This document discusses methods for assessing cardiorespiratory endurance through measurement of maximal oxygen uptake (VO2 max). It describes both submaximal and maximal exercise testing protocols using equipment like bikes, treadmills, and step tests to determine VO2 max either directly through gas analysis or indirectly through heart rate monitoring. Key indicators for assessing cardiorespiratory fitness include VO2 max, respiratory exchange ratio, workload, and heart rate response to exercise.

1. Assessing Cardiorespiratory Endurance A Fitness Indicator

2. Determination of Fitness Level Everyone possesses some degree of cardiorespiratory endurance (CRE) CRE=a health associated component that relates to the ability of circulatory and respiratory systems to supply fuel during sustained physical activity and to eliminate fatigue products after supplying fuel.

3. VO 2 max VO 2 max is the most commonly used index to assess CRE Definition - The largest amount of oxygen that an individual can utilize during strenuous exercise to complete exhaustion Has become the accepted measure of CRE

4. AEROBIC GLYCOLYSIS AND THE ELECTRON TRANSPORT CHAIN

5. KREBS CYCLE

6. METABOLISM OF FAT

7. OXIDATIVE PHOSPHORYLATION

8. VO 2 max Units liters/minute or ml/minute (absolute) ml/kg/min (relative to body weight) ml/kg of FFM/min (relative to FFM) Range 15 (sedentary with disease) to 75 (young endurance runner) ml/kg/min Women about 10-20% lower than men

9. Methods of Determining VO 2 max Submaximally Maximally

10. GXT Graded Exercise Testing - GXT (incremental increases in workload) General Guidelines measure the subject’s HR and BP and RPE at regular intervals (near the end of each stage [HR, BP, RPE] or every minute [HR]) if HR does not reach steady state during the stage extend stage 1 minute

11. GXT General Guidelines All testing begins with a 2-3 min warm-up Cool- down at a low intensity for at least 4 minutes - continue measuring HR, BP and RPE increase intensity in .5-2 MET increments closely observe subject for contraindications

12. Submaximal Assumptions 1. A steady-state HR is obtained for each exercise work rate 2. A maximal HR for a given age is uniform (220-age)

13. Assumptions 3. Mechanical efficiency (ie. VO 2 at a given work rate) is the same for everyone. This may not be true and it has been suggested that submaximal exercise testing underestimates VO 2max in the untrained and overestimates in the trained

14. Submaximal Assumptions 4. There is a linear relationship between HR and Workload 5. HR will vary depending on fitness level between subjects at any given workload

15. Age vs. HR

16. Submaximal Protocols Oxygen consumption for any given WL does not vary between subjects The slope of the line is about the same for any two given subjects The rate of increase in O2 consumption with increasing WL does not vary between subjects

17. EXERCISE INTENSITY AND OXYGEN UPTAKE

18. Submax Protocols HR does vary between subjects rate of increase in HR depends on fitness level The more fit you are the lower your HR at any given WL An untrained person will reach their HR max at a lower WL vs. a trained person of the same age.

19. HEART RATE AND INTENSITY

20. HEART RATE AND TRAINING

21. HR vs. Workload

22. HEART RATE, VO 2 , AND INCREASING WORK .

23. HR vs. WL and VO 2

24. Submaximal Protocols 1. YMCA - bike 2. Astrand Rhyming – bike 3. ACSM - bike 4. Bruce Protocol - treadmill 5. McCardles Step Test

25. YMCA Multi-stage protocol 3-4 consecutive 3 minute stages HR between 110-150 bpm (the HR range at which the relationship between VO 2 and WL is most linear)

26. YMCA Procedures 1. Adjust seat height (legs nearly straight when extended - 5º bend) 2. Measure pre-exercise BP and HR with subject seated on bike 3. Pedal at 50 rpm (if using a metronome - 100x/minute) 4. Warm-up, zero resistance for 2-3 minute

27. YMCA Protocol 5. Stage 1 .5 kp for 3 minutes at every stage measure BP at 2.0 min (more often if hypertensive) at every stage measure HR during last half of minutes 2 and 3 if HR at 2 and 3 minutes differ by more than 6 bpm extend the stage for 1 min

28. YMCA Protocol 6. Stage 2 Workload in this stage and successive stages depends on HR during stage 1 (p 75 guidelines) 7. Continue test until HR recorded at two successive WL are between 110 and 150 bpm (for many this occurs during 2nd and 3rd WL)

29. YMCA Protocol 8. Note that if HR is greater than 110 at end of 1st stage then only one more stage is necessary 9. At completion of test reduce resistance to .5kp and allow subject to pedal for at least 4 minutes or until HR falls below 100 bpm and BP stabilizes.

30. YMCA Protocol 10. The HR measured during the last minute of each stage is plotted against workload. 11. The line generated from the plotted points is extrapolated to the age-predicted HR max 12. A perpendicular line is dropped to the x-axis to estimate the work rate this person would achieve if taken to max.

32. ACSM Bike Test 1. 2-3 minute warm-up 2. Take HR twice during each stage (3 minute stages) and RPE/BP once (similar to YMCA) 3. If HRs are greater than 110, steady state should be reached (HRs within 6bpm) before increasing the workload

33. ACSM Protocol A B C (kgm/min) Stage 1 150 150 300 Stage 2 300 300 600 Stage 3 450 600 900 Stage 4 600 900 1200

34. ACSM Protocol Selection BW Very Active (kg) No Yes <73 A A 74-90 A B >91 B C *very active is defined as aerobic exercise 20 minutes, 3 days/week

35. ACSM 5. Terminate test when HR reaches 85% of age-predicted max HR or 70% of HR reserve 6. Recovery at workload equal to the 1 st stage or less for at least 4 minutes with HR, BP, and RPE monitored.

36. ACSM Plot HRs from last two stages to determine VO2max much like YMCA.

37. Astrand Rhyming Single-stage test (VO2 max is determined using 1 submaximal data point-HR) Duration of test is 6 minutes

38. Astrand Rhyming 1. Adjust seat height (legs nearly straight when extended - 5º bend) 2. Measure pre-exercise BP and HR with subject seated on bike 3. Pedal at 50 rpm (if using a metronome - 100x/minute) 4. Warm-up, zero resistance for 2-3 minute

39. Astrand Rhyming 5. Pedal rate is 50 rpm 6. Determine Workload unconditioned males - 300 or 600 kgm/min conditioned males - 600 or 900 kgm/min unconditioned females - 300-450 kgm/min conditioned females - 450 or 600 kgm/min 7. 6 minute test

40. Astrand Rhyming 8. At end of 2nd minute of pedaling take HR (BP at 1.25-1.5 min) want the HR to be between 125-170bpm if less than 125 increase resistance by 1 kp for men and 1/2 kp for women if greater than 170 bpm decrease resistance by 1 kp continue to monitor HR every minute until HR exceeds 125

41. Astrand Rhyming 9. At the end of the 5th and 6th minute take HR and average the two values (make sure values are within + 6bpm to assure a steady state HR was obtained) 10. BP at 4:30 and 5:30 11. Reduce resistance and cool-down for 4 minutes.

42. Astrand Rhyming 10. Determine VO 2 from nomogram (p. 73 guidelines, p.69 Heyward) 11. Age-correction factor (p. 74 guidelines, p.72 heyward) 12. Convert to relative value

43. Treadmill Tests Bruce Protocol Balke Ellestad Others……….

44. Treadmill Protocols Bruce and Ellestad larger increments use on younger and/or more physically active Balke-Ware smaller increments (1MET/stage or lower) use on older, deconditioned, and/or diseased subjects

45. Treadmill Protocol Single-stage (using one data point) even though we may have more than one stage May need to have a long accustomization period and explanation of procedures before beginning

46. Bruce Treadmill Protocol 1. Measure resting BP and HR while standing on the belt of the treadmill 2. Ask subject to straddle the belt while starting treadmill at 1.7 mph and 0% grade 3. Ask subject to begin walking and when comfortable release handrails 4. This is a warm-up and should continue until subject is comfortable

47. Bruce Treadmill Protocol 5. Stage 1 Increase grade to 10% 3 minutes long Measure HR at end of each minute and BP at end of each stage

48. Bruce Treadmill Protocol 6. The objective is to reach a steady state HR between 115 and 155 bpm (usually occurs during the first 6 minutes of exercise or by the end of the 2nd stage) – Page 98 guidelines 7. Once subject reaches proper HR terminate the test at the end of that stage

49. Bruce Treadmill Protocol 8. Reduce treadmill speed to 1.7mph and 5% grade and cool-down for 4 minutes. 9. VO2 is estimated from the last minute of a fully completed stage

50. Treadmill Protocol 10. Calculate VO 2 from the gender specific equations Males VO 2 =SM VO2 [(HR max -61)/(HR SM -61)] Females VO 2 =SM VO2 [(HR max -72)/(HR SM -72)] SM VO2 = submaximal VO 2 from table or ACSM equations HR SM = submax HR from test

51. Modified Bruce Protocol Start at 1.7 mph, 0% grade or at 1.7 mph and 5% grade (used on diseased and elderly populations)

52. Treadmill Protocol Protocols should be individualized Test time should ideally be 8-12min Increments of 10-15 W/min or 1-3%/min grade can be used for the elderly

53. McCardle’s Step Test Bench ht. = 41.25 cm Step Rate = 24 step/min (metronome = 96) for men and 22 step/min (metronome=88) for women 3 minutes of stepping Record HR from the first 15seconds after the stepping has stopped

54. McCardle Men VO 2 = 111.33 - (0.42 x HRrec) Women VO 2 = 65.81 - (0.1847 x HRrec) value is ml/kg/min

55. Maximal Testing Assumption: The subject was highly motivated and gave a maximal effort.

56. Max Testing Laboratory Tests 1. Open Circuit Indirect Calorimetry 2. Cycle 3. Treadmill (Bruce)

57. Maximal Protocols Field Tests 4. 12 minute run 5. 1.5 mile run 6. Rockport Walking Test

58. Measuring Energy Costs of Exercise Direct calorimetry —measures the body's heat production to calculate energy expenditure. Indirect calorimetry —calculates energy expenditure from the respiratory exchange ratio (RER) of CO 2 and O 2 .

59. A CALORIMETRIC CHAMBER

60. Open Circuit Indirect Calorimetry (Gas Analysis)

61. Respiratory Exchange Ratio The ratio between CO 2 released (VCO 2 ) and oxygen consumed (VO 2 ) RER = VCO 2 /VO 2 The RER value at rest is usually 0.78 to 0.80

62. RER Value ranges from .7-1.0 0.7 mainly uses fats as an energy source 1.0 mainly uses carbohydrates as an energy source Can exceed 1.0 during heavy non-steady state, maximal exercise, or when nervous due to hyperventilation (increased CO2)

63. KCALS (RER + 4) x (Liters of O 2 consumed per minute) = kcal/minute For example: RER determined from gas analysis = .75 4 + .75 = 4.75 L of O 2 per minute = 3 liters 4.75 x 3 = 14.25 kcal/min If exercised for 30 minutes = 427.5 kcals

64. Cycle to Max 15 W/min protocol VO 2males =10.51 (power in W) + 6.35 (BW in kg) - 10.49 (age in y) + 519.3 VO 2females =9.39 (power in W) + 7.7 (BW in kg) - 5.88 (age in y) + 136.7 values are in ml/min - divide by BW in kg

65. Treadmill to Max (Bruce) VO 2 = 14.8 - 1.379 (time in min) + 0.451 (time 2 ) - 0.012 (time 3 ) While holding handrail VO 2 = 2.282 (time in min) + 8.545

66. Population-specific Equations P. 61 Heyward Active vs. Sedentary, Gender specific, Cardiac patients

67. 12 minute run

68. 12 minute run The further you can run in 12 minutes the higher your VO 2max

69. 1.5 mile run/Rockport Walking

70. 1.5 Mile Run/1 Mile Walk The faster you can run 1.5 miles or walk 1 mile the higher your VO 2max

71. Field Tests 12 min run VO 2 = 3.126 (meters in 12 min) - 11.3 1.5 mile run VO 2 = 3.5 + 483/(time in minutes) Rockport Walking Test (1 mile walk) VO 2 = 132.853 - 0.1692 (BW in kg) - 0.3877 (age in y) + 6.315 (gender) - 3.2649 (time in min) - 0.1565 (HR) 0 for female; 1 for male; HR at end of walk

72. Normal Responses to GXT 1. Systolic BP increases in direct proportion to increasing WL 2. HR increases linearly with WL 3. Diastolic BP changes very little 4. Shortened QT Interval 5. Reduced R-wave amplitude 6. Positive upslope of ST segment

73. Abnormal responses to GXT 1. ST segment depression 2. Increased R-wave amplitude 3. V-tach 4. Multiform PVC’s 5. Failure of HR to rise with WL 6. Failure of systolic to rise 7. Systolic and diastolic greater than 250 or 120

74. Test Termination 1. Have reached a pre-determined endpoint Absolute 1. Suspicion of myocardial infarction 2. Moderate to severe angina 3. Drop in Systolic BP with increasing Workload (>20)

75. Absolute 4. Arrhythmias 5. Pale or cold and clammy skin 6. Severe shortness of breath 7. Dizzy, blurred vision, or confusion 8. Patient requests stop 9. V-tach or multiform PVC’s 10. ST segment depression

76. Absolute 11. Excessive rise in BP (systolic >250; diastolic >120) 12. Failure of HR to increase

77. Relative 1. ECG changes from baseline 2. Chest pain that is increasing 3. Wheezing 4. Leg cramps 5. High Systolic/Diastolic 6. Less serious arrhythmias 7. Less severe shortness of breath

78. Advantages of Submaximal Testing 1. Safer 2. Controlled pace (motivation not a factor) 3. Not population specific (no pacing advantage) 4. Quick assessment 5. Cost effective

79. Advantages of Submaximal Testing 6. Don’t need highly trained personnel 7. Can do mass testing 8. No physician supervision required (if symptom and disease free)

80. Disadvantages of Submaximal Testing 1. VO 2 max is not directly measured (error rate of 10-20%) 2. Don’t get a measure of true maximal HR estimates of max HR using 220-age can vary by + 15 bpm for individuals of the same age

81. Advantages and Disadvantages of a Maximal Test Advantages 1. More accurate Disadvantages 1. Motivation is a factor 2. More risk involved 3. Time 4. Cost of equipment (if using metabolic cart)

82. Walking/Running vs. Cycling/Stepping Walking/Running are the most natural forms of locomotion (most Americans are unaccustomed to cycling In general, subjects reach higher VO2max values during treadmill tests Treadmill are more expensive than cycles Treadmill is less portable

83. Walking/Running vs. Cycling/Stepping Body weight has a much smaller effect on cycle ergometry versus treadmills Treadmill more dangerous (greater risk of a fall Measurement of HR is more difficult on a treadmill and while stepping