Exercise Testing
Exercise Testing
MOHAMMAD IRFAN
Exercise testing
• Exercise testing elicit the body’s reaction to measured increase in acute exercise.
• The change in the heart rate, BP, respiration and perceived level of exercise provide
data that permit quantitative estimation of cardiovascular conditioning and function.
• Exercise test provide an opportunity to observe a person during exercise.
• By measuring and monitoring heart rate, BP, one can detect changes in the
hemodynamic and ischemic results due to exercise.
• Exercise testing – assessment of the integrate exercise responses involving
Pulmonary
Cardiovascular
Neuropsychological and
Skeletal muscle
Pre participation health screening before exercise
program
• For initiating a low intensity exercise program include a pre participation health
screening and American college of sports medicine (ACSM) risk classification.
• Individuals classified with low risk can begin exercise program at intensities up to
vigorous, whereas those classified with moderate risk can safely begin an exercise
program at intensities up to moderate.
• Individuals having high risk classification should consult their physician prior to
• Determine medications that may alter heart rate and blood pressure
responses to exercise.
• Identify risk factors for cardiovascular, pulmonary, musculoskeletal
and metabolic disorders.
• Risk factor management program - improves survival rates, reduces
recurrent events.
• The health fitness professional should create an environment supportive of risk
factor management.
Past medical history:
• A neurologic assessment .
Exercise testing and supervision
• Exercise tests are often conducted and supervised by nonphysicians (eg: exercise
physiologists, nurses, physical therapists [PTs], physician assistants [PAs]).
• Physical Therapists PTs are trained to provide care to patients who have physical
impairments, activity limitations, and participation restrictions as a result of
musculoskeletal, neuromuscular, cardiovascular/ pulmonary disorders.
• PTs should have specialized training in cardiovascular and exercise physiology,
potentially making their role in exercise testing.
• Physician supervision is recommended during maximal and submaximal exercises.
• Individuals unable to exercise because of physical limitations like arthritis, severe
peripheral vascular disease should undergo pharmacologic stress testing in
combination with a imaging modality.
• Pulmonary risk factors (include asthma, exercise induced asthma, bronchospasm,
extreme dyspnea at rest or during exercise) may require consultation with medical
personnel before exercise testing.
• Individuals with pulmonary risk factors should have spirometry and maximal
voluntary ventilation (MVV) measured.
• Metabolic risk factors (include metabolic syndrome, obesity, thyroid ,kidney disease,
diabetes) may require consultation with medical personnel before exercise testing.
• Before exercise testing, laboratory tests should be obtained to ensure the individuals
blood chemistry profile are within normal limits.
Client Preparation
Before testing:
• Each individual should be carefully prepared before all exercise testing.
• A detailed set of instructions should be provided to the individual.
• Verbal and written instructions are recommended to reduce test anxiety and to
standardize the response to testing.
• Instructions before testing include; avoid eating and smoking for a minimum of 3 hr
before testing
• Wear comfortable footwear and loose fitting clothing.
• Each individual is instructed on whether medications should be continued or
discontinued for the test based on physician orders.
• Individuals should avoid unusual physical efforts for atleast 12 hr before exercise
testing.
• Past medical and physical examination that focuses on risk factors should be
conducted before the exercise test.
• Contraindications to testing should be determined before exercise testing.
• Determining the individuals current physical activity level can aid in the selection of
appropriate testing protocols.
• Informed consent should be signed and included in the exercise test record.
• Specific instructions should be given on how to perform the exercise test, purpose of
the test, brief demonstration of the test procedure( e.g: walking on treadmill, riding
bicycle).
• Individuals undergoing an exercise stress test with ECG should follow skin
preparation guidelines to avoid ECG artifact.
Protocol selection
• Protocol selection should be based on the individuals past medical history, pre
participation screening and physical examination.
• Health care provider must determine which device (treadmill, cycle ergometer) is
most appropriate and then determine an appropriate protocol.
• Protocols for clinical exercise testing include: a low load initial warm up, a
progressive uninterrupted exercise with increasing loads and adequate time interval
in each stage and a recovery period.
• The exercise protocol can be submaximal or symptom limited.
• Sub maximal protocols have a predetermined end point, often defined as a heart rate of
120 bpm or 70% of the predicted maximum heart rate or metabolic equivalent (MET)
level of 5.
• Symptom limited tests continue until the individual presents with signs or symptoms
that require termination of exercise testing.
• The treadmill, cycle ergometer and arm ergometer are used for dynamic exercise
testing.
Indications
• Indications for clinical exercise testing encompass
three general categories:
• a) Diagnosis (e.g., presence of disease or abnormal
physiologic response)
• b) Prognosis (e.g., risk for an adverse event)
Post-Myocardial Infarction, Chronic Stable Angina
• c) Evaluation of the physiologic response to exercise
(e.g., blood pressure [BP] and peak exercise capacity)
Contraindication
• Absolute Contraindications
o Acute myocardial infarction within 2 d
o Ongoing unstable angina
o Uncontrolled cardiac arrhythmia with hemodynamic compromise
o Active endocarditis
o Symptomatic severe aortic stenosis
o Decompensated heart failure
o Acute myocarditis or pericarditis
o Physical disability that precludes safe and adequate testing
• Relative Contraindications
o Known obstructive left main coronary artery stenosis
o Moderate to severe aortic stenosis with uncertain relationship
to symptoms
o Acquired advanced or complete heart block
o Recent stroke or transient ischemia attack
o Mental impairment with limited ability to cooperate
o Resting hypertension with systolic >200 mm Hg or diastolic
>110 mm Hg
o Uncorrected medical conditions, such as significant anemia,
important electrolyte imbalance, and hyperthyroidism
Reference
• ACSM’s Guidelines for exercise testing and prescription, 7th Ed.
• ACSM’s health related physical fitness assessment manual, 3rd Ed.
• Supervision of exercise testing by non physicians, Jonathen myers, AHA J,2014.