Clinical Exercise Testing

Professor David Yu
Professor of Practice
Department of Rehabilitation Sciences
The Hong Kong Polytechnic University
Indications of an Exercise Testing
• Diagnosis – presence of disease or abnormal physiologic response
• Prognosis – risk of an adverse event
• Evaluation of the physiologic response to exercise (blood pressure,
HR, ECG..)
• For exercise prescription
Contraindications
to Symptom-
limited Ex Testing
Mode of Exercise Testing
• Field Tests (e.g 6-min walk test, Incremental shuttle walking test)

• Motor-driven Treadmills

• Mechanically braked cycle ergometers

• Step testing
Before Testing
• Proper patient preparation
• Measure body weight and body height
• Current history
• Medication use
• Blood pressure
• Pulse
• RPE
• Resting ECG
Borg Scale: 6-20 Scale of RPE
Rating Description
6
Correlations of ratings and heart rate ranging from 0.8 to 0.9
7 Very, very light
8 Scale values range from 6 – 20 = Heart rates range from 60-200bpm

9 Very light When to use this scale

1. For exercise testing, exercise prescription for sports and
10 medical rehabilitation
11 Fairly light 2. For patients who participate Cardiac Rehabilitation (post-AMI,
CHF, cardiac transplant etc)
12
13 Somewhat hard
14
15 Hard
16 Borg G. (1982) Medicine & Science in Sports & Exercise 14(5):p 377-381.

17 Very hard American College of Sports Medicine. (2018). ACSM's guidelines for exercise testing and
prescription. Lippincott williams & wilkins.
18
19 Very, very hard
20
Modified Borg Category-Ratio Scale
(Modified Borg CR10 Scale)
Rating Description
0 Nothing at all A category scale with ratio properties
0.5 Very, very weak (just
noticeable)
Correspond very well with glycogenolytic metabolism leading to
1 Very weak lactate accumulation during exercise

2 Weak (light)
When to use this scale
3 Moderate 1. Suitable for determining other subjective symptoms, such as
breathing difficulties, aches, and pain
4 Somewhat strong
2. For patients who participate Pulmonary Rehabilitation (COPD.,
5 Strong (heavy) cystic fibrosis, interstitial lung disease, lung transplant etc)

6 Borg G. (1982) Medicine & Science in Sports & Exercise 14(5):p 377-381.

7 Very strong Noble, B., Borg, G., & Jacobs, I. (1981, January). Validation of a category-ratio perceived
exertion scale-blood and muscle lactates and fiber types. In International Journal of Sports
Medicine (Vol. 2, No. 4, pp. 279-279).
8
American College of Sports Medicine. (2018). ACSM's guidelines for exercise testing and
9 prescription. Lippincott williams & wilkins.

10 Very, very strong (almost max)

Indications for termination of an Ex. Testing
 Maximal Oxygen Consumption
• Aerobic capacity, exercise tolerance, exercise capacity,
cardiopulmonary function….

Fick equation:
• VO2 max = Q x (CaO2 – CvO2)

where Q is the cardiac output of the heart, CaO2 is the arterial oxygen content, and CvO2 is the venous oxygen
content.
MET – Metabolic Equivalent of Task
1 MET = 3.5ml/kg/min

10
Normal Heart Rate & Blood Pressure Responses

~Increase 10 bpm per 1 MET

(attenuate by -blocker)

~Increase 10 mmHg per 1

MET (attenuate by
vasodilator, Ca channel
blockers, ACE inhibitors, -
and -blocker)

Circulation 1977;55:153-157
Heart Rate & Blood Pressure Responses
 What is abnormal?
Heart Rate
• The inability to appropriately increase HR during exercise
• A delay decrease by at least 12 bpm in HR during the 1st min of recovery or 22 bpm by the end of 2nd
min of recovery
• Indicate the inability of the PNS to reassert vagal control of HR, which is known to predispose
individuals to ventricular dysrhythmias

Blood Pressure-SBP
• SBP>250mmHg : stop the test
• SBP > 210mmHg in men; SBP> 190mmHg in women: exaggerated response
• Peak SBP>250mmHg or an increase in SBP> 140mmHg : predictive of future resting HT
• Decrease of SBP below the pre-test resting value or by >10mmHg after a preliminary increase,
particularly presence of ischemia
• Postexercise response: SBP should return to pre-exercise level by 6 mins of recovery
Blood Pressure-DBP
• Peak DBP>90mmHg or an increase in DBP>10mmHg during exercise above the pretest
• DBP>115mmHg is an exaggerated response: stop the test
ECG Waveform during Ex. Testing
• Minor and insignificant changes in P wave morphology
• Superimposition of the P and T waves of successive beats
• Increase in septal Q wave amplitude
• Slight decreases in R wave amplitude
• Increase in T wave amplitude
• Minimal shortening of the QRS duration
• Depression of the J point
• Rate-related shortening of QT interval
Normal Exercise ECG
The patient achieved Stage 4 of the Bruce protocol, exercising for a total of nine minutes 46 seconds
with 11.2 METs of work. ECG at peak stress showed sinus tachycardia at a rate of 146 bpm.

ST-segment depressions in leads II, III, aVF and V4–6, which were suggestive
of myocardial ischaemia. In addition, there was an isolated 1-mm ST-segment
elevation in lead aVL.
Adopted from Lim YC, et al, 2016
ECG Waveform – abnormal
Female: Age 57, BW: 55kg
Ramp Protocol, 15 watt per min, 50rpm
VO2max (ml/min)= 9.39xPOWER + 7.7X BW –
170
5.88xAGE + 136.7
163bpm
100% MHR 150

130bpm
Heart Rate (bpm)
130
80% MHR

110

90

70
VO2 max = 24.58ml/kg/min VO2 max = 31.41ml/kg/min
= ~7MET = ~9MET
50
15 30 45 60 75 90 105 120 135 150 165 180 195 210

Work Rate (watt)

Metabolic Equations for Gross VO2(ml/kg/min)
Treadmill training

• Walking • Running
VO2 = (0.1xS) +(1.8xSxG) + 3.5 VO2 = (0.2XS) + (0.9XSxG) + 3.5

S is speed in m/min
1 mile = 1609.344 m
1mph = 26.8m/min

G is grade expressed in fraction (e.g 0.1 =10%)

Metabolic Equations for Gross VO2(ml/kg/min)
• Leg Ergometry • Stepping
VO2 = (10.8xWxM-1) +7 VO2 = (0.2xf) +
(1.33x1.8xHxf) + 3.5
• Arm Ergometry
VO2 = (18xWxM-1) + 3.5 H is the step height in meters
f is stepping frequency in min-1
M is body mass in kg;
W is power in watt
Cardiorespiratory
Fitness
Classification by
age and sex –
male
 Cardiorespiratory
Fitness
Classification by
age and sex –
female

ACSM’s Guidelines for Ex testing and Prescription, 11th Ed