“Resistive Exercise Testing in
Cardiopulmonary Rehabilitation
Special Populations and the Elderly”
NCCRA Annual Symposium
March 5-6, 2015
University of North Carolina at Charlotte
Charlotte, NC
• This presentation will only focus on
muscular strength and endurance testing
• There are also multiple tests for balance,
gait, agility and flexibility that are in use
today for various patient populations
• Cardiopulmonary testing protocols are
well-established and are also necessary
for each type of patient population
WHICH SPECIAL POPULATIONS DO WE TREAT
IN CARDIOPULMONARY REHABILITATION?
• Cardiac (MI, CABG, Valvular, Stent, CHF, Transplant)
• Cardiovascular (PAD, Stroke, HTN, TIA)
• Metabolic (Diabetes, Obesity, Hyperlipidemia, Renal)
• Geriatric (Frail, Elderly, Higher Risk Older Populations)
• Immunologic (Cancer, AIDS, Fibromyalgia, CFS)
• Neuromuscular (MS, ALS, Cerebral Palsy, Parkinson’s)
• Musculoskeletal (Osteoporosis, Arthritis, Low back
pain)
Chronic muscle deconditioning leads to:
•  energy expenditure
•  basal metabolic rate
•  muscular strength
•  activity level
•  falls
•  disability
•  injuries
•  sedentary living
NO ONE TEST IS SUITABLE
ALL TYPES OF PATIENTS!
Why do we Need to Perform
Strength Testing for Our
Rehabilitation Patients?
• Must have pre- & post-rehab strength measurements
for strength improvement outcomes documentation
• Need to test after 3, 6, 12, 18 and 24 months (or
whatever outcome follow-up intervals you prefer)
• For AACVPR Program Certification and AACVPR
Cardiopulmonary Rehab Outcomes Registries
• To let the patient know how they stand up compared
to those in their age and gender groups strength-wise
• To let the patient know how much they are improving
(or regressing) throughout their rehabilitation program
• To help determine the patient’s ability to perform
basic ADL’s (walking, dressing, picking things up,
housework, squatting)
• To measure individual success in resistive exercises
with validated norms
• To boost confidence and self-efficacy
• To help assess posture and balance issues and to
prescribe posture and balance exercises
• To assess and determine the individual needs of the
patient with respect to their unique overall muscular
weaknesses
WHY IS RESISTIVE EXERCISE
TESTING UNDERUTILIZED?
 Few (if any) evidenced-based guidelines and
lack of research
 Fear of the patient becoming injured
 Lack of testing protocols and knowledge of
existing protocols
 Each special population has their own unique
and specific characteristics
 Time factor—do you perform different tests for
different patients for their individualized ITP?
HOW DO YOU SELECT THE PROPER
RESISTIVE TESTING PROTOCOL FOR
YOUR PATIENTS WITH VARYING
TYPES OF DISEASES?
• The CEP should look for established
protocols with normative data in the
literature.
• The test need not necessarily be designed
specifically for that type of patient.
•There is a significant lack of testing
research for special populations in the
literature—thus, the CEP must often use
their own best judgment on which test to use
for which type of patient.
A good place to start is the “Senior
Fitness Test Manual, 2nd edition”
(Rikli & Jones, 2013, Human Kinetics)
How do we Measure Resistive
Exercise Testing Outcomes?
1. Properly screen the patient!
2. Test with the appropriate testing modality.
3. Record entry strength testing measurements.
3. Test again at 12-16 weeks (or whatever followup interval your institution utilizes) and
throughout program participation.
5.Subtract the entry test value from the post-test
value and divide by the post-test value for the
% improvement.
Sample ITP Recording Form
Patient:
Elvira, MOD
(Age: 64)
Entry
(1-10-15)
12Week
%
Change
(4-10-15)
24Week
(7-10-15)
%
Change
(From
Entry)
50%
Normative
Data For
Age Group
6MW Test
864 ft. 1222 ft.
+41%
1684
+95%
1238 ft.
1 RM Leg
Press
75 lb.
105 lb.
+40%
130 lb.
+73%
115 lb.
30-second
Arm Curl
Test
10
25
+150%
30
+200%
25
8-foot Up
and Go Test
10 s
8s
+20%
7.2 s
+28%
5s
Handgrip
Test
15 kg
31 kg
+107%
40 kg
+167%
40 kg
• Major orthopedic limitations
• Hip or knee replacement?
• Breathing distress or “poor air” days
• SaO2 < 90%
• Acute episodes of joint inflammatory or
degenerative disease (e.g., gout, bursitis)
• Acute systemic illness (e.g., mono, flu)
• Uncontrolled metabolic disease (e.g.,  BP)
• Symptomatic patient
• Pulmonary HTN ?
ACUTE HEART RATE, BLOOD PRESSURE,
& VO2 RESPONSES DEPEND UPON:
• Muscle mass used (e.g., legs vs. arms)
• Number of repetitions
• Amount of weight lifted (e.g., body vs. arms)
• Rest duration between trials
• Valsalva influence
• Total volume of work performed
• Pulmonary/cardiac/cancer medications
• Upper vs. lower body resistive testing
• Physical condition of the patient
SAFETY ISSUES
• Always perform strength testing with a focus on
.
• Be
that your equipment set-up and maintenance
follows the specifications from national organizations
(e.g., ACSM’s Health/Fitness Facility Standards and
Guidelines, 4th edition).
• Always provide the patient with proper instructions
on resistive exercise testing from start to finish.
• Stay
close to the deconditioned or frail
patient throughout testing—be there if they start to
fall (1 on 1 instruction).
SAFETY ISSUES
• 1-RM testing is OK in properly screened patients
if performed by properly certified clinical exercise staff!
• If the patient complains of mild muscle soreness
12-24 hours after resistive testing, this is normal.
• If the patient complains of chronic (> 1 week) muscle
soreness after resistive testing, this is not normal.
• Demonstrate the test yourself first.
• Report any significant injuries or complications to
the supervising physician and the patient’s physician.
ADMINISTERING THE
TESTS
• Have the patient perform at least 5-8 minutes of
warm-up and stretching activities (typical rehab
warm-up activities)
• OK to test the patient after group warm-up
• Typically no additional physiologic monitoring
needed (telemetry ECG or SAO2 OK)
• Include dynamic stretching that exercises
the muscle groups being tested
•Prior to the test tell the patient to “Do the best
they can, but not to the point of overexertion or
beyond what they think is safe for them”
• Stop testing immediately if the patient is using
improper technique or form
• Stop testing if any clinically abnormal signs or
symptoms
• For those with visual or auditory limitation, make
the appropriate testing adjustments (e.g., have
cleared area, ask if you can help, large cones)
• Demonstrate the testing protocol
•For those with chronic pain, if > 5 on a 0-10 scale
best to delay testing until the pain level
is
lower
• Use simple words
• Speak slowly and distinctly
• Be calm, reassuring and positive
• Maintain eye contact
• Don’t give excessive verbal instructions
• Use non-verbal gestures
• Allow the patient adequate time to respond
COMMON TESTS OF
MUSCULAR STRENGTH
AND ENDURANCE
MACHINE WEIGHT TESTING
• Demonstrate proper position of the seat and other
attachments on the machine weights.
• Demonstrate proper pin placement in the weight
stack.
• Demonstrate proper placement of additional
weight on the weight stack.
• Reinforce proper breathing techniques and
posture on the machine (i.e., exhale with the
muscle contraction, pursed-lip breathing).
2014 ACSM GETP PULMONARY
RESISTIVE TESTING GUIDELINES
•
NO specific strength testing or training
recommendations or guidelines for
• Refer to chapters 7 and 8 of GETP for resistive
guidelines for healthy and older populations
•
Interesting breakdown of % 1 RM testing and
prescription for various types of healthy and
geriatric populations (evidenced-based)
•
MAY or MAY NOT be applicable for pulmonary
patients in general—CEPs use best judgment
RM Resistive Testing Techniques
• 1 RM: The maximal amount lifted once, but not
twice, with proper technique (no straining,
full extension)
• Modified 1 RM: Progressively increase weight
to determine the maximal amount lifted
twice, but not 3 times, with proper technique
• 4-, 6-, and 8-RM: Determine the maximal
amount of weight that can be lifted 4-8 times
with proper technique and prescribe a %
SAFETY OF 1-RM TESTING
Shaw et al. 1995, JCR (Healthy Older Adults)
• 40 men / 43 women (60-72 yrs.)
• Divided into 3 groups by lifting experience
• Light warm-up of 9 min; tests on 5 machines
• Many c/o muscle soreness (none by day 7)
• 2 older subjects in the inexperienced group
had injuries to the back and ribs
Conclusion: With proper prep, 1 RM testing
safe in older, apparently healthy subjects.
Use caution with older, inexperienced patients.
SAFETY OF 1 RM TESTING
Pollock et al. 1991, MSSE (Healthy Older Adults)
• Older men (70-79 yrs.)
• 11 of 57 incurred injuries during 1 RM testing
• 5 injuries knee, 5 shoulder, 1 back (19%)
• 4 of 5 knee related to prior knee problems
• 6 other injuries unrelated to previous problems
Conclusion: 1 RM testing likely inappropriate
for older men and women with joint problems
specific to the muscle being tested.
SAFETY OF 1 RM TESTING
Kaelin et al. 1999, JCR (Pulmonary Patients)
• 9 men / 11 women (43-75 yrs.)
• 1 RM testing with gradual increase of weight
• Light warm-up of 5-10 reps at 40-60% 1 RM
• HR, BP, SOB, O2sat, muscle soreness (1-4) monit.
• No sig. difference in muscle soreness after
1 week; no cardiopulmonary complications
Conclusion: No altered ADLs, muscle soreness, or
muscle injury in patients with moderate to severe
COPD
EXAMPLE OF 1 RM BENCH TESTING
PROTOCOL FOR OLDER MEN/WOMEN*
• Patient warms up in the group warm-up
• Patient lays supine on the bench in the 5point contact position
• Bar is grasped in closed, pronated grip
slightly wider than shoulder width
• Spotter is close to the patient’s head, holding bar
• Patient performs a few reps with a light
weight with the bar
EXAMPLE OF 1 RM BENCH TESTING
PROTOCOL FOR OLDER MEN/WOMEN*
• Determine the 1 RM (or multiple RM) within 4
trials with rest periods of 3-5 min. between trials
• Select an initial weight that is within the patient’s
perceived capacity (~ 50% to 70% of capacity)
• Progressively  the weight by 2.5 to 20 kg until
the patient cannot complete the repetition
• All reps should be performed at the same speed
of movement and ROM
•The final weight lifted is the absolute 1-RM or
multiple RM
*ACSM HRFM (2014), p. 83
SENIOR FITNESS TEST (SFT)*
CHAIR STAND (# of stands)
ARM CURL (# of reps)
6-MINUTE WALK (# of yards)
2-MINUTE STEP TEST (# of steps)
CHAIR SIT-AND-REACH (inches +/-)
BACK SCRATCH (inches +/-)
8-FOOT UP AND GO (seconds)
*Rikli R, Jones J. (2013) Senior Fitness Test Manual
Champaign, IL: Human Kinetics.
Jones, CJ and R Rikli
Jones, CJ and R Rikli
Jug Shelf Test1
6-Minute Peg Board and Ring Test2
Grip Dynamometer Test3
1Signorile
et. al., J Aging Phys Act 2007;15:56-74.
2Su Zhan et. al., JCR 2006;26:180-187.
3Kaminsky LA. ACSM’s Health Related Physical Fitness
Assessment Manual, 4th edition. Philadelphia: Wolters
Kluwer/LWW, 2014, pp. 80-81.
Test Protocol
(Elbow Flexor Muscular Endurance)
In a seated position, the patient performs as
many arm curls as possible in 30 seconds
Men:
weights
Women:
weights
Perform on both right and left arms
Scoring: The total number of reps performed with
each arm (once the patient quits, the time can
stop)
Ask the patient if they have any elbow, wrist or
hand pain prior to the test
If the patient cannot hold the weight properly, a
Velcro wrist weight (or wrap) may be used
If the weight is too heavy for even 1 rep, a lighter
weight may be substituted
If compared to normative values, they would receive
a “0”, with the goal of performing the test protocol
with the proper weight on the follow-up test
Make note in the patient’s ITP of the reduced weight
MEN’S SCORES*
Age
60-64
65-69
70-74
75-79
80-84
85-89
90-94
Below Average
< 87
< 87
< 80
< 73
< 71
< 59
< 52
Average
87 to 115
86 to 116
80 to 110
73 to 109
71 to 103
59 to 91
52 to 86
Above Average
> 115
> 116
> 110
> 109
> 103
> 91
> 86
WOMENS SCORES*
Age
60-64
65-69
70-74
75-79
80-84
85-89
90-94
Below Average
< 75
< 73
< 68
< 68
< 60
< 55
< 44
Average
75 to 107
73 to 107
68 to 101
68 to 100
60 to 91
55 to 85
44 to 72
Above Average
> 107
> 107
> 101
> 100
> 91
> 85
> 72
*Jones & Rikli, 2002
To Calculate Power and Watts*
Average Power in Watts =
- 504.845 + [10.793 x weight (kg)] + [21.603
x number of stands in
Peak Power in Watts =
- 715.218 + 13.915 x weight (kg) + 33.425
x number of stands in
*Smith et. al., Clinical Interventions in Aging, July 2010
NOTE: You can perform these measures during
follow-up testing as well for outcomes.
To Calculate Power and Watts*
Average Power in Watts =
- 504.845 + [10.793 x weight (kg)] + [21.603
x number of stands in
Example: An 80 kg man performs 10 chair stands
in 20 seconds.
504.845 + [10.793 x 80 kg] + [21.603 x 10] =
1079.46 – 504.845 ~ 575 watts
575 watts ÷ 80 kg = 7.2 watts/stand or 72 watts
for 10 chair stands
*Smith et. al., Clinical Interventions in Aging, July 2010
The 8 Foot “Up-and-Go” Test
– Indicates the level of the participant's
motor agility and dynamic balance
– Also a measure of muscular endurance of
the leg muscles
– Associated with the lifestyle tasks of
maneuvering in a crowd, getting on or off a
train/bus or moving around the house
The 8 Foot “Up-and-Go” Test
Required Equipment
– Chair with a straight back (17” or 43 cm)
– Chair legs should be placed against wall to
stop the chair from sliding backwards
– Cone placed so the rear of the marker is 2.44
meters (8 feet) from the front of the chair
– Stopwatch and tape measure
The 8 foot “Up-and-Go” Test
 The subject starts fully seated in the
middle of the chair with back straight.
 The hands should rest on the thighs.
 One foot is placed slightly in front of the
other, but both must be flat on the floor.
 The subject leans slightly forward.
The 8 foot “Up-and-Go” Test
On the command "Go" the time is started and the
subject stands and walks (no running) as quickly as
possible (and safely) around the cone, returning to
the chair to sit down
Timing stops as they sit down
Two trials are performed
The 8 foot “Up-and-Go” Test
Stand between the chair and cone in order to
assist the patient if they lose balance.
If frail or with neuromuscular disease, spot closer
(particularly around cone).
Make sure that they sit in the chair on the return.
If needed, a cane or rollator is OK to use.
If the patient cannot rise from the chair, OK to
start them in a standing position.
MEN’S NORMS (seconds)*
Age
60-64
65-69
70-74
75-79
80-84
85-89
90-94
Below average
> 5.6
> 5.7
> 6.0
> 7.2
> 7.6
> 8.9
> 10.0
Average
5.6 to 3.8
5.7 to 4.3
6.0 to 4.2
7.2 to 4.6
7.6 to 5.2
8.9 to 5.3
10.0 to 6.2
Above Average
< 3.8
< 4.3
< 4.2
< 4.6
< 5.2
< 5.3
< 6.2
WOMEN’S NORMS (seconds)*
Age
60-64
65-69
70-74
75-79
80-84
85-89
90-94
Below average
> 6.0
> 6.4
> 7.1
> 7.4
> 8.7
> 9.6
> 11.5
Average
6.0 to 4.4
6.4 to 4.8
7.1 to 4.9
7.4 to 5.2
8.7 to 5.7
9.6 to 6.2
11.5 to 7.3
Above Average
< 4.4
< 4.8
< 4.9
< 5.2
< 5.7
< 6.2
< 7.3
*Jones & Rikli, 2002
Parkinson’s Disease
“The 8-foot up and go test appears to be
a useful test which helps identify the
impact that PD has on the QOL of
suffers.”*
*Haaxma C, Bloem B, Borm G, & Horstink M (2008). Comparison of
a timed motor test battery to the Unified Parkinson’s Disease
Rating Scale-III in Parkinson’s disease. Movement Disorders,
23(12), 1707–1717.
The 6-Minute Pegboard and Ring Test
– The patient moves as many rings as
possible in 6 minutes on to a pegboard
– Each ring weighs 50 g or 0.5 ounce
– This test has been shown to be a reliable
and valid method to assess unsupported
arm exercise endurance in patients with
COPD1 and to be a predictive test to
help maintain and improve upper body
ADL’s in pulmonary rehab patients2
FOR MORE INFO ON THIS TEST
1.
Zhan S, Cerny F, Gibbons W, Mador J, Wu YW.
Development of an Unsupported Arm Exercise Test in
Patients With Chronic Obstructive Pulmonary Disease.
Journal of Cardiopulmonary Rehabilitation.
2006;26(3):180-187.
1.
Takeda et. al. The 6-minute pegboard and ring test is
correlated with upper extremity activity of daily living in
chronic obstructive pulmonary disease. International
Journal of COPD. 2013;8:347-351.
Signorile Gallon Jug Shelf Test*
Fill five (5) one gallon jugs with water.
Set bottom and top shelves of a bookcase level
with top of patella and tip of the acromion
process respectively
Time (in seconds) how long it takes to pick all
five jugs (one at a time) with one arm (dominant
arm) up from the bottom shelf and place them
each on the top shelf
This is a measure of power and strength
*Signorile JF. ACSM’s Certified News. 2014:24(2):9-14.
Signorile Gallon Jug Shelf Test
Equipment Needed
Five (5) one gallon jugs filled with water.
Bookshelf (84” H x 42” W x 12” D)
Stopwatch
Signorile Gallon Jug Shelf Test
Equipment Needed
QUESTION: Where would I find such a
bookcase with adjustable shelves?
ANSWER: Have a patient with carpentry
skills make a bookcase with shelving that
is adjustable with “fine tuning.”
REWARD: Give the patient 1-2 free
months of maintenance exercise in your
program for building this bookcase!
Signorile Gallon Jug Shelf Test
Set-up
Align the lower shelf with the participant’s
patella.
Align the upper shelf with the top of the
patient’s shoulder (acromion process).
Place the 5 one-gallon jugs on the bottom
shelf.
Provide detailed instructions prior to testing.
Demonstrate the test protocol.
Signorile Gallon Jug Shelf Test
Test Procedure
Patient sits comfortably in front of bookcase.
Instruct the patient to keep back straight, head
up, not lean forward, use legs as primary
source of power for lift, and abort if any feelings
of discomfort.
Provide a test trial and evaluate/correct form.
Remind patient to move 1 jug at a time, not
alternate hands, and begin test standing up.
Begin trial with “Ready” followed by “Go!”
Stop test when 5th jug placed on the top shelf.
Signorile Gallon Jug Shelf Test
Test Benefits
Measure of upper/lower body power
Measure of upper/lower body strength
Measure of upper/lower body dynamic ROM
Measure of ability to lift and place objects on
shelves
Safe
Inexpensive
Easily administered
Probably a better assessment of ADL’s than the
other tests presented
Men’s Percentile Ranks by Age
Age Groups (Years)
%
60-64
65-69
70-74
75-79
80-84
85-89
90-94
5th
12.6 (s)
10.9
13.2
14.5
14.8
18.6
18.6
25th
8.3
9
10.2
10.3
11.6
14.8
14.8
50th
7.7
7.9
8.9
9.2
9.8
12.7
12.7
75th
6.8
7.4
8.1
8.7
8.2
10.2
10.2
95th
5.9
5.2
6.7
7.5
7.3
9.4
9.4
Scoring: Signorile, 2011. Bending the Aging Curve—The
Complete Exercise Guide for Older Adults.
Human Kinetics
Women’s Percentile Ranks by Age
Age Groups (Years)
%
60-64
65-69
70-74
75-79
80-84
85-89
90-94
5th
13.2 (s)
11.5
13.5
15.2
15.6
18.7
18.7
25th
10.8
9.8
10.8
11.8
12.5
14.0
14.0
50th
8.9
9.1
9.6
10.1
11.0
12.7
12.7
75th
8.1
8.3
8.7
8.9
9.8
11.4
11.4
95th
7.1
7.5
7.7
8.0
8.7
9.3
9.3
Scoring: Signorile, 2011. Bending the Aging Curve—The
Complete Exercise Guide for Older Adults.
Human Kinetics
The Handgrip Dynamometer Test
 An isometric test that measures the grip
strength of both the right and left hands
(flexor muscles of hands and forearms)
 The grip dynamometer is adjusted so that
the 2nd joint of the fingers are bent to grip
the handle most effectively
 The patient starts in a position of elbow
flexion at 90°
The Handgrip Dynamometer Test
 The patient squeezes the handgrip
dynamometer as hard as possible without
holding their breath in each hand
 The patient may extend the elbow to
180° if desired
 Grip strength is recorded in kg
The Handgrip Dynamometer Test
 The patient performs a total of 3 trials
 The highest if the 3 readings for each hand are
combined and compared to the normative values*
 This test can be used for multiple patient
populations, but normative data is lacking
 Grip strength does not correlate with overall
body strength (in most studies)
*Normative values for healthy men and women can be found in the ACSM
Health-Related Physical Fitness Assessment Manual (2014) Philadelphia:
Wolters/Kluwer, LWW, p. 80
Maintaining muscular strength and endurance is
critical for longevity, daily functioning and  QOL for
all patients in cardiopulmonary or cancer rehab.
While musculoskeletal testing may not be a “billable”
procedure, we should all be doing this for “best
practices” and optimal patient assessment and
feedback, as well as patient outcomes.
Muscular strength and endurance testing should
become a significant component of the patient’s ITP,
regardless of what type of chronic disease(s) that
may be present.