EXERCISE TOLERENCE TEST

This presentation will help physiotherapy students for their theory as well as practical purpose for measuring the exercise tolerance level of the individual.
This presentation includes maximal and sub maximal exercise testing with it's VO2 max formula
This presentation gives brief description of the treadmill test, am-strand cycle ergo-meter test, 6MWT, symptom limited testing, shuttle walk test

1. EXERCISE TOLERENCE TEST Dr. ANERI PATWARI(PT) MPT

2. WHAT ARE WE TESTING

3. TEST TERMINOLOGY MAXIMAL OXYGEN UPTAKE(VO2 MAX )= Demand of heart and lungs METABOLIC EQUIVALENT(MET)= Caloric Consumption. 1 met=  3.5 ml O2/kg/min MYOCARDIAL OXYGEN CONSUMPTION = Supply+ Demand of heart

4. TYPES OF MUSCLE CONTRACTION 1. Mechanical Dynamic: isotonic: concentric, eccentric; isokinetic; isoinertial Static: isometric 2. Metabolic Aerobic anaerobic

5. TYPES OF EXERCISES 3 types of exercise can be used to stress cardiovascular system. Static( Isometric) Dynamic( Isotonic) Mixed

6. ETT Exercise is most common physiological stress and places major demand on cardiopulmonary system ETT, stress testing is non invasive tool to evaluate cardiopulmonary system to accommodate to increasing metabolic demand. ETT is 2 nd most common cardiologic procedure performed .

7. usually use the end point of the PMHR or terminate when a patient is limited by symptoms . used to measure functional capacity as well as to diagnose CAD. The protocol for testing involves performing a progressive workload until the patient perceives an inability to continue because of some limiting symptom such as shortness of breath, leg fatigue, or chest discomfort. Examples: Treadmill Naughton, Åstrand ,, Balke , Ellestad , Harbor Bruce and Modified bruce 2. Bicycle ergomrter and 3. Arm ergometer 4. Shuttle walk test: Incremental and endurance 5. Canadian and queens step test Submaximal Tests Are Terminated On Achievement Of A Predetermined End Point (Unless Symptoms Otherwise Limit Completion Of The Test). The Predetermined End Point May Be Either The Achievement Of A Certain Percentage Of The Patient’s Predicted Maximal Heart Rate ( Pmhr ; E.G., 75% Of PMHR) Or The Attainment Of A Certain Workload (E.G., 2.5 Mph, 12% Grade) . A Special Subset Of Submaximal Testing Is Low-level Testing, Performed On Patients During The Recuperative Phase After Myocardial Injury Or Coronary Bypass Surgery Examples: 6mwt Copper 12 min test Bag and carry test Time up and go test Maximal stress tests

8. INDICATIONS Patients with s/ sx suggestive of CAD Patients with significant risk factors for CAD To evaluate in patients with unexplained fatigue and shortness of breath To evaluate BP response to exercise in patients with borderline hypertension To look for exercise-induced serious irregular heart beats To evaluate effect of medical and surgical therapy or intervention

9. ABSOLUTE CONTRAINDICATIONS Acute MI, within 2 days Ongoing unstable angina Uncontrolled cardiac arrhythmia with hemodynamic compromise Active endocarditis Symptomatic severe aortic stenosis Decompensated heart failure Acute pulmonary embolism, pulmonary infarction, or deep vein thrombosis Acute myocarditis or pericarditis Acute aortic dissection Physical disability that precludes safe and adequate testing

10. RELATIVE CONTRAINDICATIONS Known obstructive left main coronary artery stenosis Moderate to severe aortic stenosis with uncertain relation to symptoms Tachyarrhythmias with uncontrolled ventricular rates Acquired advanced or complete heart block Hypertrophic obstructive cardiomyopathy with severe resting gradient Recent stroke or transient ischemic attack Mental impairment with limited ability to cooperate Resting hypertension with systolic or diastolic blood pressures >200/110 mm Hg Uncorrected medical conditions, such as significant anemia, important electrolyte imbalance, and hyperthyroidism

11. TESTING INTERMITTENT CONTINUOU S utilize incrementally progressive workloads until the test is terminated because of patient symptoms or a defined end point. intersperses progressive workloads with short rest periods to give the subject time to recover and decrease the effect of peripheral fatigue

12. METHODOLOGY OF EXERCISE TESTING Exercise testing appears safer today (< 1 untoward event per 10,000 tests) than it did 20 years ago. The equipment's use should have front and side rails to help subjects steady themselves. It should be calibrated monthly. A defibrillator must be instantly available. A complete trolley of cardiac resuscitation equipment should be on hand, including intubation equipment and full range of cardiac drugs. Automate blood pressure measurement during exercise not recommended. The time-proven method of holding the subject’s arm with a stethoscope placed over the brachial artery remains the most reliable. SAFETY PRECAUTIONS AND EQUIPMENT

13. INTERPRETATIONS Stress test are interpreted as either positive (+) or Negative (-) A positive ETT Indicates that there is a point at which the myocardial oxygen supply is in adequate to meet the myocardial oxygen demand. And the test is positive for ischemia. A Negative ETT Indicates that at every tested physiological workload there is a balanced myocardial oxygen supply and demand. A false negative ETT is one that is interpreted as negative but the patient in fact has ischemia. A false positive ETT is one that is interpreted as positive but the patient does not have ischemia.

14. TREADMILL TESTING

15. PRE-TEST PREPERATIONS The  patient should be instructed not to eat, drink, or smoke at least 2 hours prior to the test and to come dressed for exercise, including proper footwear. The physician should also review the patient’s medical history, making note of any conditions that can increase the risk of testing (the absolute and relative contraindications to exercise testing). A physical examination— including assessment of systolic murmurs— should be performed before all exercise tests. An echocardiogram should be considered prior to testing. Pretest standard 12-lead ECGs are necessary

16. PRE-TEST PREPERATIONS Good skin preparation is necessary for good conductance to avoid artifacts and is especially important for elderly patients who have a higher skin resistance and tendency toward contact noise. The areas for electrode application are first shaved and then rubbed with alcohol-saturated gauze. Disposable electrodes used in exercise testing are generally silver– silver chloride combinations with adherent gel. The changes caused by exercise electrode placement can be kept to a minimum by keeping the arm electrodes off the chest and placing them on the shoulders, placing the ground (right leg) electrode on the back out of the cardiac field, placing the left leg electrodes below the umbilicus PRETEST PREPARATIONS (Cont‘d)

17. MONITORING HR , ECG; Cardiac Rhythm; BP; Perceived Exertion; Clinical Signs Patient-reported Symptoms Suggestive Of Myocardial Ischemia, Inadequate Blood Perfusion, Gas Diffusion, And Limitations In Pulmonary Ventilation

18. REQUIRED EQUIPMENT Commercial Treadmill, Stopwatch A 12 Lead ECG Machine & Leads Sticking Tape, Clips Stethoscope And Sphygmomanometer (With Hand-held Dial Or With A Stand) Ratings Of Perceived Exertion (RPE) Scale Heart Rate (HR) Monitor (Optional) Medical Tape

19. PROTOCOLS

20. ASTRAND-RYHMING CYCLE ERGOMETER TEST

21. DEFINITION The Astrand Test Is A Submaximal Cycle Ergometer Aerobic Fitness Test, Based On The Relationship Between Heart Rate During Work And Percentage Of Maximal Aerobic Capacity. 

22. EQUIPMENT REQUIRED Cycle Ergometer Clock Or  Stopwatch   Heart Rate Monitor   ECG Monitor  (Optional)

23. PRE-TEST   Explain The Test Procedures To The Subject. Perform Screening Of Health Risks And Obtain Informed Consent. Prepare Forms And Record Basic Information Such As Age, Height, Body Weight, Gender, Test Conditions. Calibrate And Adjust The Cycle Ergometer. Attach Heart Rate Monitor. 

24. What is steady state heart rate? If The Intensity Of Exercise Remains Constant Then The Heart Rate Will Rise Until It Reaches What Is Known As “ Steady State “ ,,,, Where It Stays Relatively Constant As The Cardiovascular System Meets The Demands Placed On It By The Exercise.

25. PROCEDURE Instruct The Client To Maintain A Steady Pace Throughout The Test. Record RPE And HR At Each Minute To Ensure The Client Is Staying Within The Recommended Target Heart-rate Range (THRR). Blood Pressure Should Be Assessed And Recorded At The Four-minute Mark. Record The Client’s HR At Minute 5 And Minute 6. These Values Will Be Averaged And Used For Determining Vo2max. Once The Test Is Completed, The Client Should Cool Down At A Reduced Workload For Three To Five Minutes, Until Hr And Breathing Rate Return To Normal. The Trainer Should Continue To Observe The Client, As Negative Symptoms Can Arise Immediately Post-exercise.

26. PROCEDURE Allow The Subject To Warm‐up On The Cycle Ergometer For 2 To 3 Minutes With A Resistance Of 0 Kg And At A Cadence Of 50. The Subject Pedals For 6 Minutes At A Workload Chosen To Try And Elicit A Steady-state Heart Rate Between 125 And 170 Bpm.   Record Heart Rate Every Minute During The Test and HR during the fifth and sixth minutes. If The Heart Rate difference At 5 And 6 Minutes Is Not Within 5 Beats/Min, Continue For One Extra Minute until the steady –state HR is achived . If The Steady-state Heart Rate Achieved Is Not Between 125 And 170 Bpm, Adjust The Workload Appropriately And Continue For A Second 6 Minute Period Otherwise, The Test Is Completed

27. SCORING (NOMOGRAM) Generally The Lower The Steady-state Heart Rate The Better Your Fitness. The Steady-state Heart Rate And Workload Are Looked Up On The Nomogram To Determine An Estimation Of Vo 2max . Scoring (Formula):  Here Is Also The Formula ( Buono Et Al. 1989) That The Nomogram Is Based On, Where Predicted Vo 2max  Is In L/Min, Hrss Is The Steady Heart Rate After 6 Min Of Exercise, And The Workload In Kg.M /Min. To Convert A Load In Watts To Kg.M /Min, Multiply The Watts By 6.12.

28. Females : Vo 2max  = (0.00193 X Workload + 0.326) / (0.769 X Hrss - 56.1) X 100 Males : Vo 2max  = (0.00212 X Workload + 0.299) / (0.769 X Hrss - 48.5) X 100

29. SUBMAXIMAL Men women Conditioned 600-900  450-600  unconditioned 300-600 kip/m/min 300-450 kp /m/min MAXIMAL WOMEN MEN 300 KG /MIN 600 kg/min

30. ADVANTAGES This is A simple test to administer, reasonably accurate and appropriate for ECG monitoring during exercise. DISADVANTAGES The Test Score Would Be Influenced By The Variability In Maximum Heart Rate In Individuals. It Would Underestimate The Fitness Of Those With A High Maximum Heart Rate, And Overestimate Fitness With Advancing Age (As Max Hr Reduces With Age). As It Is Performed On A Cycle Ergometer, It Would Favor Cyclists.

31. SYMPTOM LIMITED TEST

32. Clinical exercise testing has been part of the differential diagnosis of patients with suspected ischemic heart disease (IHD) for more than 50 yr. Also called as symptom limited test. During a clinical exercise test, patients are monitored while performing incremental (most common) or constant work rate exercise using standardized protocols and procedures and typically using a treadmill or a stationary cycle ergometer The clinical exercise test typically continues until the patient reaches a sign ( e.g. , ST-segment depression) or symptom-limited ( e.g. , angina, fatigue) maximal level of exertion.

33. INDICATIONS FOR A CLINICAL EXERCISE TEST (A) Diagnosis ( E.G. , Presence Of Disease Or Abnormal Physiologic Response), (B) Prognosis ( E.G. , Risk For An Adverse Event), (C) Evaluation Of The Physiologic Response To Exercise ( E.G. , Blood Pressure [BP] And Peak Exercise Capacity).

34. The Most Common Diagnostic Indication Is The Assessment Of Symptoms Suggestive Of IHD. The American College Of Cardiology (Acc) And The American Heart Association (Aha) Recommend A Logistic Approach To Determining The Type Of Test To Be Used In The Evaluation Of Someone Presenting With Stable Chest Pain.

35. Testing Mode and Protocol , . In the United States, treadmill is the most frequently used mode whereas a cycle ergometer is more common in Europe

36. Monitoring and Test Termination Hr ; Ecg ; Cardiac rhythm; Bp; Perceived exertion; and Clinical signs and patient-reported symptoms suggestive of myocardial ischemia, inadequate blood Perfusion, inadequate gas diffusion, and limitations in pulmonary ventilation

37. Measurement Of Expired Gases Through Open Circuit Spirometry During A CPET And Oxygen Saturation Of Blood Through Pulse Oximetry And/Or Arterial Blood Gases Are Also Obtained When Indicated

38. SCALES

39. INTERPRETING THE CLINICAL EXERCISE TEST Heart Rate Response: To Increase With Increasing Workloads At A Rate Of ≈10 Beats · Min−1 Per 1 MET Blood Pressure Response : Response : An SBP >250 Mm Hg Is A Relative Indication To Stop A Test. Hypotensive Response: A Decrease Of SBP Hypotensive Response: A Decrease Of SBP Below The Pretest Resting Value Or By >10 Mm Hg After A Preliminary Increase, Particularly In The Presence Of Other Indices Of Ischemia , Below The Pretest Resting Value Or By >10 Mm Hg After A Rate-pressure Product (Also Known As Double Product ) Is Calculated By Multiplying The Values For HR And SBP That Occur At The Same Time During Rest Or Exercise. There Is A Linear Relationship Between Myocardial Oxygen Uptake And Both Coronary Blood Flow And Exercise Intensity. The Normal Range For Peak Ratepressure Product Is 25,000–40,000 Mm Hg · Beats · Min−1 reliminary Increase, Particularly In The Presence Of Other Indices Of Ischemia , Hypertensive : An SBP >250 Mm Hg Is A Relative Indication To Stop A Test. Hypotensive : A Decrease Of SBP Below The Pretest Resting Value Or By >10 Mm Hg After A Preliminary Increase, Particularly In The Presence Of Other Indices Of Ischemia ,

40. Electrocardiogram St-segment Changes ( I.E. , Depression And Elevation) Are Widely Accepted Criteria For Myocardial Ischemia And Injury. Horizontal Or Downsloping St-segment Depression ≥1 Mm (0.1 Mv) At 80 Ms After The J Point Is A Strong Indicator Of Myocardial Ischemia. Clinically Significant St-segment Depression That Occurs During Postexercise Recovery Is An Indicator Of Myocardial Ischemia. St-segment Depression At A Low Workload Or Low Rate-pressure Product Is Associated With Worse Prognosis And Increased Likelihood For Multivessel Disease. Symptoms Symptoms That Are Consistent With Myocardial Ischemia ( E.G. , Angina, Dyspnea Or Hemodynamic Instability ( E.G. , Light-headedness) Should Be Noted An Correlated With ECG, HR, And BP Abnormalities (When Present). Exercise-induced Angina Is Associated With An Increased Risk For Ihd .

41. Exercise Capacity Evaluating Exercise Capacity Is An Important Aspect Of Exercise Testing. Healthy Individuals With A Peak Exercise Capacity Of 13–15 METS & In Patients With Cardiac Or Pulmonary Disease METS High exercise capacity Absence of limitation

42. Symptom limited test WITH IMAGING exercise testing may be coupled with other techniques. Various radioisotopes can be used to evaluate the presence of a myocardial perfusion abnormality. When Exercise Testing Is Coupled With Myocardial Perfusion Imaging (E.G., Nuclear Stress Test) Or Echocardiography, All Other Aspects Of The Exercise Test Should Remain The Same, Including HR And BP Monitoring During And After Exercise, Symptom Evaluation, Rhythm Monitoring, And Symptom-limited Maximal Exertion. The Two Most Common Isotopes Are Thallium And Mtechnetium Sestamibi ( Cardiolite ).

43. 08-11-2023 6 Minute Walk Test 59 6 Minute Walk Test

44. DEFINITION The 6MWT is a practical simple test that requires a 100-ft. This test measures the distance that a patient can quickly walk on a flat, hard surface. 08-11-2023 6 Minute Walk Test 60

45. INDICATIONS 08-11-2023 6 Minute Walk Test 61

46. CONTRAINDICATIONS 08-11-2023 6 Minute Walk Test 62

47. SAFTEY ISSUES Rapid and appropriate response to an emergency is possible. Required equipment's and supplies must be there. The technician should be certified in CPR with a minimum of BLS by an AHA–approved CPR course. Oxygen should be given at their standard rate or as directed by a physician or a protocol. 08-11-2023 6 Minute Walk Test 63

48. REASONS FOR IMMEDIATELY STOPPING A 6MWT 08-11-2023 6 Minute Walk Test 64

49. 08-11-2023 6 Minute Walk Test 65

50. TECHNICAL ASPECTS OF THE 6MWT 1 LOCATION It should be performed indoors, along a long, flat, straight, enclosed corridor with a hard surface that is seldom traveled. The walking course must be 30 m in length. A 100-ft hallway is, therefore, required. The length of the corridor should be marked every 3 m . A starting line, which marks the beginning and end of each 60-m lap, should be marked on the floor using brightly colored tape. 08-11-2023 6 Minute Walk Test 66

51. 08-11-2023 6 Minute Walk Test 67

52. 08-11-2023 6 Minute Walk Test 68 REQUIRED EQUIPMENT

53. PATIENT PREPARATION 1 08-11-2023 6 Minute Walk Test 69

54. PROCEDURE 1 No “warm-up” period before the test. Subject sat on chair located near the starting position, for at least 10 minutes before the test starts. During this time, all the vitals were checked: BP, RR, PR, SPO 2 , HR, BORG SCALE Use an even tone of voice when using the standard phrases. Post-test: Record the post walk Borg dyspnea and asked this: “What, if anything, kept you from walking farther?” and check all vital again Record the number of laps and additional distance covered (the number of meters in the final partial lap). Congratulated the subject on good effort and offer a drink of water. 08-11-2023 6 Minute Walk Test 70

55. PHRASES 1 Only the standardized phrases can be used during the test. 08-11-2023 6 Minute Walk Test 71 After the first minute (In even tones): You are doing well. You have 5 minutes to go. When the timer shows 4 minutes remaining Keep up the good work. You have 4 minutes to go. When the timer shows 3 minutes remaining You are halfway done. When the timer shows 2 minutes remaining, Keep up the good work. You have only 2 minutes left. When the timer shows only 1 minute remaining You are doing well. You have only 1 minute to go. When the timer is 15 seconds from completion, In a moment I’m going to tell you to stop. When I do, just stop right where you are and I will come to you.

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57. FACTORS AFFECTING 6MWD 1 FACTORS DECREASING 6MWD Shorter height Older age Higher body weight Female sex Impaired cognition A shorter corridor (more turns) Pulmonary disease (COPD, asthma, cystic fibrosis, interstitial lung disease) Cardiovascular disease (angina, MI, CHF, stroke, TIA, PVD, AAI) Musculoskeletal disorders (arthritis, ankle, knee, or hip injuries, muscle wasting, etc.) FACTORS INCREASING 6MWD Taller height (longer legs) Male sex High motivation A patient who has previously performed the test. Medication for a disabling disease taken just before the test Oxygen supplementation in patients with exercise-induced hypoxemia. 08-11-2023 6 Minute Walk Test 73

58. CONCLUSION The 6-minute walk test (6MWT) is a simple, practical, reliable, and valid measure of submaximal exercise capacity in healthy children and with chronic disease or neuromuscular disorders or cardiopulmonary disease. 6MWT is standardized, safe, inexpensive, and requires minimal equipment, training, and time to administer. It is considered as the most relevant walk test that reflects physical activity of daily living as well as cardiopulmonary fitness.  08-11-2023 6 Minute Walk Test 74

59. CRF MEASUREMENT 6MWTD is the alone significantly associated with objectively measured fitness than other simple, laboratory and field based submaximal exercise test as a predictor of both functional (distance) and objective (VO2 max) fitness . The published ATS standardized guidelines for performing the test and considers factors such as gender, height, age, length of the walkway and encouragement to have impact on the distance walked (6MWD). FORMULA TO MEASURE VO 2max VO 2 max (mL⋅kg−1 ⋅min−1) = 70.161 + (0.023 × 6MWT [m]) – (0.276 × weight [kg]) – (6.79 × sex, where m = 0, f = 1) − (0.193 × resting HR [beats per minute]) – (0.191 × age [y]) 08-11-2023 6 Minute Walk Test 75

60. INCREMENTAL SHUTTLE WALK TEST

61. INCREMENTAL SHUTTLE WALK TEST

62. INCREMENTAL SHUTTLE WALK TEST It was developed to simulate a cardiopulmonary exercise test using a field walking test. Developed to overcome problems associated with fixed-time, self-paced walking tests. 10m course marked by 2 cones set 0.5m from each end. Walking speed set by an audio signal on a tape/cd. Initial pace is 0.5m/sec . Walking speed increases by 0.17m/sec each minute of the test, indicated by a triple beep from the tape.

63. INCREMENTAL SHUTTLE WALK TEST Number of shuttles increases by 1 each time the speed of walking increases. Test ends when the patient is exhausted or too breathless to continue or when the patient is more than . 5m from the cone when the turn signal sounds. Max 12 levels.

64. STANDARDISATION The ISWT must be measured on two occasions to account for a learning effect. Please note that: The best result is recorded. If the repeat test is performed on the same day, 30 minutes rest should be allowed between tests. Debilitated individuals may require tests to be performed on separate days, but aim for tests to be less than one week apart. Only standardized instructions from the CD should be used. In contrast to the six-minute walking test, no encouragement should be given throughout the ISWT. A comfortable ambient temperature and humidity should be maintained for all tests. The walking track must be the same for all tests for a patient: Cones are placed nine meters apart. The distance walked around the cones is 10 meters.

65. END THE ISWT The patient exhibits any of the following signs and symptoms : Chest pain that is suspicious of / for angina. Evolving mental confusion or lack of coordination. o Evolving light-headedness. Intolerable dyspnea. Leg cramps or extreme leg muscle fatigue. Persistent SpO2 < 85%. Any other clinically warranted reason.

66. AT THE END OF THE ISWT Seat the patient or, if the patient prefers, allow the patient to stand. Note : The measurements taken before and after the test should be taken with the patient in the same position. Immediately record oxygen saturation (SpO2)%, heart rate and dyspnea rating. Two minutes later, record SpO2% and heart rate to assess the recovery rate. Record the total number of shuttles. Record the reason for terminating the test. The patient can be asked: “What do you think stopped you from keeping up with the beeps?” The patient should remain in a clinical area for at least 15 minutes following an uncomplicated test.

67. ISWT AS AN OUTCOME MEASURE The change in the distance walked in the ISWT can be used to evaluate the efficacy of an exercise training program and / or to track the change in exercise capacity over time. An improvement of 47.5 meters in ISWT indicates that patients with COPD are slightly better and an improvement of 78.7 meters represents better .

68. THE ENDURANCE SHUTTLE WALKING TEST (ESWT)

69. THE ENDURANCE SHUTTLE WALKING TEST (ESWT) It is a derivative of the ISWT, where patients walk for as long as possible at a predetermined percentage of maximum walking performance as assessed by the ISWT, frequently in the range of 70–85%. To set the speed for the ESWT, the ISWT must have been determined previously. One test is sufficient to obtain a reliable measure.

70. THANK YOU