Exercise Assessment Flashcards
(77 cards)
1
Q
When do patients need medical clearance for exercise?
A
- known cardiac, metabolic, renal dz and asymptomatic
- any signs/symptoms suggestive of cardiac, metabolic, renal dz (regardless of status)
- regular exercise before + asymptomatic + vigorous exercise
2
Q
What are the absolute contraindications to symptom-limited maximal exercise testing?
A
- Acute myocardial infarction within 2 days
- Ongoing unstable angina
- Acute pulmonary embolism
- Acute myocarditis or pericarditis
- etc
3
Q
What are the relative contraindications to symptom-limited maximal exercise testing?
A
- Recent stroke
- Mental impairment with limited ability to cooperate
- Resting hypertension with systolic greater than 200 mm Hg
Relative contraindications = good to get medical clearance first before carrying out any exercise tests
4
Q
Additional contraindications for exercise testing
A
- Unstable angina or acute myocardial infarction (non STEMI) during prev. month
- Severe pulmonary hypertension
- Pre-exercise HR > 125 bpm (relative contraindication)
- Resting SpO2 < 90% (check accuracy)
- Physical disability = prevent safe performance (e.g. balance, unstead gait)
5
Q
What is the criteria to terminate an exercise test?
A
- Patient requests to terminate test
- Any unexpected medical occurrence, sign, symptom occurring during test
6
Q
Why would a patient request to terminate the exercise test?
A
- Intolerable dyspnea not relieved by rest (shortness of breath)
- Onset of palpitations/chest pain
- Severe leg pain/cramps
- Profound weakness/fatigue
- Severe wheezing
- Pain from comorbid condition
7
Q
What are some signs/symptoms occurring during the exercise test to cause termination?
A
- Onset of chest pain suggestive of ischemia
- Abnormal HR response confirmed by palpation (e.g. failure of HR to rise unless fixed rate pacemaker in situ, fall in HR), persistent tachycardia
- Signs/symptoms of poor perfusion (sudden pallor, dizziness, light headache, fainting)
- Development of abnormal gait/loss of coordination
- Signs suggestive of mental confusion
- Excessive rise in BP
- Drop in SBP > 10 mm Hg
8
Q
What kind of cardiorespiratory fitness tests are there?
A
- Maximal
- Sub-maximal
9
Q
What are maximal cardioresp. fitness tests?
A
Protocols where subjects are required to exercise to volitional exhaustion (full exhaustion)
- Pros: direct results, X estimates
- Cons: usually need technical equipment, stressful/distressing for subjects
10
Q
What are sub-maximal cardioresp. fitness tests?
A
Protocols during which subjects do not exercise until exhaustion = assessor sets a certain limit/threshold
- Pros: easy administer, less stressful
- Cons: results are estimates & not exact figures
11
Q
What is the criteria for determining if effort is maximal?
A
- Achieves a plateau in VO2
- HR reaches 90% of predicted HR / HR reserve is < 15 beats/min
- Evidence of ventilation limitation
- RPE for leg fatigue/breathlessness > 9/10 (mBorg)
- RPE > 17 (6-20 scale)
- Peak exercise blood lactate conc. > 8mmol/L
12
Q
What is the use of cardiopulmonary exercise testing (CPET)?
A
- to determine peak oxygen consumption (VO2) & level of disability
- to identify factors contributing to dyspnoea & exercise limitation
- to screen for coexistent ischemia heart dz, peripheral vascular dz, arterial hypoxemia
- to objectively evaluate the impact of therapeutic interventions = O2, bronchodilators, vasodilators, exercise training
- to generate prognostic information = surgical risk, survival, time to clinical worsening ,exacerbations
- to assist in planning individualized exercise training
13
Q
What are the possible pulmonary mechanisms of exercise limitations?
A
- Ventilation
- Resp. muscle dysfunction
- Impaired gas exchange
14
Q
What are the possible peripheral mechanisms of exercise limitations?
A
- Inactivity/Sedentariness
- Muscle atrophy
- Neuromuscular dysfunction
- Reduced oxidative capacity
- Malnutrition
- Joint pain
15
Q
What are the possible cardiovascular mechanisms of exercise limitations?
A
- Reduced stroke volume
- Abnormality of HR responses
- Abnormality of circulation (e.g. claudication)
- Abnormality of blood (haemoglobin) = affect O2 carrying capacity
16
Q
What are the other possible mechanisms of exercise limitations?
A
- Motivation vs fear
- Environment
- Perceptual/cognition
17
Q
What are some types of field tests?
A
- 6 minutes walk test (6MWT)
- Incremental shuttle walk test (ISWT)
18
Q
When do you stop a field test?
A
- Chest pain suspicious for angina
- Evolving mental confusion/lack of coordination
- Evolving light-headedness
- Intolerable dyspnoea
- Leg cramps/extreme leg muscle fatigue
- Persistent SpO2 < 80% (community setting, maybe <85%)
- Any other clinically warranted reason
19
Q
What is the 6 minute walk test?
A
- 30 m walkway (min 25 m)
- Cones to indicate point of turning (inform patient turn around or at cones = consistent!)
- Fixed/standardised encouragement
- Rests allowed
- Have chairs set up on either side & halfway along the walkway (so can rest)
- X pace patient
- Strong learning effect!
Walk as far as possible in 6 min
20
Q
What to record during 6 minute walk test?
A
- How far they have walked
- How many times they stopped
- When they took their rest break
- When did they restart
- HR, SpO2, rate of perceived exhaustion
21
Q
How to calculate METs for 6MWT?
A
((6MW distance / 6) x (0.1) +3.5 / 3.5
22
Q
1 MET = ____ VO2
A
1 MET = 3. 5 ml/kg/min VO2
23
Q
How to do exercise prescription using 6 minute walk test?
A
- Find average speed in km/h (dist walked/6 x 60)
- Find 80% of average speed (using average speed from above)
- Duration (e.g 20 min)
- Find distance to walk in the set duration =80% speed x duration
24
Q
How to progress exercise based on 6 minute walking test?
A
- Inc. distance in 20 min (Inc. speed)
- Dec. rest time/number of rests
- Inc. duration to 25-30 min
25
What is the incremental shuttle walk test (ISWT)?
- 10m distance
- Cones placed 0.5 m away from each end (so can turn around)
- Speed of walking increased every minute by 0.17m/s, controlled by audio signal
- X encouragement
- Strong learning effect
Progressive shuttle walking test, increasingly faster speed
26
When is incremental shuttle walk test (ISWT) not suitable?
if patients use a walking aid / supplementary oxygen
- min. speed is 1.8km/h
- patients unable to follow rhythm/instructions of audio signals
27
What is treadmill ISWT limited by?
- Limited by dyspnea than leg fatigue
- Patients may have difficulty adapting to treadmill walking-possible reasons:
- Inc. work of breathing
- Dyspnea
- Giddy
- Altered gait
May underestimate total distance
28
How to do exercise prescription for Incremental speed walking test?
1. Find the peak walking speed depending on the level completed
2. Prescribe 75% of peak walking speed
3. 20 minute walking goal distance = speed / 3 = 1.21
29
How to progress exercise based on incremental shuttle walk test?
- Inc. distance in 20 min = Inc. speed
- Inc. duration to 25-30 min
30
What are some step tests that can be done?
- Harvard Step test
- Chester step test
- YMCA/3 minute step test
- 2 minute step test
31
What are advantages of treadmills?
- Standardized speed &/or ramp
- Many available formulas to calculate work done, calories expended, aerobic capacity, etc
32
What are the disadvantages of treadmills?
- Unfamiliarity with walking on treadmills
- Expensive
- 'Expertise' interpreting parameters (need experts to interpret)
- Space needed
- Not suitable for those with walking aids
33
What is the most optimum treadmill protocol?
Bruce protocol
34
What are the advantages of the bike test?
- Standardized speed
- Many available formulas to calculate work done, calories expended, aerobic capacity
- Easier to measure power output & parameters
- Portable & less expensive
- Lower oxygen consumption & desaturation
35
What are the disadvantages of the bike test?
- May not be suitable for those with knee pain when cycles/lack ROM at hip/knee
- Need expert to interpret parameters
- Blood pressure may be greater due to greater muscular contraction
- Relevance to function
- Limited usually by leg fatigue than dyspnea
36
Example of the sequence of a step incremental cycle test
Cycling speed of 60 revolutions per m in
1. Warm up: cycle 3 mins at 10W
2. Warm up: Followed by 2 mins at 20W
3. After warm up, rest quietly for 5 min (seated on bicycle)
4. Test starts with 2 mins at 30W
5. Every 2 mins, work rate increased by 10W until symptom-limited end point
6. Patients instructed to keep exercising until too breathless or too tired
7. Seated on bike for 4 mins of recovery/ HR and BP return to near baseline levels
37
What is constant bike test which depends on HR responses?
- Total test duration = 6 min
- Subject maintained at cycling cadence of 50-60 rpm
Unconditioned male = 50-100W
Conditioned male = 100-150W
Unconditioned female = 50-74W
Conditioned female = 75-100W
38
"Ramp" incremental vs "Step" incremental vs "Constant-intensity"
"Ramp" incremental = Slowing increasing change in terms of work rate
"Step" incremental = Every 2-3 mins, the work rate changes
"Constant-intensity" = Load is constant after warm-up
39
Constant vs Incremental
Constant
- Deoxygenated Hb higher = higher O2 extraction is required to keep constant load for longer duration
- Lactate may build up driving release of O2 from Hb
- Higher muscle oxygen extraction rate
Incremental
- Higher CO as need greater bld flow with inc. work-load
- Higher SBP
- Higher VCO2
40
What can VE/VO2 tell us?
Used as an index of ventilatory efficiency
- If patient's lung very efficient at gas exchange, the subject will not need a very high VE for a given VO2
41
What does high resting VE/VO2 values tell us?
Marker of inefficient ventilation
- Hyperventilation
- Inc. dead space (structural/dz)
42
How to calculate VO2?
VO2 = Minute ventilation x (Fraction of inspired air - Fraction of expired air)
43
How to calculate VCO2?
VCO2 = Minute ventilation x fraction of expired carbon dioxide
44
Cycle vs treadmill: peak oxygen content (PVO2)
Cycle = lower
Treadmill = higher
45
Cycle vs treadmill: work rate measurement
Cycle = Yes
Treadmill = No
46
Cycle vs treadmill: Blood gas collection
Cycle = Easier
Treadmill = More difficult
47
Cycle vs treadmill: Noise & artefacts
Cycle = Less
Treadmill = More
48
Cycle vs treadmill: Safety
Cycle = safer
Treadmill = less safe
49
Cycle vs treadmill: Weight bearing in obese subjects
Cycle = less (seated)
Treadmill = more
50
Cycle vs treadmill: Degree of leg muscle training
Cycle = Less
Treadmill = more
51
Cycle vs treadmill: More appropriate for?
Cycle = patients
Treadmill = active normal people
52
What can be used for sub-maximal testing on stroke patients?
Total body recumbent stepper submax test
- E.g. one-sided weakness = X move smoothly on treadmill + X push down adequately on the bike
53
What is the reliability of the VO2 max test?
0.97 or greater
54
What equipment needed for the VO2 max test?
- O2 & CO2 analyser
- workload modifiable ergometer
- stopwatch
55
What is the procedure for the VO2 max test?
- Performed on treadmill, cycle/rowing ergometer (but can be done with any exercise method)
- Standard protocols exist for diff exercise and subject ability
- Subject works until peak VO2 is reached = indicated by:
1. VO2 plateau
2. respiratory exchange ratio of 1.15 or higher
3. voluntary exhaustion
56
What are the advantages of VO2 max test?
- Most accurate to measure VO2 aerobic capacity
57
What are the disadvantages of the VO2 max test?
- Expensive equipment
- Requires higher tester experience (need expertise)
58
Is there any difference between VO2peak obtained when performed on cycle ergometer vs treadmill?
Yes
Peak exercise capacity 5-20% lower on cycle ergometer
59
Why is peak exercise capacity lower on cycle ergometer than treadmill?
Possible reasons
- Regional muscle fatigue
- Interindividual variability
- Data from different studies = variability
More likely to have leg fatigue than breathlessness
Exceptions:
- Hold handrails of treadmill for support = may over-estimate exercise capacity
- Highly trained cyclists = higher exercise capacity
60
How to calculate VO2?
VO2 (ml/min) = cardiac output (ml/min) x arteriovenous oxygen difference
- Fick equation
61
What affects the VO2 value?
Stroke volume (SV) = cardiac responses
HR = cardiac responses, pulmonary responses, muscle diseases, deconditioning
a-v (diff b/w arterial & venous O2 content at capillary) = anaemia, low iron, pulmonary dz which impacts SpO2
62
What does reserve mean in HRreserve and VO2reserve?
Refers to the difference between the maximum & resting values which provides better predictive capabilities (bc HR and VO2 will never be 0 unless dead)
- HRR more effective than HRmax
63
What is the angina scale?
- Subjective = what the patient feels
1+ light (barely noticeable)
2+ moderate (bothersome)
3+ severe (very uncomf)
4+ very severe (most severe pain ever experienced)
64
What is the breathlessness/leg fatigue scale?
0-2: very slight to slight
3: moderate
4-5/6: severe
6/7-9: very severe
10: maximal
65
1 mph = _____ m/min = _____ km/h
1 mph = 26.8 m/min = 1.608 km/h
66
1 m/min = _____ km/h
1 m/min = 0.06 km/h
1 m/min / 1000 = 0.001 km/min
0.001 km/min * 60 = 0.06km/min
67
1MET = _____ ml/kg/min
1MET = 3.5 ml/kg/min
resting VO2
68
1 watts = _____ kg/m/min
1 Watts = 6 kg/m/min
69
1kg = _____ lb
1 kg = 2.2 lb
70
1 inch = _____ m
1 inch = 0.0254m
71
1 m = _____ inch
1m = 39.37 inch
72
Arm ergometry equation?
VO2 = [3 x work rate (watts x 6) / body mass (kg)] + 3.5
73
What is the % of HRR needed for improvement in cardio-respiratory fitness in deconditioned individuals?
At least 40% VO2R or HRR
74
What is the % of HRR needed for improvement in cardio-respiratory fitness in more active individuals?
At least 50% VO2R or HRR
75
What does grip strength identify?
Identify risks of sarcopenia
76
What is the 1RM/multiple RM test procedures like?
1. Warm up
2. Determine 1 RM within 4 trials with rest periods of 3 - 5 min b/w trials
- Select initial weight within perceived capacity (~50-70% of capacity)
- Resistance progressively inc. 5-10% for upper and 10-20% for lower
- Final weight lifted is absolute 1RM or multiple RM (for older adults, do 10 full range reps & cant do 11th one)
77
How to protect yourself during exercise prescription/tests?
Informed consent
Common claims against exercise prescribers:
Failure to:
1. Monitor exercise test properly
2. Evaluate physical impairments completely
3. Prescribe a safe exercise programme
4. Provide appropriate supervision
5. Refer clients onwards
6. Rendition of advice later construed as medical diagnosis
