviations brachial cuff pressure on the multichannel Beckman
Subject Age (Yrs) Height (cm) Weight (kg) R recorder. Oxygen cost was monitored by the open-
circuit system using meteorological balloons, a Collins
1 33 176.3 70.0
2 29 177.8 65.9 P-350 dry-gas meter,ff and Beckman OM-11 and

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3 36 190.5 94.0 LB-2 gas analyzers.*
4 30 170.1 65.9 The protocol for data collection required that sub­
5 27 170.0 57.0 jects initially stand at rest for five minutes, then
6 30 177.5 84.1
perform each calisthenic exercise for five minutes.
7 36 177.5 86.4
8 30 172.7 70.0 The order of performance of the calisthenic exercises
9 30 180.0 84.1 was randomized. Expired gas was collected during
10 34 170.0 71.4 the fourth and fifth minutes at rest, during the fourth
Mean 31.5 176.2 74.9 and fifth minutes of Calisthenics One to Four, and
SD 3.1 6.2 11.6
during the fifth minute of Calisthenics Five and Six.
The heart rate was monitored each minute on several
associates, which predicts MV02 on the basis of pres- subjects to establish that a stable heart-rate response
sure-rate products, to data reported by Astrand re­ indicative of steady-state conditions would be
sulted in the prediction of much higher MV02 values achieved at all exercise levels. Heart rate was moni­
for arm than for leg work performed at the same total tored during the last 10 seconds of the fifth minute of
energy cost. b exercise. SBP was monitored immediately after exer­
cise (an average of 17.2 seconds after exercise). MV02
was predicted from the regression equation of Kita-
METHOD
mura and associates 2 :

Ten normal men were chosen from graduate stu­ MV O 2 = 0.14-SBP- HR • 10~ 2 - 6.3
dents and faculty volunteers from our physical ther­
apy programs. Means and standard deviations for the ft Warren E. Collins, Inc. 220 Wood Rd, Braintree, MA 02184.
age, height, and weight of these subjects are given in
Table l. Each subject performed the six calisthenic
Count Number
exercises illustrated in Figure 1. These graded exer­
CPM 1 2 3 4 View
cises were selected from a larger set of calisthenics
that were originally studied by Weise and Karpovich 1. 66 Anterior
and that have been used in the Montefiori Hospital
Cardiac Rehabilitation Program. "
All exercises were performed in a laboratory main­ Anterior
tained at 25°C (77°F). Each calisthenic exercise was
performed for five minutes to ensure steady-state
3. 66 Anterior
conditions. Heart rate (HR) was monitored by elec­
trocardiography using the CM r , chest-lead configura­
tion and recorded on a Beckman R recorder.* Systolic Anterior
blood pressure (SBP) was monitored by a Parks dop-
pler ultrasonic blood-flow sensor (model 802-A),f a
Statham Pressure Diaphragm (model VBP5) and Lateral
Universal Transducer (UC3 Gold Cell)4 and an
automatic pump from a Godart noninvasive blood
5. 66 Anterior
pressure monitor.** This system has several advan­
tages. The use of an automatic pump eliminates errors
ia k
caused by excessively fast or slow rates of cuff infla­ Lateral
tion and deflation. This system allowed the simulta­ rr rr
6. 80 Anterior
* Beckman Instruments, Inc. 3900 River Rd, Schiller Park, IL
60176.
f Parks Electronics Laboratory, 12770 SW First, Beaverton, OR
97005. Lateral
£ Statham Instruments, 2230 Statham Blvd. Oxnard, CA 93030.
** Gould Godart BV. Jan van Eycklann 2, Bilthoven 2660 (The
Netherlands). Fig. 1. Calisthenic Exercises (CPM = counts per minute).

856 PHYSICAL THERAPY

 TABLE 2
Means and Standard Deviations for Metabolic Equivalents, Heart Rate, Systolic Blood Pressure, and Myocardial Oxygen
Cost for Calisthenic Exercises (N = 10)
Exercise Heart Rate Systolic Blood Pressure
METs" MV02''
Level (beats/min) (mm Hg)

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At Rest and
Standing 1.24 ± 0.25 87.3 ± 14.6 119.6 ± 11.38 8.23 ± 2.14
1 1.73 ± 0.45 90.7 ± 12.5 123.0 ± 9.63 9.26 ± 2.23
2 2.28 ± 0.36 95.9 ± 19.5 127.3 ± 11.55 10.69 ± 3.20
3 2.76 ± 0.79 99.3 ± 18.3 125.2 ± 12.44 11.10 ± 3.67
4 2.87 ± 0.34 99.7 ± 21.5 128.4 ± 13.82 11.49 ± 3.62
5 5.02 ± 0.78 111.2 ± 24.4 134.9 ± 17.34 14.58 ± 4.72
6 5.87 ± 0.69 126.8 ± 20.4 153.7 ± 15.03 20.84 ± 4.13

" Metabolic equivalents, or multiples of the average resting oxygen requirement of 3.5 ml 02-Kg 1-min
h Myocardial oxygen cost predicted from HR X SBP and expressed as ml 0>• lOOgm 1 of left ventricle.

RESULTS that total energy cost values accurately reflect the

Values for METs, HR, SBP, and predicted MVo 2
are presented in Table 2. The metabolic cost progres­
sively increases from 1.7 to 5.9 METs for Calisthenic
Exercises One through Six. The mean HR response
progressively increases from 91 to 127 beats per min­
ute for Exercises One through Six. Except for a drop
between Exercises Two and Three, the SBP progres­
sively increases from 123-154 mmHg. The predicted
MV02 progressively increases from 9.3 to 20.8 ml 0 2
per 100 gm of left ventricular muscle mass.
Correlations, slopes, and intercepts for the relation­
ship between MVo 2 and total energy cost for each
subject are presented in Table 3. The regression line
for myocardial oxygen cost plotted against total oxy­
gen cost in METs is displayed in Figure 2. The mean
regression equation is as follows:
cardiac effort required for these calisthenic exercises.
DISCUSSION
The energy cost of these calisthenics was deter­
mined previously by Weise and Karpovich.' The
results of the present study demonstrated the same
progression of intensity levels as did the Weise and
Karpovich study. Our MET values for these calis­
thenics are also very similar to the values reported by
Weise and Karpovich (2.2, 2.8, 3.1, 3.6, 4.6, and 5.1
METs for Exercises One to Six, respectively). We
observed differences in energy cost that may be the
result of differences in methodology and subject se­
lection. Weise and Karpovich performed all measure­
ments on one aviation student "having a calm and
steady temperament" and used the closed system to

Y = slope (± SD) X -(- intercept (± SD)

MVO2 = 2.31 (± 0.51) METs + 5.07 (± 2.38)

The average correlation (.91) between MVo 2 and 25

METs of the six selected calisthenics was statistically
significant (p < .01). The results of this study indicate
20

5 E 15
to CD
TABLE 3
8 9
Correlation and Regression of Metabolic Equivalents and
Myocardial Oxygen Cost for Calisthenic Exercises 10
-O ®
Q)
MV n = 2.31 METs + 5.07
Subject Correlation Slope Intercept 1° 2

1 0.929 2.912 4.027 £ E

2 0.878 2.072 5.630
3 0.860 2.195 2.626 J I I I i I I
1 2 3 4 6 7
4 0.955 2.648 6.956
5 0.893 2.558 5.337 Metabolic Equivalents
6 0.993 2.506 7.788
7 Fig. 2. Regression line of myocardial oxygen cost in relation
0.921 2.731 3.850
0.954 2.295 0.429 to total oxygen cost (in metabolic equivalents) of calisthenic
8
0.969 8.032 exercises (N = 10). The dots and vertical lines represent the
9 2.115
0.730 6.027 mean ± SD determined at rest and for Calisthenic Exercises
10 1.087
One to Six.

Volume 59 / Number 7, July 1979 857

 measure energy cost. The closed system is excellent
for resting determinations, but it affords a high re­
sistance to expired gas and is no longer used to
monitor responses to exercise. Energy-cost values in
our study were derived from the low resistance, open-
circuit method of measuring oxygen cost. Also, our
measurements were performed during the steady
state, while Weise and Karpovich monitored one
minute of exercise and the recovery period to deter­
mine energy cost. Finally, our subjects were primarily
graduate students known for spirited disputation and
dedication to all endeavors rather than for their calm
and steady temperament. Although it is likely that
our values are applicable to a larger population of
orthopedically and neurologically normal men, the
energy cost of these calisthenics can be expected to
vary with body build and with the manner of their
performance. For instance, more rapid limb acceler­
ation and deceleration will increase the energy cost
of these exercises. Therefore, rapid, jerky movement
should be avoided by study subjects and patients
when performing these calisthenics.
METs are conventionally determined from the
gross oxygen cost of an activity1; however, Weise and
Karpovich originally calculated multiples of basal
oxygen cost from the net oxygen cost. Expressed in
this manner, the energy cost of these calisthenics was
reported to be 1.2, 1.8, 2.1, 2.6, 3.6, and 4.1
for Exercises One to Six, respectively. The inten­
sity of these calisthenics has also been reported as
kcal-min \ 8 The Montefiore Hospital Program uses
kilocalorie (kcal) values for these calisthenics. The
subject used by Weise and Karpovich to determine
the energy cost of these calisthenics weighed 59 kg
(130 lb); therefore, 1 kcal was equal to 1 MET.
Obviously one MET is equivalent to more than 1 kcal
for subjects weighing more than 59 kg. For example,
one MET is equivalent to 1.575 kcal if the subject
weighs 90 kg (198.5 lb). This was calculated as fol­
lows:
90 kg-1 MET- 3'5
5 7. Weise RA. Karpovich PV: Energy cost of exercises for convales­
MET
= 315 ml 0 2 - min -1
0 . 315 liters 0 2 *min^5 kcal-liter 0 2 _1
= 1.575 kcal-min
When an activity involves only the active movement
of the body against gravity, the MET level will be a
constant that is independent of body weight. This is
858
true for the results of this study, and it has been
demonstrated in many studies of walking, running,
and bench stepping. 910 The kilocalorie cost of these
calisthenics or of walking, running, or bench stepping
will be directly proportional to body weight and can
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be estimated from MET values as described above.
CONCLUSION
The high correlation between total energy cost and
cardiac effort observed in this study indicates that
one can be relatively certain that low-MET-level
calisthenic exercises will also result in a low myocar­
dial oxygen cost. These calisthenic exercises are
needed in rehabilitation programs for patients with
ischemic heart disease and are especially useful for
group exercise and for home programs. 11 When a
patient's medical history indicates that myocardial
blood flow is likely to be limited, an exercise program
must start with low MET levels and progress slowly
to higher MET levels as permitted by exercise toler­
ance. The energy-cost values determined in this study
establish the order of intensity and provide a mean­
ingful index of the cardiac effort or the myocardial
oxygen cost of the six calisthenic exercises analyzed.
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PHYSICAL THERAPY