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CLINICAL EXERCISE
TESTING
 To evaluate person’s ability to tolerate
increasing levels of work output
 parameters measure...
APPLICATIONS
 Diagnostic, Prognostic and Therapeutic
 Exercise Prescription
 Occupation
 Activities of daily living
DIAGNOSTIC TESTING
 Not appropriate for the general
population
 Age, gender, risk factors , symptoms
and vigor of exerci...
TESTING FOR DISEASE
SEVERITY (PROGNOSIS)
 Symptoms, functional capacity and
ischemia during exercise are evaluated
 Magn...
TESTING AFTER AN INSULT
 Prior to hospital discharge
 Submax tests may be used
 Symptom limited tests done 4 day post
M...
FUNCTIONAL TESTING
 Used for exercise prescription, activity
counseling, or disability limitations
 Usually described in...
CLINICAL TEST
MODALITIES
 Treadmill--yields the highest VO2 and
HR
 Hand rails--needs and purposes
 Stop belt--Stop exe...
MORE
 Cycle ergometers--lower VO2 (5-25%)
and HR
 Better HR and BP measures
 Less expensive, less noise, less space
 D...
PROTOCOLS
 Based on purpose of test, desired outcomes
and the individual
 Bruce, Ellestad--larger incremental changes-
f...
PROTOCOLS
 Submax tests are usually terminated based
on a predetermined end point like 120 bpm or
a MET level of 5
 Even...
TESTING FOR RETURN TO
WORK POST INSULT
 15-20% of MI survivors do not return to work
 Medical and nonmedical factors con...
SPECIALIZED TESTS
 Weight carrying tests-evaluates
tolerance for dynamic and static lifting
 Repetitive lifting--evaluat...
MEASURES DURING TESTS
 Pretest--ECG, HR, BP, RPE--supine,
sitting, standing
 Exercise--3-lead ECG every min., 12-
lead E...
MEASURING EXPIRED
GASES
 The most accurate way of determining
VO2, functional capacity and VT
 Not necessary for all cli...
ECG MONITORING
 Quality of ECG very important
 Skin prep is essential
 shave
 alcohol
 abrasion
 Electrode placement...
SUBJECTIVE RATINGS
 RPE- 0-10 or 6-20 scale
 Note instructions on p. 105-6
 Symptomatic scales are different
 rating f...
POST EXERCISE PERIOD
 Healthy individuals do an active and
passive recovery
 Symptomatic individuals may require
supine ...
EXERCISE TESTING WITH
IMAGING
 Used to determine extent or distribution
of disease
 An additional confirmation when ECG
...
Nuclear Imaging
 -limitations include exposure to
radiation, additional equipment and
personnel and physician training in...
PHARMACOLOGIC TESTING
 For patients not able to do an exercise
test--to establish diagnosis of CAD or
evaluating efficacy...
CONSIDERATIONS FOR
PULMONARY PATIENT
 Degree of dyspnea
 Cause of dyspnea
 Distinguish between cardiac or
pulmonary lim...
TESTING SUPERVISION
 Physician supervision
 Physician in the immediate vicinity
 Paramedical personnel
 Expertise vers...
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Chapter 5

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Chapter 5

  1. 1. CLINICAL EXERCISE TESTING  To evaluate person’s ability to tolerate increasing levels of work output  parameters measured include but are not limited to  ECG  hemodynamic response  symptomatic ischemia  electrical abnomralities  exertion related problems
  2. 2. APPLICATIONS  Diagnostic, Prognostic and Therapeutic  Exercise Prescription  Occupation  Activities of daily living
  3. 3. DIAGNOSTIC TESTING  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
  4. 4. TESTING FOR DISEASE SEVERITY (PROGNOSIS)  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
  5. 5. TESTING AFTER AN INSULT  Prior to hospital discharge  Submax tests may be used  Symptom limited tests done 4 day post MI  Use to gage activity level and therapy
  6. 6. FUNCTIONAL TESTING  Used for exercise prescription, activity counseling, or disability limitations  Usually described in terms of a percentage of “normal” in units of METS
  7. 7. CLINICAL TEST MODALITIES  Treadmill--yields the highest VO2 and HR  Hand rails--needs and purposes  Stop belt--Stop exercise  Additional directions for the novice like???
  8. 8. MORE  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%)
  9. 9. PROTOCOLS  Based on purpose of test, desired outcomes and the individual  Bruce, Ellestad--larger incremental changes- for 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
  10. 10. PROTOCOLS  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
  11. 11. TESTING FOR RETURN TO WORK POST INSULT  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
  12. 12. SPECIALIZED TESTS  Weight carrying tests-evaluates tolerance for dynamic and static lifting  Repetitive lifting--evaluates tolerance to bouts of lifting
  13. 13. MEASURES DURING TESTS  Pretest--ECG, HR, BP, RPE--supine, sitting, standing  Exercise--3-lead ECG every min., 12- lead 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
  14. 14. MEASURING EXPIRED GASES  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
  15. 15. ECG MONITORING  Quality of ECG very important  Skin prep is essential  shave  alcohol  abrasion  Electrode placement in supine position  10 electrodes for 12 lead
  16. 16. SUBJECTIVE RATINGS  RPE- 0-10 or 6-20 scale  Note instructions on p. 105-6  Symptomatic scales are different  rating for angina  rating for leg pain  rating for dyspnea
  17. 17. POST EXERCISE PERIOD  Healthy individuals do an active and passive recovery  Symptomatic individuals may require supine recovery  Test termination based on absolute or relative indications
  18. 18. EXERCISE TESTING WITH IMAGING  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  identifies wall abnormalities for ischemia
  19. 19. Nuclear Imaging  -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
  20. 20. PHARMACOLOGIC TESTING  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
  21. 21. CONSIDERATIONS FOR PULMONARY PATIENT  Degree of dyspnea  Cause of dyspnea  Distinguish between cardiac or pulmonary limitations  Deconditioning factors such as obesity, anxiety  Exercise induced oxygen desaturation
  22. 22. TESTING SUPERVISION  Physician supervision  Physician in the immediate vicinity  Paramedical personnel  Expertise versus physician presence  Implications for Costs

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