CLINICAL EXERCISE TESTING
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To evaluate person’s ability to tolerate
increasing levels of work output
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parameters measured include but are not
limited to
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ECG
hemodynamic response
symptomatic ischemia
electrical abnomralities
exertion related problems
APPLICATIONS
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Diagnostic, Prognostic and Therapeutic
Exercise Prescription
Occupation
Activities of daily living
DIAGNOSTIC TESTING
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Not appropriate for the general
population
Age, gender, risk factors , symptoms
and vigor of exercise will determine test
necessity
Geared toward individuals with a higher
probability of disease
TESTING FOR DISEASE
SEVERITY (PROGNOSIS)
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Symptoms, functional capacity and
ischemia during exercise are evaluated
Magnitude of ischemic response and at
what replicable point does it occurr
Double-Product --SBP x HR= myocardial
oxygen consumption
TESTING AFTER AN INSULT
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Prior to hospital discharge
Submax tests may be used
Symptom limited tests done 4 day post
MI
Use to gage activity level and therapy
FUNCTIONAL TESTING
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Used for exercise prescription, activity
counseling, or disability limitations
Usually described in terms of a
percentage of “normal” in units of METS
CLINICAL TEST MODALITIES
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Treadmill--yields the highest VO2 and
HR
Hand rails--needs and purposes
Stop belt--Stop exercise
Additional directions for the novice
like???
MORE
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Cycle ergometers--lower VO2 (5-25%)
and HR
Better HR and BP measures
Less expensive, less noise, less space
Driven by patient motivation
Localized fatigue
Arm ergometery-lower VO2 (20-30%)
PROTOCOLS
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Based on purpose of test, desired outcomes
and the individual
Bruce, Ellestad--larger incremental changesfor healthy
Naughton, Balke-Ware, USAFSAM--smaller
incremental changes--for older and
deconditioned
Submax tests-used for individuals that are too
unstable or high risk to take to max
PROTOCOLS
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Submax tests are usually terminated based
on a predetermined end point like 120 bpm
or a MET level of 5
Even so, most end points are patient specific
Ramp Protocol-- increasingly popular--based
on constant and continuous increase in
workload-seemingly more accurate in
estimations and more individualized
TESTING FOR RETURN TO
WORK POST INSULT
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15-20% of MI survivors do not return to work
Medical and nonmedical factors contribute to
outcome
Job demands, timelines for return to work,
rehab based on job demands, and to
determine special work related needs
GXT can provide necessary info but
specialized tests can be used also
SPECIALIZED TESTS
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Weight carrying tests-evaluates
tolerance for dynamic and static lifting
Repetitive lifting--evaluates tolerance to
bouts of lifting
MEASURES DURING TESTS
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Pretest--ECG, HR, BP, RPE--supine,
sitting, standing
Exercise--3-lead ECG every min., 12lead ECG last 15 sec, of each stage, BP
last min. of each stage, RPE last min. of
each stage--BP, 12-lead ECG, and RPE
at MAX
Posttest--same as during the exercise
portion
MEASURING EXPIRED GASES
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The most accurate way of determining
VO2, functional capacity and VT
Not necessary for all clinical testing
Most appropriate for: evaluating a
therapeutic intervention, in research,
when cause of exercise limitation is
uncertain, evaluation for prognosis and
need for transplantation, and exercise
prescription for cardiac rehab
ECG MONITORING
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Quality of ECG very important
Skin prep is essential
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shave
alcohol
abrasion
Electrode placement in supine position
10 electrodes for 12 lead
SUBJECTIVE RATINGS
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RPE- 0-10 or 6-20 scale
Note instructions on p. 105-6
Symptomatic scales are different
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rating for angina
rating for leg pain
rating for dyspnea
POST EXERCISE PERIOD
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Healthy individuals do an active and
passive recovery
Symptomatic individuals may require
supine recovery
Test termination based on absolute or
relative indications
EXERCISE TESTING WITH
IMAGING
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Used to determine extent or distribution
of disease
An additional confirmation when ECG
changes are hard to interpret
Echocardiography-cheaper than nuclear
testing but operator dependent
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identifies wall abnormalities for ischemia
Nuclear Imaging
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-limitations include exposure to
radiation, additional equipment and
personnel and physician training in
nuclear medicine and interpretation
advantages include sharper and
improved images over 180 degrees
rotation--depicts heart in 3 dimensions
so multiple myocardial segments can be
viewed separately
PHARMACOLOGIC TESTING
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For patients not able to do an exercise
test--to establish diagnosis of CAD or
evaluating efficacy of CABG
Dobutamine and Thallium are the most
used tests
Images obtained are similar to
echocardiography
CONSIDERATIONS FOR
PULMONARY PATIENT
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Degree of dyspnea
Cause of dyspnea
Distinguish between cardiac or
pulmonary limitations
Deconditioning factors such as obesity,
anxiety
Exercise induced oxygen desaturation
TESTING SUPERVISION
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Physician supervision
Physician in the immediate vicinity
Paramedical personnel
Expertise versus physician presence
Implications for Costs