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Exercise Testing & Prescription including ECG Part A.

Exercise Testing & Prescription including ECG Part A. Natalia Fernandez, PT, MS, MSc, CCS University of Michigan Health Care System Department of Physical Medicine and Rehabilitation. Objectives. Exercise Testing Choosing a Test (Indications & Contraindications)

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Exercise Testing & Prescription including ECG Part A.

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  1. Exercise Testing & Prescriptionincluding ECG Part A. Natalia Fernandez, PT, MS, MSc, CCS University of Michigan Health Care System Department of Physical Medicine and Rehabilitation.

  2. Objectives • Exercise Testing • Choosing a Test (Indications & Contraindications) • Administering a Test including 12 lead ECG during maximal graded exercise testing • Interpreting the Test Results • Why? outcome measure, baseline, determine limits • Exercise Prescription • Developing the Exercise Prescription • Training Progression • Re-evaluations

  3. Why Exercise Test • Determine the safety of exercise • Develop Exercise Guidelines • Monitor Progress • Promote Patient Education/Motivation • Research on treatment/training interventions

  4. Risks of Exercise Testing • Exercise Testing is Relatively Safe 170,000 GXT at 73 medical centers • mortality rate 0.01% per 10,000 • morbidity rate 0.03% per 10,000 • Rochmis et al JAMA 1971 518,448 GXT at 1375 medical centers • mortality rate 0.0005% per 10,000 • morbidity rate 0.09% per 10,000 • Stuart & EllestadChest 1980 • 6 per 10,000 tests

  5. Risks during Cardiac Rehabilitation • In Cardiac Rehab • Risks extremely low for supervised moderate activity • Home & Clinic risk is equal • Exception: Vigorous Exercise • 100 x risk of healthy population

  6. Minimizing Risks • Pre-participation Screening/Health Risk Appraisal • Identify individuals at risk for adverse events from exercise • Exacerbation of conditions: • Cardiovascular, Pulmonary, Metabolic Diseases • ↑ Risk Factors requiring medical consult • Require supervised exercise • Special needs

  7. Risk Factors

  8. Risk Factors

  9. Risk Factors

  10. Risk Factors

  11. Risk Factors

  12. Minimizing Risks • Assessment • Determine who requires medical clearance, exercise testing, physician supervised testing • ACSM Algorithm • AHA/ACSM Questionnaire • PAR-Q • AACVPR & AHA Risk Stratification

  13. Screening • Risk Factors • Low • Younger asymptomatic • With 1 or less risk factors • Moderate • Older or 2 + risk factors • High • 1+ signs/symptoms or known disease

  14. Screening • Major Signs & Symptoms • Anginal Pain • SOB • Dizziness or Syncope • Orthopnea or Nocturnal Dyspnea • Intermittent Claudication • Known heart murmur • Unusual fatigue/SOB /w activity

  15. Screening

  16. Minimizing Risks • Pre-Exercise Evaluations (con’t) • Physical Examination Box (3-2) • Body Comp • Pulse rate and rhythm & Peripheral pulses • BP; seated, supine & Standing • Heart & Lung Auscultation • Abdominal Evaluation • Orthopedic/Neurological Function • Skin & Lower Extremities

  17. Minimizing Risks • Pre-Exercise Evaluations (con’t) • Laboratory Analysis (3-2) • Lipid Profiles • Glucose • Thyroid Function • Other (High Risk or known disease) • Holter Monitor, ECG, angiography, Chest Radiograph, Ultrasound, PFT

  18. Minimizing Risks

  19. Contraindications to Testing • Absolute Contraindications • Recent significant ECG Change • Unstable Angina • Uncontrolled Arrythmias • Severe Aortic Stenosis • Uncontrolled Heart Failure • PE or PI, Acute Myocarditis or pericarditis • Dissecting aneurysm • Acute Infections • ACSM Ch. 3 p.50

  20. Contraindications to Testing • Relative Contraindications • Left main coronary stenosis • Moderate stenotic valve disease • Electrolyte imbalance • Severe HTN (200/110) • Tachy-arrhythmias or brady-arrythmias • Cardiomyopathy

  21. Contraindications to Testing • Other Relative Contraindications • Neuro/Ortho disorders • High Degree AV Block • Ventricular aneurysm • Uncontrolled metabolic disease • Chronic infectious disease

  22. Minimizing Risks • Signed/Informed Consent (Fig 3-1) • Be of lawful age • Not be mentally incapacitated • Know and comprehend risks • Give voluntary consent • Ambient Environment • Temperature/humidity 70-75 degrees F • Organization, safety, privacy

  23. Patient Pretest Instructions • Wear comfortable shoes & clothing • Drink plenty of water (See Fluid Guide Pyramid, Gatorade, Inc.) • Avoid food, tobacco, alcohol & Caffeine 4 hrs prior to testing (or overnight) • Avoid strenuous exercise the day of the test • Get adequate sleep prior to the test

  24. General Principles of exercise Testing

  25. Minimizing Risks • Monitoring HR and Rhythm [HR monitor or ECG], BP, RPE, SAO2 if h/o hypoxia (e.g. pulmonary disease, CHF, Renal Failure, etc.) • Before, during and after • Know in advance when to Stop the Test • Be Prepared for an Emergency

  26. RPE Scale

  27. Choose the Exercise Tests • Acute Care (Functional Assessment) • Field Tests • Submaximal Exercise Tests • Symptom Limited GXT • Maximal GXT • Oxygen Analysis Tests • Noonan & Dean • ACSM

  28. Submaximal Vs Maximal Tests • Method • Choose appropriate test protocol • Bike test; treadmill test. Functional assessment • Determine HR response to workloads • Predict VO2 with equations or graphs

  29. Functional Assessment

  30. Exercise Guidelines From R.S. Sayre and B.C. Marcoux, 1992, L. Pfalzer 1988, Winningham, 1986

  31. Clinical Exercise Testing • Laboratory Testing Protocols (Fig 5-3) • Screening/Diagnostic/Research • Choose test protocol for individual • Lasts ~ 9-12 minutes • Types • SLGXT • Submaximal • Maximal

  32. Submaximal Vs Maximal Tests • Accuracy • Prediction Equations • Assumptions • Steady State HR achieved & measured • HR increases linearly with workload • HR & BMR are uniform for age/gender • Mechanical Efficiency • Submax is for functional interventions, to get target for EX percription. • Maximal if for cardiac assessment.

  33. Exercise Prescriptions Training HR Rate Range-Methods • Age Adjusted Predicted Training Heart Rate Range [220- age] x (.50 to .70) • HRR – Heart Rate Reserve/Karvonen Method HR threshold = HR rest + 0.60 (HR max - HR rest)

  34. Submaximal Tests • Astrand Bicycle Test • 6 minute test • Wattage: conditioning & gender • Nomogram • Correction Factor

  35. Submaximal Tests • YMCA Bicycle Test • Start at 150 kg/m & 50 rpm • Assess HR & determine next stage • Use plot/graph to estimate max HR

  36. Field Tests • Walking/Running Tests • Step Testing

  37. Field Tests • Walking/Running Tests • 6 min & 12 min walk tests • Rockport 1.0 Mile Test • Cooper 12 minute & 1.5 mile Walk Tests • Disadvantages • Maximal tests & Little monitoring • Assumes same mechanical efficiency • Assumes similar Resting HR & HR response, BMR

  38. Field Tests • 6 min & 12 min walk tests • Descriptive: Max distance • Rockport 1.0 Mile • VO2 max incorporates age, gender, mass, time & HR • Cooper 12 minute & 1.5 mile Walk Tests • VO2 max = 3.5 + 483/ time in minutes

  39. Field Tests • Step Tests • Benefits • Used to assess large groups of subject • Disadvantages • Assesses Fitness Categories • Similar Assumptions to other predictive equations

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