Exercise testing

Exercise testing is a non invasive procedure that provides diagnostic and prognostic information and evaluates an individual’s capacity for dynamic exercises

1. Exercise Testing Dr.Nidhi Ahya ( Asst Prof) (Cardio-vascular & Respiratory Therapy) DVVPF College of Physiotherapy, Ahmednagar 414111 1/9/2014 1 Dr.Nidhi Ahya

2. Objectives Definition Need for exercise testing VO2 maximum Exercise Physiology Types of exercise testing Bruce Protocol Shuttle walk test 6 minute walk test Summary 1/9/2014 2 Dr.Nidhi Ahya

3. Exercise Testing Exercise testing is a non invasive procedure that provides diagnostic and prognostic information and evaluates an individual’s capacity for dynamic exercises 1/9/2014 3 Dr.Nidhi Ahya

4. Why do we need to do exercise testing ?? Exercise is a common physiological stress that can elicit cardiovascular and respiratory abnormalities which are not present at rest and it can be used to determine the adequacy of cardiac and pulmonary function Both the systems are adequately stressed out during the exercise 4

5. Body’s Response to Exercise During exercise, multiple cardiovascular, respiratory and metabolic changes occur. These include- Increase in Heart Rate Increase in Systolic Blood Pressure Diastolic Blood pressure either remains same or declines slightly Increase in respiratory rate All these responses are an attempt to meet the increased oxygen demand during exercise 1/9/2014 5 Dr.Nidhi Ahya

6. VO 2 max It is also called as maximum O2 consumption , max O2 uptake , peak O2 uptake or aerobic capacity Definition : It is the maximum capacity of an individual’s body to transport and use oxygen during incremental exercise ,which reflects the physical fitness of the individual It is expressed as- VO2 max = ……. Litre of O2 / min = ……. ml of O2 / kg body wt /min 1/9/2014 6

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8. To measure the VO2 max , individual is involved in physical effort sufficient in duration and intensity to fully tax the aerobic energy system VO2 max is reached when O2 consumption remains at steady state despite an increase in the workload 1/9/2014 8 Dr.Nidhi Ahya

9. Types of exercise testing Maximal exercise testing Submaximal exercise testing 1/9/2014 9

10. Maximal exercise testing Maximal exercises means an individual works upto maximum effort of his work capacity They are further divided into- Field tests Laboratory test These tests predict or directly measure VO2 max Cooper 12 min test Shuttle Walk test Field test Stepping tests Treadmill tests Laboratory test 10

11. Treadmill Tests Treadmill Tests involve making the patient walk on a treadmill in accordance to set protocols that stress the individual to their maximal exercise capacity. These tests are highly sensitive for clinical diagnosis of CAD The HR and rhythm, BP response, RR and rate of percived exertion are closely monitored before, during and after the tests to determine abnormality 1/9/2014 11 Dr.Nidhi Ahya

12. The most common treadmill test protocol used are – BRUCE PROTOCOL BALKE PROTOCOL 1/9/2014 12 Dr.Nidhi Ahya

13. Bruce Protocol The Bruce treadmill test protocol was designed in by Robert .A. Bruce in 1963 It is a non-invasive test to assess patients suspected with heart disease. It is also a common method to indirectly estimate VO2 Max in athletes. In this protocol, the individual walks on the treadmill uptill complete exhaustion as the treadmill speed and inclination increases every 3 minutes 1/9/2014 13 Dr.Nidhi Ahya

14. Stage Speed Grade % Duration METs Modified Full 1 1.7 3 1.7 2 1.7 5 3 2.9 3 1 1.7 10 3 4.7 4 2 2.5 12 3 7.1 5 3 3.4 14 3 10.2 6 4 4.2 16 3 13.5 7 5 5.0 18 3 17.3 8 6 5.5 20 3 24.6 9 7 6.0 22 3 28.4 1/9/2014 14 Dr.Nidhi Ahya

15. Assessment Variables: Hemodynamics Heart Rate Systolic/ Diastolic Blood Pressure Responses ECG Waveforms RPE Limiting Clinical Signs & Symptoms 1/9/2014 15 Dr.Nidhi Ahya

16. Variable Before Exercise Test During the Test After Exercise Test ECG Monitored continuously; recorded in supine and exercise posture Last 15 sec of each stage Last 15 sec of each 2 min time period Immediately post exercise, last 15 sec of first min of recovery, then every 2 mins HR During last 5 sec of each min During last 5 sec of each min BP Last 45 sec of each stage Last 45 sec of each 2 min time period Immediately post exercise, every 2 mins thereafter SIGNS/ SYMPTOMS Recorded as observed RPE Scale explained Last 5 sec of each min Peak exercise value obtained 1/9/2014 16 Dr.Nidhi Ahya

17. Rate of Perceived Exertion(RPE ) 15 –Grade Borg scale for RPE 6 No exertion at all 7 Extremely light 8 9 Very light 10 11 12 13 Somewhat hard 14 15 Hard (heavy) 16 17 Very hard 18 19 Extremely 20 1/9/2014 17 Dr.Nidhi Ahya

18. Subjective Ratings & Symptoms Angina 1.Mild, barely noticeable 2.Moderate bothersome 3.Moderately severe, very uncomfortable 4.Most severe or intense pain ever experienced Dyspnea 1.Light barely noticeable 2.Moderate bothersome 3.Moderately severe 4.Very uncomfortable 1/9/2014 18 Dr.Nidhi Ahya

19. Claudication 1.Definite discomfort or pain but only at the initial or modest levels 2.Moderate discomfort or pain from which the patients attention can be diverted 3.Intense pain from which patients attention cannot be diverted 1/9/2014 19 Dr.Nidhi Ahya

20. Indications for Termination Drop in systolic blood pressure of > 10 mm Hg from baseline, despite increase in workload Moderately severe angina ( 3 on scale) Increasing nervous system symptoms Signs of poor perfusion Subject desires to stop Sustained ventricular tachycardia ST elevation ( +10mm) in leads without diagnostic Q-waves 1/9/2014 20 Dr.Nidhi Ahya

21. Interpretation Exercise tests are interpreted as either- Positive: (+) ETT indicates that there is a point at which the myocardial oxygen supply is inadequate to meet myocardial oxygen demand Negative:(-) ETT indicates that at every tested physiological workload, there is balanced oxygen supply and demand 1/9/2014 21 Dr.Nidhi Ahya

22. Submaximal test Submaximal exercises means an individual works below maximum effort of his work capacity Self- paced walking test Modified shuttle walking test Bag and carry test Timed up and go test 6 Minute walk te st 1/9/2014 22 Dr.Nidhi Ahya

23. Modified Shuttle walk test The shuttle walk test is an adaptation of 20 meter shuttle running test The 20-mt shuttle running test (20-MST) assesses maximal aerobic power The test required subjects to run between 2 lines spaced 20 m apart at a pace set by signals on a prerecorded cassette tape Starting speed is 8.5 km and the frequency of the signals was increased by 0.5 km each minute. 1/9/2014 23 Dr.Nidhi Ahya

24. This test was designed for athletes participating in sports requiring constant stopping and starting It was too streneous for many patients, which resulted in the development of a 10 meter ,12 level shuttle walking test in adults with COPD. This was called as ‘Shuttle walk test’ Somehow in some patient groups the test was felt to be too easy, so modified shuttle walk test was devised in which three additional levels were added. Thus it now has15 levels 24

25. Indications: Before and After Treatment Comparisons Lung transplantation or lung resection Pulmonary rehabilitation Pulmonary hypertension Heart failure To Measure Functional Status Chronic obstructive pulmonary disease Cystic fibrosis Peripheral vascular disease In elderly patients 1/9/2014 25 Dr.Nidhi Ahya

26. Contraindications: Absolute Acute myocardial infarction (3–5 days) Unstable angina Uncontrolled arrhythmias causing symptoms or hemodynamic compromise Syncope Acute myocarditis Pericarditis Symptomatic severe aortic stenosis 1/9/2014 26 Dr.Nidhi Ahya

27. Relative Moderate stenotic valvular heart disease Severe untreated arterial hypertension at rest ( 200 mm Hg systolic, 120 mm Hg diastolic) High-degree atrioventricular block Hypertrophic cardiomyopathy Significant pulmonary hypertension Advanced or complicated pregnancy Orthopedic impairment 27

28. Procedure Treatment area that is at least 12 meters in length and a tape player The standard instructions are given on the audiocassette tape. Subjects are required to walk back and forth, turning around two cones placed 9 meters apart making the shuttle distance 10 meters long The subject must keep pace with the prerecorded auditory signal such that they complete a turn as each sound beeps Every minute the audio signal sounds at increasingly shorter intervals 28

29. One beep indicates the length of one shuttle and three beeps indicates an increase in speed There are 12 levels of speed beginning at 0.50 m/s and ending at 2.37m/s. The test is measured in meters and no encouragement is provided If the patient chooses to stop or fails to keep up to auditory signals after one warning the test will end The test will also terminate if patient reaches 85% of their maximal heart rate 29

30. Protocol 6 8 3.02 1.35 7 9 3.40 1.52 8 10 3.78 1.69 9 11 4.16 1.86 10 12 4.54 2.03 11 13 4.92 2.20 12 14 5.30 2.37 Levels Shuttles / level Speed (mph) Speed ( m/s ) 1 3 1.12 0.50 2 4 1.50 0.67 3 5 1.88 0.84 4 6 2.26 1.01 5 7 2.64 1.18 1/9/2014 30 Dr.Nidhi Ahya

31. 6 minute walk test The 12-MWT was introduced by McGavin and colleagues to assess the distance covered in 12 minutes in individuals with Chronic Bronchitis This test was modified from the 12-MRT described by Copper for individuals without health problems Butland et al reported that similar results could be obtained in 6 minutes Guyatt et al applied the 6-MWT in individuals with heart failure 1/9/2014 31 Dr.Nidhi Ahya

32. Indications A) Pre - Post – treatment comparisions Lung transplantation Lung volume reduction surgery Pulmonary rehabilitation COPD Pulmonary hypertension Heart failure 1/9/2014 32 Dr.Nidhi Ahya

33. B) Functional status COPD Cystic fibrosis Heart failure Peripheral vascular diseases Older patients C) Predictor of morbidity and mortality Heart failure COPD Primary pulmonary hypertension 33

34. Contraindications Absolute Contraindications   unstable angina and myocardial infarction   during the previous month Relative Contraindications Resting heart rate of more than 120 beats/min Systolic blood pressure   of more than 180 mm Hg Diastolic blood pressure of more   than 100 mmHg 1/9/2014 34 Dr.Nidhi Ahya

35. Required Equipments Countdown timer (or stopwatch) Two   small cones to mark the turnaround points   A chair that can   be easily moved along the walking course   Worksheets on a clipboard   A source of oxygen   Sphygmomanometer   Telephone   Automated   electronic defibrillator   1/9/2014 35 Dr.Nidhi Ahya

36. Patient Preparation Comfortable clothing should be worn.   Appropriate shoes for   walking should be worn.   Patients should use their usual walking   aids during the test   (cane, walker, etc.).   The patient's usual   medical regimen should be continued.   A light meal is acceptable   before early morning or early afternoon   tests. Patients should   not have exercised vigorously within 2 hours   of beginning the   test.   1/9/2014 36 Dr.Nidhi Ahya

37. The patient should sit at   rest in a chair, located near the   starting position, for at   least 10 minutes before the test starts During this time, check   for contraindications, measure pulse   and blood pressure, and   make sure that clothing and shoes are   appropriate Have the patient stand and rate   their baseline dyspnea and overall   fatigue using the Borg scale Set   the lap counter to zero and the timer to 6 minutes. Assemble   all necessary equipment 37

38. Termination of test Patients vitals are taken immediately after the test and then at the end of 2 minutes,5 minutes or till return to baseline Count the number of laps on the worksheet and calculate the distance covered by the patient Refer to worksheet for details 1/9/2014 38 Dr.Nidhi Ahya

39. Summary Definition exercise testing VO2 maximum Exercise Physiology Types of exercise testing Bruce Protocol Shuttle walk test 6 minute walk test 1/9/2014 Dr.Nidhi Ahya 39

40. THANK YOU….. 1/9/2014 Dr.Nidhi Ahya 40