Exercise testing involves measuring an individual's physiological response to exercise in order to evaluate cardiovascular and respiratory function. There are maximal and submaximal tests, with maximal tests directly measuring VO2 max and submaximal tests estimating functional capacity. The Bruce protocol is a common maximal treadmill test that progressively increases speed and incline over stages. The six-minute walk test is a submaximal test measuring distance walked over six minutes to assess functional exercise ability.

1. © 2009 McGraw-Hill Higher Education.All rights reserved.
Exercise Testing
By,
Dr. Sonia Bhatia
1

2. Objectives
Definition
Need for exercise testing
VO2 maximum
Exercise Physiology
Types of exercise testing
Bruce Protocol
Shuttle walk test
6 minute walk test
Summary
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2

3. Exercise Testing
Exercise testing is a non invasive
procedure that provides diagnostic and
prognostic information and evaluates an
individual’s capacity for dynamic exercises
3
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4. Why do we need to do exercise testing
??
 Exercise is a common physiological stress that
can elicit cardiovascular and respiratory
abnormalities which are not present at rest and it
can be used to determine the adequacy of cardiac
and pulmonary function
 Both the systems are adequately stressed out
during the exercise
4
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5. Body’s Response to Exercise
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 During exercise, multiple cardiovascular,
respiratory and metabolic changes occur.
include-
Increase in Heart Rate
Increase in Systolic Blood Pressure
These
Diastolic Blood pressure either remains same or
declines slightly
Increase in respiratory rate
 All these responses are an attempt to meet the
increased oxygen demand during exercise
5

6. VO2 max
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 It is also called as maximum O2 consumption ,
max O2 uptake , peak O2 uptake or aerobic
capacity
 Definition :
It is the maximum capacity of an individual’s
body to transport and use oxygen during
incremental exercise ,which reflects the physical
fitness of the individual
 It is expressed as-
VO2 max = ……. Litre of O2 / min
= 1
…
/9/201
…
4
. ml of O2 / kg body wt /min 6

7. 7
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8.  To measure the VO2 max , individual is involved in
physical effort sufficient in duration and intensity to
fully tax the aerobic energy system
 VO2 max is reached when O2 consumption
remains at steady state despite an increase in the
workload
8
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9. Types of exercise testing
 Maximal exercise testing
 Submaximal exercise testing
9
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10. Maximal exercise testing
 Maximal exercises means an individual works
upto maximum effort of his work capacity
 They are further divided into-
 Field tests
 Laboratory test
 These tests predict or directly measure VO2
max
Cooper 12 min test
Shuttle Walk test Field test
Stepping tests
10
Treadmill tests Laboratory test
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11. Treadmill Tests
11
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 Treadmill Tests involve making the patient walk on
a treadmill in accordance to set protocols that
stress the individual to their maximal exercise
capacity.
 These tests are highly sensitive for clinical
diagnosis of CAD
 The HR and rhythm, BP response, RR and rate of
percived exertion are closely monitored before,
during and after the tests to determine abnormality

12.  The most common treadmill test protocol
used are –
BRUCE PROTOCOL
BALKE PROTOCOL
12
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13. Bruce Protocol
13
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 The Bruce treadmill test protocol was designed in
by Robert .A. Bruce in 1963
 It is a non-invasive test to assess patients
suspected with heart disease.
 It is also a common method to indirectly estimate
VO2 Max in athletes.
 In this protocol, the individual walks on the treadmill
uptill complete exhaustion as the treadmill speed
and inclination increases every 3 minutes

14. Stage Speed Grade
%
Duration MET
s
Modified Full
1 1.7 0 3 1.7
2 1.7 5 3 2.9
3 1 1.7 10 3 4.7
4 2 2.5 12 3 7.1
5 3 3.4 14 3 10.2
6 4 4.2 16 3 13.5
7 5 5.0 18 3 17.3
8 6 5.5 20 3 24.6
9 7
1/9/2014
6.0 22 Dr.Nidhi
3
Ahya
28.4 14
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15.  Assessment Variables:
 Hemodynamics
– Heart Rate
– Systolic/ Diastolic Blood Pressure Responses
 ECG Waveforms
 RPE
 Limiting Clinical Signs & Symptoms
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15

16. Variable Before Exercise
Test
During the Test After Exercise
Test
ECG Monitored
continuously;
recorded in
supine and
exercise posture
Last 15 sec of
each stage
Last 15 sec of
each 2 min time
period
Immediately post
exercise, last 15
sec of first min
of recovery, then
every 2 mins
HR During last 5 sec
of each min
During last 5 sec
of each min
BP Last 45 sec of
each stage
Last 45 sec of
each 2 min time
period
Immediately post
exercise, every 2
mins thereafter
SIGNS/
SYMPTOMS Recorded as observed
RPE Scale explained Last 5 sec of
each min
Peak exercise
value obtained 16
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17. Rate of Perceived
Exertion(RPE)
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15 –Grade Borg scale for RPE
6 No exertion at all
7 Extremely light
8
9 Very light
10
11
12
13 Somewhat hard
14
15 Hard (heavy)
16
17 Very hard
18
19 Extremely
Dr.N
20
idhi Ahya 17

18. Subjective Ratings & Symptoms
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 Angina
1.Mild, barely noticeable
2.Moderate bothersome
3.Moderately severe, very uncomfortable
4.Most severe or intense pain ever experienced
 Dyspnea
1.Light barely noticeable
2.Moderate bothersome
3.Moderately severe
4.Very uncomfort
1a
/9/2
b
01l4e 18

19.  Claudication
1.Definite discomfort or pain but only at the initial or
modest levels
2.Moderate discomfort or pain from which the patients
attention can be diverted
3.Intense pain from which patients attention cannot be
diverted
19
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20. Indications for Termination
20
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 Drop in systolic blood pressure of > 10 mm Hg
from baseline, despite increase in workload
 Moderately severe angina ( 3 on scale)
 Increasing nervous system symptoms
 Signs of poor perfusion
 Subject desires to stop
 Sustained ventricular tachycardia
 ST elevation ( +10mm) in leads without
diagnostic Q-waves

21. Interpretation
21
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Exercise tests are interpreted as either-
Positive: (+) ETT indicates that there is a point
at which the myocardial oxygen supply is
inadequate to meet myocardial oxygen demand
Negative:(-) ETT indicates that at every tested
physiological workload, there is balanced oxygen
supply and demand

22. Submaximal test
22
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Submaximal exercises means an individual
works below maximum effort of his work
capacity
 Self- paced walking test
 Modified shuttle walking test
 Bag and carry test
 Timed up and go test
 6 Minute walk test

23. Modified Shuttle walk test
23
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 The shuttle walk test is an adaptation of 20 meter
shuttle running test
 The 20-mt shuttle running test (20-MST) assesses
maximal aerobic power
 The test required subjects to run between 2 lines
spaced 20 m apart at a pace set by signals on
a prerecorded cassette tape
 Starting speed is 8.5 km and the frequency of the
signals was increased by 0.5 km each minute.

24.  This test was designed for athletes participating in
sports requiring constant stopping and starting
 It was too streneous for many patients, which
resulted in the development of a 10 meter ,12 level
shuttle walking test in adults with COPD. This was
called as ‘Shuttle walk test’
 Somehow in some patient groups the test was felt
to be too easy, so modified shuttle walk test was
devised in which three additional levels were
added. Thus it now has15 levels
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24

25. Indications:
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 Before and After Treatment Comparisons
 Lung transplantation or lung resection
 Pulmonary rehabilitation
 Pulmonary hypertension
 Heart failure
 To Measure Functional Status
 Chronic obstructive pulmonary disease
 Cystic fibrosis
 Peripheral vascular disease
 In elderly patie
1/9
n
/20t
14
s 25

26. Contraindications:
Absolute
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 Acute myocardial infarction (3–5 days)
 Unstable angina
 Uncontrolled arrhythmias causing symptoms or
hemodynamic compromise
 Syncope
 Acute myocarditis
 Pericarditis
 Symptomatic severe aortic stenosis 26

27. Relative
27
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 Moderate stenotic valvular heart disease
 Severe untreated arterial hypertension at rest
( 200 mm Hg systolic, 120 mm Hg diastolic)
 High-degree atrioventricular block
 Hypertrophic cardiomyopathy
 Significant pulmonary hypertension
 Advanced or complicated pregnancy
 Orthopedic impairment

28. © 2009 Ms
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Eduicn
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. Alr
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ghta
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erved.
Procedure
 Treatment area that is at least 12 meters in length
and a tape player
 The standard instructions are given on the
audiocassette tape.
 Subjects are required to walk back and forth, turning
around two cones placed 9 meters apart making the
shuttle distance 10 meters long
 The subject must keep pace with the prerecorded
auditory signal such that they complete a turn as
each sound beeps
 Every minute the audio signal sounds at increasingly
28

29.  One beep indicates the length of one shuttle and
three beeps indicates an increase in speed
 There are 12 levels of speed beginning at 0.50 m/s
and ending at 2.37m/s.
 The test is measured in meters and no
encouragement is provided
 If the patient chooses to stop or fails to keep up to
auditory signals after one warning the test will end
 The test will also terminate if patient reaches 85% of
their maximal heart rate
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29

30. Protocol
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Levels Shuttles / level Speed (mph) Speed ( m/s )
1 3 1.12 0.50
2 4 1.50 0.67
3 5 1.88 0.84
4 6 2.26 1.01
5 7 2.64 1.18
6 8 3.02 1.35
7 9 3.40 1.52
8 10 3.78 1.69
9 11 4.16 1.86
10 12 4.54 2.03
11 13 4.92 2.20
12 14 5.30 2.37
30

31. 6 minute walk test
31
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 The 12-MWT was introduced by McGavin and
colleagues to assess the distance covered in 12
minutes in individuals with Chronic Bronchitis
 This test was modified from the 12-MRT described
by Copper for individuals without health problems
 Butland et al reported that similar results could be
obtained in 6 minutes
 Guyatt et al applied the 6-MWT in individuals with
heart failure

32. Indications
32
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A) Pre - Post – treatment comparisions
 Lung transplantation
 Lung volume reduction surgery
 Pulmonary rehabilitation
 COPD
 Pulmonary hypertension
 Heart failure

33. B) Functional status
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 COPD
 Cystic fibrosis
 Heart failure
 Peripheral vascular diseases
 Older patients
C) Predictor of morbidity and mortality
 Heart failure
 COPD
 Primary pulmonary hypertension 33

34. Contraindications
34
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 Absolute Contraindications
unstable angina and myocardial infarction during
the previous month
 Relative Contraindications
Resting heart rate of more than 120 beats/min
Systolic blood pressure of more than 180 mm Hg
 Diastolic blood pressure of more than 100 mmHg

35. Required Equipments
35
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 Countdown timer (or stopwatch)
 Two small cones to mark the turnaround points
 A chair that can be easily moved along the
walking course
 Worksheets on a clipboard
 A source of oxygen
 Sphygmomanometer
 Telephone
 Automated electronic defibrillator

36. Patient Preparation
36
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 Comfortable clothing should be worn.
 Appropriate shoes for walking should be worn.
 Patients should use their usual walking aids during
the test (cane, walker, etc.).
 The patient's usual medical regimen should be
continued.
 A light meal is acceptable before early morning or
early afternoon tests.
 Patients should not have exercised vigorously
within 2 hours of beginning the test.

37.  The patient should sit at rest in a chair, located near
the starting position, for at least 10 minutes before
the test starts
 During this time, check for contraindications,
measure pulse and blood pressure, and make sure
that clothing and shoes are appropriate
 Have the patient stand and rate their baseline
dyspnea and overall fatigue using the Borg scale
 Set the lap counter to zero and the timer to 6
minutes. Assemble all necessary equipment
37
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38. Termination of test
38
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 Patients vitals are taken immediately after the
test and then at the end of 2 minutes,5 minutes or
till return to baseline
 Count the number of laps on the worksheet and
calculate the distance covered by the patient
 Refer to worksheet for details

39. Summary
Definition
exercise testing
VO2 maximum
Exercise Physiology
Types of exercise testing
Bruce Protocol
Shuttle walk test
6 minute walk test
39
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40. THANK YOU…..
40
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