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

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 exercise will determine test necessity

Geared toward individuals with a higher probability of disease

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

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

FUNCTIONAL TESTING

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

Treadmill--yields the highest VO2 and HR

Hand rails--needs and purposes Stop belt--Stop exercise Additional directions for the novice

like???

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%)

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

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

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

SPECIALIZED TESTS

Weight carrying tests-evaluates tolerance for dynamic and static lifting

Repetitive lifting--evaluates tolerance to bouts of lifting

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

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

ECG MONITORING

Quality of ECG very important Skin prep is essential

shave alcohol abrasion

Electrode placement in supine position

10 electrodes for 12 lead

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

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

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

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

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

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

TESTING SUPERVISION

Physician supervision Physician in the immediate vicinity Paramedical personnel Expertise versus physician

presence Implications for Costs