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1/18/2022

Exercise testing • Exercise testing is the single most important

noninvasive procedure used in diagnosis and
management.
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• Originally exercise testing was used to
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---- ,~..:. measure functional capacity or to evaluate
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coronary circulation .
_ i,. ~"\--l/j
==.. -! t ~ • Exercise testing involves ·systematic and
~ .. ·- ---· -~~ progressively increasing the oxygen demand
<~~- ✓✓-
BY : DR. SAlllAN MOOI
,- •eececer..-n and evaluating the responses to the increased
demand.

Indication of exercise testing

• Evaluation of chest pain suggestive of

coronary disease.
EXERCISE TESTING FOR HEALTHY • Determination of prognosis and severity of
INDIVJDUAL coronary artery disease.
• Evaluation of the effect of medical or surgical
therapy or intervention.

·,
 contraindication of exerci_se testing

• Evaluation of arrhythmias.
• Evaluation of hypertension.
Absolute contraindication
Recent myocard 1
after Ml for a
·al ·i nfarction (less than 4 to 6 weeks
maximal,

• Acute pericarditis or myocarditis

• •
symptom limited test) \
• Assessment of functional capacity. • Resting or unstable angina
• Screening to provide an exercise prescription. • Untreated second or third degree heart block

• Providing motivation for lifestyle change to • overt congestive heart failure

reduce the risk of developing coronary artery
disease.

.
Maximal versus submaxim al exercise
testing
Relative contraindication • Submaximal test are terminat
predicted end point. ed on achievement of a
• Acute stenosis.
(systolic blood pre ssure>l65 • The predetermine end point . .
h hypertension
• Severe . achievement of cert . may be either the
mm g at rest; diastolic blood pressure>llO h
mm g predicted maximuma~: p~rcentage of patient's
at rest or both).
the attainment of certa~n rate (e.g. 75% of MHR) or
• Severe depression in ST segment. 12% grade). workload (e.g. 2.5 mph;
• Compensated heart failure.
• A special subset of subma .
testing; performed on pat:~a~ te~ting is low level of
phase after Ml or corona b unng the recovery
ry ypass surgery.

• Maximal test usually use the end point of the MHR
or termination when patient ls limited by symptoms.
• Maximal test is used to measure functional capacity
as well as diagnose CAD.
• The protocol for testing includes performing a
progressive workload until the patient perceives an
inabllityto cohtinue because of some limiting
symptoms such as shortness of breath, leg fatigue, or
chest discomfort.
• Individual should avoid physical effort for at
least 12hr-s before testing.
• Informed consent must accurately describe all
procedure and potential risk/benefits
associated·with these procedure.
• Sleep·for at I.east 6 to 8 hours before test.
• Drink plenty of fluid in the 24 hours preceding
the assessment.
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CLIENT PREPARATION
BEFORE TESTING :
• Verbal and written instructions are recommended to
reduce test anxiety and to standardize the response
to testing.
• Instructions include; avoid eating and smoking for a
minimum of 3hr before testing.
• Individual should wear comfortable footwear and.
loose-fitting clothing.
Environmental preparation
• Maintain room temperature of 20-22C
• Room should be private, quite and well ventilated .
• Test should be made comfortable during resting
measurement and all non strenuous assessment
procedure.
• Test administer should be relaxed and confident
 Maximal treadmi ll protocols

I th• i!till! wl••·~I;( f~ will hO~\)ltlljjfl •h1Hilrl lln ~hffYll~I

on.1ca protocol
, 'I'll@mo~t frn(l!,Ulfltly 1.mid for the dlaP,n05tlc test for
~1,1! t l~~lli'tl (l)ronMV h1'1Jrt dlo@a~e and th~ befit valid ated for
, I\Ufit ul,1•111h1M •u1i11111 M(J, n 11~11rllr lll I(J,1 llflll Ill'
111 \i 1ffllll1111Plifl!lrl \•I ihl\dlll1ili ~ "IJl)(Hlllillllltt§ 1111LI 11~tlm1Jtln1& V02rnll)( from maximal performance.
111,~llifJflN I I \IUifli~ • Thi#protoeol §tlJrt§ ot low work level, allowing time
• 1h• 111rJM11tt•I ,h111Jld IJ@ \11m11G\ld t"I"" IJ!lrhPI a11d to w11rm•YP cardlova~cular adaptation.
w11t111n •"'''' ~11•11011 m, ~II ;n1hl thal will hll 1m1d, 11.K, • Thll lncrctl.160 In work load are relatlvely large
,w,a,l'fiili 1t1r , ..11,11t,n1~c~la tor 1tv111m111, 11"111, oomparo to other protocol (3•4 MET per stage) thu s
1t•uLllrijllf111(l IAll -~) ilfld a1,11l11n, !!lO,
th@t@51:c,:m be comple~ed early.

Pr.•tttl PIOCAldur f:
• M1murp f}lf •IJ(tfellli Hf( ·1
l(!lit>ftl lfi.li lli lUtil on I •• ;ltn:'ro~~n: ltllndlns, nnd
• Doscrlbe the purpo
• ru1 n11t• tho tubmtJ(lrn11I •· - r d1t1 l hl!llt. the stages Is thre se of the treadmill
(~ 1-r0uli ~(II r•I/O)!tlnl Mlj~r~~rcl10 HR ualng Incline will Iner e minutes In length ;est. Each of
lllJ .. Reoord tht, v, lue on II IP,Z x(lKe} X Interval
'
ease at the end of . he speed and
each th
rJf tho tetl. Mdpolr1h). t1ut1na form (thl11, Onit • Secure the blo d ree-mlnute
• lli~c1i1 ai l~PI: ;nd rt mlnd Ihfl ., arm. Chock th·: a pre$sure (BP) cuff
ll11 like!$ for percelvod 1txtrf~ll 0~1 that ho or •ho WIii being used. ccuracy of the HR on t_he client's
rhi, tc,sl. on , valHhrouahout monitor if one 1s
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• Equipment:
- Motor driven treadmill
• Allow the clieht to walk on the treadmill to warm up
- ECG monitoring
ahd get used to the apparatus (sl.7 mph). He or she
should avoid holding the handrails. If the client Is too -Timer
unstable without holding onto the rails, consider Bruce Protoco l
using another testing modality. The results will not
be accurate If the client must hold on to the mlllcmmllllima:rl:lllltm?llilml'B,
handrails the entire time. 3 lO 2 .7 1.7 5
2 6 12 4 .0 2.S
3 9 1A S .4 ,1 .4 , 1.0
4 17. 16 6 .7 4 .2 .13
s 1S 18 8 .0 s.o 15
6 18 20 8 .8 5.5 18
,7 21 22 9 .G 6 ,0 20

• The test should be performed until signs or

symptoms develop that warrant test termination or
until the subject's HR response exceeds 85% of MHR.
• To ensure test validity and accuracy, the client's HR · • Calculate VO2 max and metabolic equivalent (MET)
responses should exceed 115 bpm for at least two level using the following conversion formulas
stages.
• Upon completion of the test, the client should cool • Men: VO2 max= 14.8- (1.379 x time)+ (0.45lx
down on the treadmill, walking at a moderate speed tlme 2 ) - (0.012 x time 3 )
until breathing returns to normal and HR drops • Women: V02 max= 4.38 (time)- 3.90
below 100 bpm. Three to five minutes should be
sufficient

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Contraindlcatlons h Id not be conducted Bruce

\ • Treadmill exerclse testl~g s 0~th·
when working with a client w ·
• Visual or balance problems, or who cann t alk on a
treadm\11 without using the handrails o w
.
Orthopedic problems that crkeat~ p(a~~;~~n 2.5 12
be
\ prolonged walking. low bac pa n
aggravated at inclines exceeding 3 to S%.
Mobese individuals may suffer from th
3.4 14

l
4.2
and orthopedic Issues, treadmlll testinbo balanc~ 16

an appropriate modality for t~em. Theyg may bot e 5.0 18

better suited to a bicycle test .,f cardl may e 6. 5.5
testing is considered appropriate. oresplratory
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I • Foot neuropathy
7 . 6.0 22

Modified Bruce
Modified Astrand Protocol
• It is ideal for well trained athletes who
1.7
s includes running se training
1.7
10
• The par'ticipa_nt is able to select the ideal
2.5
12 speed at
which to test and then is tested at a cons
-'-
3.4
14 of 5-8.S mph tant speed
4.2
16 • The initial stage is 3 min with a i) % grad
s.o e, then the
18- grade is increased 2.5 % With each stage
s.s 20 minutes every 2 .
6.0 22

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Criteria for terminatin g maximal

Treadmill test Bicycle ergometer
It ls a large instrument require It is smaller, quieter and less
exercise testing
morespac:e. expensive. Increasing frequency of premature ventricular complexes.
Require balance and co Independent of weight bearing • Ventricular tachycardia
ordination during the test. because the seat support the
, Rapid arterial arrhythmias
body.
, Development of second or third degree heart block.
Movement of the body making less movement. of thorax and
auscultation ,md blood ' arm, quality of ECG monitoring • Increases angina\ pain.
pressure monitoring making · and blood pressure_monitoring Hypotensive blood pressure (20mm Hg or greater decrease)
diffirult. is easy. Extreme shortness of breath
walking is a functional activity May be unfamiliar for many Diuiness, mental confusion, lack of co ordination
so muscles do not get fatigue patient and its testing tool is
as rapidly as they do with highly depend on motivation;
cycling. thus test may end before true
cardiopulmonary end point.

Advantage and disadvantage of

• Severe ST segment depression (2.00 mm or more)
, ·Extremely elevation of systolic and/or diastolic blood
pressure.
• On achievement of maximal heart rate; it is usually safe to
proceed with the test beyond the predicted maximal heart ·
rate if the patient IS willing to continue and if other indications
to terminate the test ls absent.
• Presence of leg fatigue or leg cramps or daudication pain.
• Patient request for termination of test.
maximal test
• Maximal test usually provides better estimation of VO2max
than do s·ubmaximal test.
• Maximal exercise produce great cardiovascular stress than the
submaximal test
• So more appropriate for young population that have
minimum incidence of heart disease and asymptomatic
Individuals who have beep previously screened for heart
disease.
• The major disadvantage of treadmill test are the large, abrupt
changes in work load with each stage and awkward speed.

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 V

• vo max (also
• maxim al ox YQen
•
1Mb maximal Testing 2 mption,
consu maxim~ 1 oxyge~ uptake, peak
oxygen uptake or maximal aerob1~ capacity) is the
red
maximum rate of oxygen ~onsumptron as measu
• Sub maximal performance testing is a way of exercise, most typically on
during incremental
estimating either V0 2 max or "aerobic fitness" in motoriZed treadmill. a

sports medicine. reflects the

• Maximal oxygen consumption
• The test protocols do not reach the maximum of the individual, and is an
aerobic physical fitness
of the respiratory and cardiovascular systems. important determ inant of their endur ance capac ity
during prolonged, sub-m axima l exerc ise.

• V02 max is expresnsed eith .

in litres of oxyge per .er as an a_bsolute rate
· step Tests
relative rate in millifitre:1'~ute (Umrn) or as a
of body mass per minut.~ (oxyge n per kilog;iram
e.g., mU(kg·min).
•Harvard step test
•Queens college step t
•s·,conolfi step t . est
. est
 Di sa dv an ta ge s
Ad va nt ag e
test are based on
• Most of the submaximal
istered to many measurement of he art rate.
• Step test can be admin ela pse d time _ aft er
• HR can also vary with
people at same time. ting hemoglobin,
previous meal, total circula
ment. nt temperature.
• Portable inexpensive eq.uip degree of hydration and am bie
too str en uo us for
• Harvard step test ma y be
20 inch step he igh t
older, less fit individuals and
sho rte r or he alt hie r
cause local leg fatigue in

EQ UI PM EN T
Ha rv ar d st ep te st
m in he igh t.
• Brouha, Graybiel and hea
th developed a simple • Platform of 20 inc h or 50 .8c
ege age men at_the
single stage step test on coll • Metronome
harvard fatigue Laboratory.
• Timer
n of exercise .and
• This test use ! _ duratio
Index of aerobic
re~overy HR to determine an
capacity.
 pr-otocol
• Set the metronome to 120 bpm to ellcite a stepping The subject steps up and down on the platform at a rate of 30
steps per minute for a period of 5 min or until exaution.
rate of 30 .steps per minute .
The subject Is considered as exhausted when he or she
Demonstrate the stepping cycle to the subject
cannot maintain the pace for 15sec.
• A full cycle reperesents a 4-count beat: on count
• At the end of the test the subject lmmedlet ly sits down.The
1 ,the subject places one foot on the step, on count 2,
duration of exercise Is recorded.
the other leg is lifted onto the the step ,on count 3, the
• Count the S\Jbjects pulse from 1 to 1.5, 2 to 2.5 and 3 to
first foot is brought back down: followed by the second
3.5mln Into recovery. The number of heartbeats during the
foot on count 4. three 30sec Is recorded.

Calcul ations

• Index= I 00 x(duration of exercise i'n seconds)/ • For

· examp.le ' an •in d'ividual
. stepped for 4 min 12
2x(sum of pulse counts in recovery) sec with pulse counts of 78, 70 and 62 beats for
the three recovery intervals .
• Based on his score the sut:?ject can be placed in
• The calculated score ,·s 60 , which places the
one of the following classification of aerobic
individual in the low average cfassification for
capacity. fitness .
• 100><252/2><210=60

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Calculations
The following equation was d .
· · V02 max from the recovery HR f enve Siconolfi ste p tes t
· d to estimate
• or wom en .
• V0 2 max (ml. kg·1.mm ·1 )= 65 (
HR) . . ·81 • 0.1847><recovery • Siconolfi, garber, laster and carleton
designed a
for example ..~5sec recovery HR
of multiS tage step test to assess aerob ic
fitness in the
recovery HR Is 4><35 beats= 0bpm 35 beat
14 s her general population . This study included
• 40 ml.kg·1.min·1 48 healthy
men and women aged 19 to 70 years.
The following equa tion was d .
·
. V02 max from the recovery HR forenved to e t· t • The subject stepped for a maximum
men. s ima e of 3 minu te
• V0 2 max (mtkg·1.min·1 )= 111 33 .
HR) (0 42 stag es or until their exercise HR
. . · - · for a stage
><recovery
exceeded 65% of age predicted maximum
.

Eq uip me nt Protocol
• Attach HR monitor
• Platform or step 1O inch 25.4 cm in
• Set metronome rate at 68 bpm to elicit
a stepping
height. rate of 17 steps per min (stage 1). Dem
onstrate the
stepping cycle to the subject.

• Metronome • The subject performs stage 1 by stepp

ing up and .
· down on the step for 3 min at a stepp
ing rate of 17
· steps per min. record the subjects HR
• timer in beats per ·
min during the last 30 seconds of this stage
.

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 Sl.,u e_e!lU.:o lle g e step test
• Index Cl assification
>90
• McArdle et al developed 3 min stop tost to
Excellent
80-89 Good evaluate the aerobic fitness in 41 college aged
65-79 High average women .
55-64 Low average
• A 15 sec HR was measured between 5 and 20sec
<55 Poor
of recovery.

• Platform or step of 18.25 Inch or 41.3cm In

height.

Protocol

• Set the metronome at 88bpm to elicit a stepping

rate of 22 steps per minute.
• Demonstrate the stepping cycle to the subject.
• The subject should practice for 15sec to adjust to
the metronome cadence.
• The subject performs the test by stepping for 3min
at a rate of 22 steps per minute.
• After the test the subject remains standing.
• The pulse Is counted for a 15sec period stating at
5 sec into recovery. Convert this value to beats per
minute.

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 • A1 the end of stage 1, the subject sits for 1 min of recovery. if At the completion of stage 2, the subject sits for 1 min
tt,e· rec:orded HR for stage 1 is less than 65% of the subjects
of recovery. if the stage 2 HR is less than 65%of age
age p,-edicted maximum 220-a~e,then the subject goes to
predicted maximum, the subject will continue to stage
stage 2.if the HR is greater than 65% of age predicted
3;else the test is terminated .
maximum,.the test Is terminated.
• For stage 3,set the metronome at 136 bpm for a
• For stage 2 set the metronome rate at 104 bpm to elicit a
stepping rate of 34 steps per min , the subject steps
stepping rate of 26 steps per min. the subject steps for 3
for 3 min at this rate . Record the HR for the last
min. record ~ rate for the last 30 sec of exercise.
30secs of exercise.

Criteria for _terminat ing sub

maximal exercise testing

• ]0% to ]S% of age-predicted maximal heart rate

achieved.
• Fatigue or dyspnea.
• Maximal HR 120 to 130 beat/min
• ST segment depression THANK YOU ©
• daudication pain. .
• Decrease in systolic pressure 10 to 15 mm HG below
peak value. ·
Hypertension(systolic>200mm Hg diastolic>110 mm
Hg) .
• Level 1 angina