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FUNDAMENTALS OF EXERCISE TESTING
 FUNDAMENTALS OF
EXERCISE TESTING
K. LANGE ANDERSEN, M.D.
Project Leader, International Biological Programme,
Norwegian National Committee, Oslo, Norway

R. J. SHEPHARD, M.D., Ph.D.

Professor of Applied Physiology, School (jf Hygiene,
University of Toronto, Ontario, Canada

H. DENOLIN, M.D.
Pr(jfessor and Head, Department of Cardiology, Hopital Universitaire Saint-Pierre,
Brussels, Belgium

E. VARNA USKAS, M.D.

Professor of Medicine, Department of Cardiology, University Hospital,
Leiden, Netherlands

R. MASIRONI, Ph.D.
Scientist, Cardiovascular Diseases, World Health Organization,
Geneva, Switzerland

in collaboration with
F. H. BONJER, M.D.
J. RUTENFRANZ, M.D., Ph.D.
Head, Department of Occupational
Professor and Head,
Medicine, Netherlands Institute for
Department of Occupational Medicine,
Preventive Medicine, Leiden, Netherlands
Justus Liebig University, Giessen,
Federal Republic of Germany
Z. FEJFAR, M.D.
Chief, Cardiovascular Diseases,
World Health Organization,
Geneva, Switzerland

WORLD HEALTH ORGANIZATION

GENEVA
1971
 © World Health Organization 1971
Publications of the World Health Organization enjoy copyright protection in accord-
ance with the provisions of protocol 2 of the Universal Copyright Convention. Never-
theless governmental agencies or learned and professional societies may reproduce data
or excerpts or illustrations from them without requesting an authorization from the
World Health Organization.
For rights of reproduction or translation of WHO publications in toto, application
should be made to the Office of Publications and Translation, World Health Organization,
Geneva, Switzerland. The World Health Organization welcomes such applications.
The designations employed and the presentation of the material in this publication
do not imply the expression of any opinion whatsoever on the part of the Director-
General of the World Health Organization concerning the legal status of any country
or territory or of its authorities, or concerning the delimitation of its frontiers.
Authors alone are responsible for the views expressed in this publication.
The mention of specific companies or of certain manufacturers' products does not
imply that they are endorsed or recommended by the World Health Organization in
preference to others of a similar nature which are not mentioned. Errors and omissions
excepted, the names of proprietary products are distinguished by initial capital letters.
PRINTED IN BELGIUM
 CONTENTS

Page
Preface . . . . . . . . . . . . . . . . . . .
7
Chapter 1. Fundamentals of exercise physiology
9
Chapter 2. Types of exercise test
27
Chapter 3. Types of ergometer
31
Chapter 4. Safety precautions
Chapter 5. 42
Environmental specifications and preparation for testing
Chapter 6. 47
Proposed clinical procedures for submaximum exercise
tests . . . . . . . . . . . . . . . . . . . . . . .
Chapter 7. 53
Techniques for collection and evaluation of cardiovascular
and respiratory data during exercise . . . . . . . . .
Chapter 8. 58
Expression of results: Maximum.work output and maxi-
mum oxygen uptake . . . . . . . . . . . . . . . .
Chapter 9. 74
Evaluation of results: Diagnostic and prognostic value of
exercise tests ........... .
Annex 1. 83
Exercise tests in rehabilitation programmes
Annex 2. 102
Exercise tests in children and adolescents
Annex 3. 105
Exercise tests in population studies
Annex 4. 110
Exercise tests in assessment of fitness for jobs and work
activity . . . . . . . . . . . . . . . . . . .
Annex 5. 113
Comparability and standardization of exercise tests
Annex 6. 119
Specialized terms and units used in exercise testing
References 124
.......................
129
Preface

In an age when cardiovascular diseases are among the leading causes of

death, procedures for assessing the functional efficiency of the heart and cir-
culation are obviously of paramount importance to the medical profession.
Exercise tests are widely used for this purpose and a great many articles and
monographs have been published on exercise physiology and its cardio-
vascular implications. Unfortunately, this information is scattered in specialized
literature and is not always easy to retrieve. This probably partly explains
why no general agreement has been reached on how to perform exercise tests
and how to interpret the results.
A great variety of tests are in use and each has its advocates. Some are
relatively cheap and easy to perform but are unsuitable for taking compli-
cated measurements and do not yield such reliable results as more elaborate
tests. Hence there is a need to collect and summarize the scattered infor-
mation on exercise tests, to collate data from sports medicine with those from
clinical departments, and to standardize the various testing procedures in
order to facilitate comparisons of investigations in different places and on
persons of different ages, sex, and state of health.
The aim of the present book is to describe only the more widely used exer-
cise tests for assessment of cardiovascular function and to advise on the inter-
pretation of the results with a view to their practical application. Only the
so-called "submaximum" tests that can be used in clinical practice and in
routine surveys of population and occupational groups are described. The
more strenuous "maximum" tests, which are especially of interest for basic
research on exercise physiology and in assessing fitness for athletic performan-
ces, are not considered. Attention is, however, given to the applications of
exercise tests in growth studies in children, in population studies, and in
assessing suitability for specific jobs.
This book is not addressed to the specialist in exercise physiology, who
would probably find it too elementary and limited in scope. On the other
hand, it should not be considered a "do-it-yourself" instruction manual: the
techniques described should be carried out only by persons who have already
undergone a basic training in exercise testing in a specialized laboratory. It
is hoped, however, that the book will provide useful guidance to cardiologists,
epidemiologists, genera/practitioners, public health workers and paramedical
staff interested in cardiovascular diseases and the assessment of physical
fitness, suitability for jobs, and related problems.

-7-
CHAPTER 1

Fundamentals of Exercise Physiology

Man, like most other animals, has the ability to move in relation to his
environment and to perform various types of mechanical work by moving
the different parts of his body. Such ability depends on the activity of the
skeletal muscles, which are able to transform chemically stored energy into
mechanical work during their contractions. Exercise performance engages
the muscles in either static or dynamic work. All daily-life activities are
maintained by various combinations of these two types of muscular work
or by continuous shifts from one type to the other. In static effort, the
maximum tension that can be produced by a given muscle group and the
length of time it can be maintained (endurance) depend on the local func-
tional capacity of the muscle, whereas in dynamic work the endurance and
maximal power output depend on the efficiency of the energy-delivering
mechanisms and their interactions with other body functions.
From a functional point of view, the total mass of skeletal muscles may
be considered as an organ system, making up about 40% of the weight of the
human body. Maintenance of posture and most daily activities involve
only a small fraction of the muscular system, but vigorous activities related
to heavy labour, sports and recreation require the integrated activity of
nearly all the muscles. These seldom operate at maximum level at the
same time: their activity pattern changes continuously as the individual
muscles are called into play or are released under the control of the central
nervous system.
At rest, the metabolic rate of the muscle tissue is low, demanding about
3 ml/min of oxygen per 100 ml of tissue, but during maximum dynamic
activity the metabolic rate increases to 100 times the resting value. To
cover the energy demand of the large muscle masses during strenuous
effort, an ability to increase greatly the supply of oxygen is thus necessary.
The oxygen-transporting system, which comprises the cardiovascular sys-
tem (central and peripheral), the lungs and the blood, is constructed with
such functional dimensions that it can meet the demand of the muscles,
even where these are under maximum effort.

-9-
10 FUNDAMENTALS OF EXERCISE TESTING

The Oxygen-transporting System in Exercise

Heart rate

The resting heart rate depends on a number of factors, including age,

sex, position, fitness and environmental conditions. It is higher in the
standing than in the supine position (Table 1) and it decreases with age.
Physical training also reduces heart rate at rest, although the mechanism is
so far unknown.

TABLE 1. HAEMODYNAMICS AT REST AND DURING EXERCISE IN RELATION

TO BODY POSITION'

Maximum
Rest Moderate exercise exercise
Function
Supine
I Upright Supine
I Upright Upright

Cardiac output (iitres/min) 5.6 5.1 19 17 26

Stroke volume (ml) 90 80 164 151 145
Heart rate (beats/min) 60 65 116 113 185
Systemic systolic
arterial pressure (mm Hg) 120 130 165 175 215
Pulmonary systolic
arterial pressure (mm Hg) 20 19 36 33 50
Arteriovenous oxygen difference
(ml/litre) 70 64 92 92 150
Total peripheral resistance
(dynes sec/cm 5 ) 1490 1 270 485 555 415
Left ventricular work (kpm/min) 6.3 7.8 29.7 27.3 47.7
Oxygen uptake (ml/min) 250 280 1750 1850 3200
H aematocrit 44 44 48 48 52

• Observations made on young sedentary adult men; approximate values based on data compiled from
the literature.

Physical effort causes the heart rate to increase. Such increase is under
nervous control, mainly through a reinforcement of the ortho-sympathetic
discharge, and occurs in spite of the increased peripheral arterial pressure.
Liberation of catecholamines from the adrenal medulla may also play some
role in the increase of heart rate, whereas temperature and chemical changes
that occur in the blood do not seem to playa significant role. The heart
rate during exercise, like the resting heart rate, also decreases with age (Fig.l).
A direct, linear relationship exists between heart rate and level of physical
effort, at least in the range 50-90% of maximum oxygen uptake. This
relationship is widely employed in a number of exercise tests. How-
ever, there are considerable individual differences because the correlation
varies with sex, age, and physical fitness; for the same heart rate oxygen
uptake is higher in males than in females and it is also higher in younger
and in fitter subjects (Fig. 2).
During light exercise the first increase in the heart rate may be exag-
gerated, but subsequently it diminishes to a lower level which is maintained
 EXERCISE PHYSIOLOGY
11
throughout the period of exercise. However, during prolonged work and
particularly if the load is heavy, there is a tendency for the heart rate to
increase as exercise progresses (Fig. 3); this reflects in part the tendency for
stroke volume to diminish in heavy work (see below), and in part such fac-
tors as rising body-temperature, increasing lactate accumulation, and impen-
ding exhaustion.
During maximum work the heart rate increases until a state of exhaustion
is reached. The terminal heart rate recorded in this situation is considered
as the maximum attainable heart rate.
The highest attainable heart rate during the performance of heavy
muscular work depends upon age and state of training (see Fig. 1 and 2).
At the age of 20 years the maximum heart rate is about 200, but is reduced
to about 160 at the age of 64. Slightly lower values are observed in women.
The decrease in maximum heart rate with increasing age can be consi-
dered as a sign of the inevitable and general reduction of biological functions

FIG. 1
DECLINE OF MAXIMUM HEART RATE WITH AGE IN HEALTHY MEW

!
200

+ I r
190

.. ~j
11 HI
•
1 .f
r •r
co
180

• jil r 1
1 1
I
Jril
170
~ 170
D

1
~

j~
r
~
~

~
160 160 fl1 11
."
'"
11 1 I
~

'"
::; 150 150
or

)( Robinson .a. Kasch et al. e

140 I¥ Astrand. et al. • Saltin & Grimby
II Astrand 140
• Hollman & Knipping
e Bruce
.. Binkhorst
130 + Anderson
• lester, et al. 130

25 30 35 40 45 50 55 60 65
AGE IYears)

<From Fox et al. (1969). Data from studies of North American and European males under varying
conditions and with differing criteria for those considered acceptably close to "maximum". The vertical
lines give the spread of one standard deviation. The numbered horizontal lines are the "target" heart rate
levels
and for stress
listed on p. testing
45. in each decade as proposed by the Scandinavian Committee on ECG Classification
 FUNDAMENTALS OF EXERCISE TESTING
12

FIG.2
HEART RATE DURING SUBMAXIMUM AND MAXIMUM EXERCISE IN YOUNG ADULT (20-30YEARS)
MEN AND WOMEN. SHOWING SEX DIFFERENCES AND VARIATIONS
BETWEEN FIT AND UNFIT SUBJECTS"

200.------------------------------------------------------------,

MEN

~ 150

f-
er:
<t
WJ
r
A
100

B
1--__________

oL- 3.0 4.0

1.0 2.0
o OXYGEN UPTAKE \titres.lmin)

Maximum
WOMEN
200 -

Maximum

WJ 150
f-
<t
A
er:
f-
er:
<t
WJ
:c

100 -

oiL--_ _ _ _~~ 4.0

o 1.0 2.0 3.0
OXYGEN UPTAKE (tltres/min)

A. Sedentary (unfit) subjects. B. Athletic (fit) subjects.

"Based on Hermansen & Lange Andersen (1965).

 EXERCISE PHYSIOLOGY
13
FIG. 3
HEART RATE RESPONSE TO EXERCISE OF VARIOUS DEGREES OF INTENSITY'

A. Light exercise.
B. MOderate exercise.
C. Heavy exercise.

'Redrawn from Brouha (1960).

with aging. However, the precise mechanism involved in this age-induced

decrease in maximum heart rate is not understood.

Stroke volume

At rest and in the supine position, the stroke volume of an adult non-
athletic man is about 90 ml, depending upon his body size. In the stan-
ding position, the stroke volume is lower (see Table 1). The stroke volume
of women is about 25% lower than that of men in both body positions.
As a result of the greater venous return which occurs on transition from
rest to exercise, the stroke volume increases rapidly under effort, reaching a
level that is maintained constant during an exercise of 5-10 minutes' dura-
tion, but decreases slightly if the exercise is prolonged.

Cardiac output

Cardiac ouput is a function of stroke volume and heart rate (Q =

Qs x fh ), which in turn depend on two fundamental characteristics of the
heart muscle-namely, its contractility and its automatism-and can be
modified by hormonal and neural influences.
 FUNDAMENTALS OF EXERCISE TESTING
14
The resting cardiac output depends upon body position because gravity
exerts a marked effect upon the circulation. When the body changes from
horizontal to upright, there is a tendency for blood to pool in the lower
extremities; the central blood volume and the venous return decrease, and
as a result the stroke volume and cardiac output are reduced (see Table 1).
The resting cardiac output is a highly variable function, inasmuch as it is
also greatly influenced by sex, age, environmental conditions, and emotional
disturbances. It is necessary to take account of all of these factors in the
analysis of cardiac function at work, but their importance becomes less as the
intensity of exercise is increased. When a subject is lying down under basal
conditions, the cardiac output is at a "steady state" level of about 5-62
litres
/min (or if expressed on the basis of surface area, 3-3.5 litres/min/m1 •
During the first few minutes of rhythmic dynamic muscularwork the car-
diac output increases, first rapidly and then more gradually, to a new "steady
state" level, which is a function of the intensity of work (Fig. 4). The new
steady state level is reached at about the same time as the oxygen uptake
levels off at its own steady exercise value.

FIG.4
ADAPTATION OF CARDIAC OUTPUT TO EXERCISE ON TREADMILL'

----------------------------.--~
20 I

15

I
EXERCISE RECOVERY
o REST I " - - _ " - ,_---"----~
1

.~_i.--_
4 5 6
o TIME (min)

Intensity of exercise, with 8% slope:

. - - . 3.2 km/h
x - - x 4.9 km/h
A--A 6.8 km/h
'Redrawn from Cerretelli et al. (1966),

In spite of the tendency of stroke volume to decrease during prolonged

exercise, cardiac output remains constant on account of the increased heart
rate. Similarly, the higher maximum cardiac output and maximum oxygen
uptake achieved in young as compared with old subjects is also due to a
1 The response to isometric work is radically different. However, it will not be discussed here, being
beyond the scope of this manual.
 EXERCISE PHYSIOLOGY
15
higher maximum heart rate in the young sUbjects. After cessation of exer-
cise, cardiac output does not promptly return to the previous resting level,
but decreases gradually following a somewhat exponential curve (Fig. 4).

Pulmonary function
The pulmonary ventilation of a resting adult man is 5-7 litres/min, but
during muscular exercise hyperventilation develops parallel with the increase
in oxygen consumption. In brief maximum exercise, fit subjects may reach
values well above 100 litres/min, i.e., 20-25 times the resting level. The
raised ventilation is a result of increases in both respiratory frequency and
tidal volume. Rates of 40-50 breaths/min are observed in heavy exercise,
and the tidal volume may reach 50% of the vital capacity.
The total lung capacity does not change much during exercise although it
may decrease slightly as a result of the increased intrathoracic blood volume.
The tidal volume increases from 10-15% to about 50% of the vital capacity,
mainly at the expense of the inspiratory reserve volume, which is corres-
pondingly reduced (Fig. 5). The expiratory reserve volume, however, changes
little, even at the highest level of exercise. The vital capacity tends to
decrease in exercise since residual volume is increased, while the functional
residual capacity may remain practically unchanged. This has some physio-
logical significance: the oscillations of the air volume in the lungs are,
obviously, much larger in exercise than at rest, and the maintenance of a

FIG. 5
PULMONARY FUNCTION AT REST AND DURING MAXIMUM EXERCISE'

REST
MAXIMUM EXERCISE

Breathing
frequency
fR 10-15
-, ,- -

I. R. V.

Intlathoracic
Intrathoracic blood volume
blood vo:ullle

t
• Redrawn from Margaria & Cerretelli (1968). copyright Academic Press.
16 FUNDAMENTALS OF EXERCISE TESTING

large functional residual capacity thus assists in damping the pressure chan-
ges and holds the fluctuations of alveolar CO 2 tension to a tolerable level.
Pulmonary ventilation is closely related to CO 2 production. It increases
in linear relationship with the increase in metabolism except in heavy exer-
cise, when it increases disproportionately. Such disproportionate hyperven-
tilation is due to anaerobiosis of the working muscle, and contributes an
extra drive to the respiratory centre. The causes of such a drive are most
likely the H + concentration in the blood and/or the CO 2 released as a con-
sequence of the high blood lactate level.
Neural theories have been proposed to explain the regulation of respi-
ration during exercise. Such theories involve either conditioned reflexes or
irradiation of impulses from the motor centres at the same time as neuro-
muscular transmission, and would explain why ventilation sometimes increases
even before the muscular effort begins. It is also possible that different
factors playa role at different times: peripheral reflexes act at the beginning
of exercise whereas chemical and thermal factors take over later to main-
tain hyperventilation during exercise.
The mechanism of hyperventilation during effort is still unknown. It is
known, however, that exercise-induced hyperventilation is always of a lesser
degree than the maximum voluntary ventilation and that respiration is not
the main limiting factor in muscular exercise.

Blood pressure
(a) Systemic circulation
Despite an immediate and drastic dilatation of the resistance vessels of
the working muscles on transition from rest to exercise, the systemic arterial
pressure is not only maintained, but actually increases.
The initial period of increasing arterial pressure during performance of
rhythmic exercise lasts 1-2 minutes, after which a fairly constant value is
reached and maintained, the level depending upon the intensity of exercise.
When work is stopped there is an immediate pressure drop to below pre-
vious resting values, the minimum being reached 5-10 seconds after cessa-
tion of work. The extent of the fall in pressure depends partly on posture,
partly on room temperature and the duration of exercise, and partly on
whether exercise is stopped suddenly or is tapered off. Subsequently,
arterial pressure rises to a little above the pre-exercise level.
The systolic pressure taken at the apparently steady state level is roughly
proportional to the intensity of work, and in maximum exercise it may reach
levels well above 200 mm Hg (Table 1 and Fig. 6).
The diastolic systemic pressure remains practically unchanged in light and
moderate exercise, but may increase slightly during heavy exercise. As a
consequence of the differential rise in systolic and diastolic pressure, the
pulse pressure increases greatly.
 EXERCISE PHYSIOLOGY
17
FIG.6
PRESSURE IN BRACHIAL ARTERY IN RELATION TO INTENSITY OF
WORK (BICYCLING IN UPRIGHT POSITION OURING 6-10 MINUTES)'

200

150 -
on
:r:
E
E Maximum

---------.~
f
UJ

""
~
UJ

"" 100
0.. _

f--+
Maximum
-----------~
---+--j

OL-____~__~I____~__________~__________~
o 1.0 2.0 3.0 1]067'1

OXYGEN UPTAKE (Iilres/min)

. - - . Systolic.
0---0 Mean.
0 - - 0 Diastolic.

'Submaximum values taken from Lund-Johansen (1967); maximum values taken from
Grimby (unpublished data).

The type of effort also influences the rise in arterial pressure: an effort
performed with the legs increases the arterial pressure to a lesser extent than
the same effort performed with the arms. Static effort entails a considerable
arterial hypertension, while heart rate and cardiac output increase only
slightly.
The total resistance falls considerably during work, especially in
transition from rest to light exercise (see Table 1). This fall is due to the
drastic vasodilatation that occurs in the working muscles and also in the skin
as exercise progresses.
Venous return to the heart during exercise is usually assured by muscular
contraction, by intrathoracic "negative" pressure, and by modifications in
the tonus of the walls of the capacitance vessels.
(b) Pulmonary circulation
Because of their anatomical structure and their intrathoracic locali-
zation, pulmonary vessel; have a low resistanc~ 10 blood flow and are
highly compliant. They can therefore accept a several-fold increase of
 FUNDAMENTALS OF EXERCISE TESTING
18
cardiac output with only slight increase in pressure, at least during moderate
effort. However, under heavy effort the limits of vascular compliance are
approached and the pulmonary arterial pressure may increase markedly.
At rest and in the upright position the systolic pressure in the pulmonary
arteries is 15-20 mm Hg, the diastolic pressure is 5-8 mm Hg, and the mean
pressure is 8-12 mm Hg. In the supine position the pressures are somewhat
higher.
During moderate work the pulmonary arterial pressure increases (see
Table 1) in relation to the increase in cardiac output and heart rate (Fig. 7).

FIG.7
MEAN VALUES OF PRESSURE IN PULMONARY ARTERY AT
REST AND DURING BICYCLE EXERCISE IN SUPINE POSITION'

} Systolic

!i!' 30
E
E

1/-----'___ --1_-_-,.,.
__-_-_-_-__ -_-_-_-~-o__ }_D_ia_st_oli_C_ _I
o 100 150 200
08675
PULSI: RATE (beats / min)

_ _ Athletes.
_ _ _ _ Non,athletes.

'Redrawn from Bevegard et al. (1963).

Blood flow
During exercise, the body attempts to increase blood flow to the muscles
to cover the increased metabolic needs, and the blood flow may rise to 20
times the resting level. Regulation of body-temperature puts an additional
strain on the circulatory system during exercise, because the extra heat
produced by the contracting muscles must be carried to the body surface.
Consequently, muscular exercise involves a drastic adjustment of the circu-
latory function, with an increased total cardiac output and fine regulation
of regional blood flow.
 EXERCISE PHYSIOLOGY 19

In addition to the increased cardiac output and the greater force exerted
by the cardiac muscle resulting in higher mean systemic pressures, a redis-
tribution of cardiac output occurs during exercise. Changes in organ blood
flow are exemplified in Table 2.

TABLE 2. DISTRIBUTION OF CARDIAC OUTPUT AT REST AND DURING EXERCISE"

Rest Exercise (ml/min; %)

Circulation
(ml/min; %)
Light
I Moderate
I Maximum

Splanchnic 1400; 24 1 100; 12 600; 3 300; 1

Renal 1100; 19 900; 10 600; 3 250; 1
Cerebral 750; 13 750; 8 750; 4 750; 3
Coronary 250; 4 350; 4 750; 4 1000; 4
Skeletal muscle 1200; 21 4500; 47 12500; 71 22000; 88
Skin 500; 9 1500; 15 1900; 12 600; 2
Other organs 600; 10 400; 4 400; 3 100; 1

I 5800; 100 9500; 100 17500; 100

I 25000; 100

• Estimated figures; taken from Lange Andersen (1968).

(a) Muscle blood flow

Blood flows through the resting muscle at the rate of 4-7 mlfminjl00 ml
of tissue. During strenuous rhythmic contractions the flow increases
greatly, reaching rates of more than 100 mi/min/IOO ml of tissue, or
15-20 times the resting value. The number of open capillaries in the work-
ing muscle may be up to 50 times the number in the muscle at rest.
The blood flow increases at the onset of exercise or even in anticipation
of exertion, and it continues to increase until a plateau-a steady state be-
tween inflow and outflow-is reached. This period of adaptation usually
takes one to two minutes in light or moderately heavy exercise, but is possibly
longer in maximal exercise. The steady state level is closely related to the
intensity of work performed and to the aerobic metabolic activity of the
tissue. After cessation of work the blood flow gradually decreases in relation
to the restoration of normal tissue homoeostasis.
The increase of muscle blood flow during exertion is made possible in
part by the constriction of the resistance vessels of the muscles that are still
at rest. During exercise there is indeed an increase of vasoconstrictor tone
in the muscles not involved in the effort: for example, in the forearm muscles
the blood flow decreases slightly during leg exercises.
Although the rate of blood flow in the muscle during exercise increases
only 15-20 times above the resting value, the aerobic metabolism for muscle
fibres may increase up to 100 times. This implies a greater extraction of
oxygen from the blood passing through the tissue. While normal utiliza-
tion of oxygen amounts to only 20-25% in most organs, the muscle is indeed
capable of extracting more than 80% of the oxygen offered to it by the

--------....-------------
20 FUNDAMENTALS OF EXERCISE TESTING

blood so that the oxygen tension of the blood flowing out of the active
muscles may be close to zero.

(b) Coronary blood flow

The rate of blood flow to the cardiac muscle increases during muscular
exercise and is linearly related to the increase in cardiac output. The
rate of blood flow to the cardiac muscle at rest is about 60-70 ml/min/I 00 ml
of tissue, and it may increase at least fivefold during exercise. The oxygen
extraction in the myocardium is very high even at rest (70-80%). Thus,
any increased demand for oxygen must be met by an increased coronary
blood flow. Accurate regulation of the coronary flow is important inas-
much as the cardiac muscle cannot utilize anaerobic glycogenolysis as a
source of energy.
The resistance vessels of the myocardium have sympathetic innervation,
but it is by no means agreed how important the autonomic nerves are to
normal flow regulation. Contrary to their action in many other tissues, the
catecholamines cause a vasodilatation of the myocardium's resistance vessels.
It seems established, however, that the nervous vasomotor control of the
coronary blood flow plays a minor role in the regulation of the intracardial
circulation. The control mechanism is that of an autoregulation, and two
factors are mainly responible for setting the rate of coronary blood flow: the
rate of myocardial metabolism and the pressure in the aorta.

(c) Pulmonary blood flow

During exercise in the upright position, which may increase the cardiac
output up to 4-5 times that of the resting level, the blood in the lungs flows
through more capillaries, and, because of the rise in arterial pressure, per-
fusion of the upper zones is improved. The cross-sectional area of the
capillary bed of the lungs increases by a factor of 2-3 during maximal
exercise. This means that the velocity of blood flow through the capillaries
increases during work. It has been estimated that, at rest, a red blood cell
remains in the pulmonary capillaries for 0.75 second, while in heavy exercise
the time is reduced to 0.3 second.
The pulmonary capillary bed at rest contains about 70-100 ml blood, an
amount that may be doubled during performance of heavy exercise. The
blood content of the total pulmonary circuit ranges between 350 ml and
800 ml at rest, and rises to 1400 ml or more in exercise.

(d) Blood flow in visceral organs

In a normal resting man with a cardiac output of 5 litres/min the visceral
organs (kidneys, liver, spleen and gastrointest;nal tract) receive about
2.5 litres/min or 50% of the cardiac output.
During muscular exercise both the resistance and the capacitance vessels
of the visceral organs constrict greatly, so that the blood flow to these organs
 EXERCISE PHYSIOLOGY 21

decreases and the volume of blood in the splanchnic area is reduced. The
kidneys suffer the most drastic reduction of blood flow. At rest, renal blood
flow is about 1100 ml/min, or about 20% of the cardiac output (Table 2), but
during exercise the absolute renal blood flow is reduced by 50-80%. This
decrease is roughly related to the intensity of effort and, indeed, zero values
for kidney blood flow have been obtained occasionally during short spells
of heavy exercise.
A large share of the resting cardiac output flows through the vessels
supplying the intestines and the spleen, whence it is directed to the portal
venous sytem; 100 ml/min circulate through this system at rest. The portal
system plus the arterial blood to the liver constitute the splanchnic circulation
whose blood flow at rest is about 1400 ml/min, i.e., about 24% of the car-
diac output (Table 2).
It seems a general principle that the degree of vasoconstriction of the
visceral organs induced by muscular exercise is related both to the relative
intensity of work and to the circulatory requirements of heat dissipation.

(e) Skin blood flow

Circulation through the skin has two major functions: to provide
transportation of metabolic material to the tissue and to conduct heat from
inside the body to the surface for exchange with the environment.
The rate of blood flow through the skin is highly variable. The flow
required depends on the cooling power of the surrounding air and the over-
all metabolic rate of the body, but excitement and emotional disturbances
may also lead to marked variations in skin blood flow.
Under ordinary conditions the total blood flow to the skin is about 500
ml/min in the average adult man. On passing from rest to exercise blood
flow through the skin decreases, but continuous exercise results in subsequent
vasodilatation and increased flow (Table 2). When the skin vessels are
fully dilated, such as during exercise, they may conduct up to seven times as
much blood as when at rest, i.e., 3 litres/min, or about 15 % of the cardiac
output.

Blood gases and pH during exercise; haematocrit

The increased pulmonary ventilation during exercise secures a normal or
increased oxygen tension in the alveoli. The oxygen tension in arterial
blood does not change much at submaximum exercise, but at very high
work rates a small decrease may be observed. The P C0 2 and the alkaline re-
serve determine the pH of the arterial blood; this is about 7.4 for a man at
rest under ordinary conditions. Blood pH is unaffected by exercise as long
as PC 0 2 and the alkaline reserve remain unchanged. The arterial P C02 changes
only slightly during exercise in a normal subject, at least during moderate
work. Marked changes occur, however, during heavy work.
 FUNDAMENTALS OF EXERCISE TESTING
22
When anaerobiosis occurs in muscles (to supplement the aerobic proces-
ses in providing energy for muscle contraction), lactic acid is formed and the
pH of the blood decreases. In exercises of up to 10 minutes' duration this
takes place at work rates higher than 50-60% of the maximum aerobic capa-
city, depending on the physical fitness of the subject and on the type of exer-
cise performed (Fig. 8).

FIG.8
BLOOD LACTATE, ARTERIAL BLOOD GASES AND BLOOD pH AT
VARIOUS LEVELS OF MUSCULAR EXERCISE'

i Id·," ".~~"""'".." .~. '." .'". -', ;.:. "'-. " :~~~~"-
120 Pa, O2

~7.30~~
:~\ :.". .......~
.. .....

7.20-
L _ _ _ _J-----L---~----~--~~
~
75 100 125
25 50
[nergy output (% of aerobic capacity) JQ676

'Redrawn from Lange Andersen & Smith Sivertsen (1966).

During brief periods of exercise the haematocrit values also increase

(see Table 1) in rough relation to the intensity of work. Such haemocon-
centration, due to loss of plasma volume, occurs over the first few minutes
and may amount to as much as 20%. During prolonged work there seems
to be no further change.
The haemoconcentration entails some functional consequences. The
oxygen-carrying capacity of the blood is raised owing to the increased con-
centration of red blood corpuscles. The acid-buffering capacity of the blood
is also increased, owing to the increased concentration of plasma proteins.
These adjustments are beneficial in exercise. On the other hand, haemo-
concentration also increases the viscosity of the blood, thus hampering the
 EXERCISE PHYSIOLOG Y 23

blood flow. Clotting time and white cell count are also changed by the
haemoconcentration.

Energy Requirements and Oxygen Uptake during Exercise

The energy requirement of the resting man is approximately 1.25 cal/min

(or 0.25 litre/min of oxygen (see Table 1); this figure varies somewhat with
body-size, age, sex and environmental factors. During muscular exercise
the energy requirement may increase 15- to 20-fold. The energy cost of
work is conveniently determined by indirect calorimetry, which involves
determination of oxygen uptake (Yo,).
When rhythmic dynamic muscular exercise is performed at a steady sub-
maximum rate on a bicycle ergometer or similar instrument, oxygen uptake
increases during the first few minutes of exercise and then reaches a plateau,
the so-called" steady state" level. Regardless of the intensity of effort, an
oxygen deficit is established at the beginning of exercise (adaptation phase
or "on-transient") and remains throughout the whole exercise period: this
oxygen debt is repaid after the cessation of exercise (recovery phase or
"off-transient") (Fig. 9). During the recovery period, oxygen uptake and
CO2 production gradually decrease to resting levels following either a single
exponential curve, if the work-load has been light and did not result in
excess lactate formation, or a two-component exponential curve if the exer-
cise was heavy. The length of both the adaptation and the recovery phase is
a function of the intensity of exercise, of age, of sex and of the state of
physical training (Lange Andersen, 1959).

FIG. 9
OXYGEN UPTAKE IN RELATION TO PERFORMANCE OF MODERATE (70 kpm/min)
MUSCULAR EXERCISE ON A BICYCLE ERGOMETER'

1000
c Oxygen deficit
E
'-.
E
~
~
ro 500
§-
~

~
0
_ _ Wock 0170 kpm/m;" ~A

10 l5 20 25
00617
Time (min)

• Figure kindly supplied by Professor K. Lange Andersen.

In light and moderate work the duration of the" on-transient" is one to

two minutes; fit subjects adapt to exercise more quickly than unfit or older
subjects, in which the adaptation phase may occupy several minutes. This
24 FUNDAMENTALS OF EXERCISE TESTING

lag in circulatory adjustment causes partly anaerobic conditions in the mus-

cles at the beginning of work and results in an oxygen deficit.
When steady state oxygen uptake is plotted against the rate of work per-
formed, e.g., on a bicycle ergometer, the oxygen cost of exercise is seen to
be linearly related to the rate of work up to a limiting value, above which a
further increase of work load does not bring about any further increase in
oxygen uptake. This level of O 2 consumption is defined as the maximum
oxygen uptake, (VO)max, for a particular type of exercise.!

Maximum aerobic power and maximum oxygen uptake

Maximum aerobic power is defined as the highest attainable rate of
aerobic metabolism during the performance of rhythmic dynamic muscular
work that exhausts the subject within 5-10 minutes. It depends on the type
of exercise performed, on the mass of muscles employed in the activity,
and on various physiological variables. The highest values are obtained in
activities like running, stepping, and bicycling, with only small differences
between them. Large enough muscle groups are brought into play during
these activities for the oxygen-transporting system to be loaded to, or close to,
its maximum capacity.
Maximum aerobic power is assessed through the measurement of the
maximum oxygen uptake attained in dynamic muscular exercise (see Chapter
8, page 76).
Oxygen uptake depends upon the muscle mass and the functional dimen-
sions of the oxygen-transporting system, including such factors as respira-
tory and cardiac efficiency, the oxygen-transporting capacity of the blood,
alveolocapillary diffusion, peripheral circulation, capillary-to-cell diffusion,
and tissue diffusion.
Maximum oxygen uptake is related to the heart rate, stroke volume, and
arteriovenous oxygen difference through the equation:
(Vo,)max = fh x Qs x (Ca,02 - Cv,o')
The maximum oxygen uptake and, consequently, the maximum aerobic
power of an individual are mainly determined by his age, sex, and body
constitution, but a number of racial and environmental factors, and also
pathological disturbances, are known to modify this parameter (Lange
Andersen, 1968; Shephard, 1969).
Age exerts a considerable influence on maximum oxygen uptake (Fig. 10),
an influence that has been established in a number of populations. The
course of age-related changes is also affected by cultural attitudes to activity.

1 Some authors make a distinction between" maximum" and "hypermaximum" work, on the basis that
the maximum work rate corresponds to maximum oxygen consumption, and additional work is performed
anaerobically, However, this distinction is not universally accepted.
 EXERCISE PHYSIOLOGY
25
FIG. 10
MAXIMUM OXYGEN UPTAKE IN RELATION TO AGE AND SEX'

." I
I
3.0 ~

';; 2.0
ill

1.0 ~

20 30 40 50 60 70 80 90
AGE (years)

"From Lange Andersen (unpublished data).

In early childhood there are no sex differences in (VO)max, but at the onset
of adolescence sex differences do appear and result in higher values for
boys (see also Table 7 (page 108) and Table 8 (page 109).
Maximum oxygen uptake increases during childhood at approximately the
same rate as weight and height, and in male subjects it reaches peak values
during early adulthood. A gradual and steady decline with age takes place
from 25-30 years and at the age of 70 maximum aerobic power is about 50%
of that found at 20 years. In women the peak value-about 70 % of that of
men-is reached at the end of adolescence and remains fairly constant during
the fertile part of life, declining thereafter at about the same rate as in men.
Maximum oxygen uptake is directly related to body weight (Astrand, 1952;
Lange Andersen, 1966) and it is therefore common to express it in mljmin/kg
body-wt. It is also directly related to height and some authors favour this
way of expression. When assesssing the cardiovascular performance of
obese people it is questionable whether maximum oxygen uptake should be
expressed per kg of body weight; this penalizes the obese, but it may be a fair
penalty since most forms of activity are weight dependent. Considerable
evidence is available that maximum oxygen uptake deteriorates in certain
26 FUNDAMENTALS OF EXERCISE TESTING

acute and chronic diseases. This deterioration may be a result of special

pathological conditions, but is also due to physical inactivity, e.g., bed-rest.
When maximum oxygen uptake is reduced by acute disease or injury,
it may be quickly restored to a normal value by an adequate rehabilitation
regimen involving endurance exercises.
The measurement of maximum aerobic power has been introduced as a
clinical routine programme to evaluate the functional status of the cardio-
vascular system (Wahlund, 1948; Sj6strand, 1960; Reindell etal., 1967; Deno-
lin, 1966; Chapman, 1966; Hellerstein & Hornsten, 1966; Fried & Shep-
hard, 1968).
In clinical practice, reference standards for maximum oxygen uptake must
be employed. The normality with regard to this parameter may be des-
cribed by the mean ± two standard deviations previously established by
studying samples of healthy people. As mentioned above, most laboratories
express the maximum oxygen uptake in relation to body size (ml/min/kg
body-wt or mljmin/cm body-ht).
It is also common to express it in relation to the volume of the heart as
determined by X-ray technique (Rein dell et aI., 1967), or to total blood vol-
ume and total haemoglobin (Astrand, 1952). The determination of maxi-
mum oxygen uptake is particularly relevant in the clinical testing of fitness for
work and sport, in the diagnosis of the current status of the cardiovascular
system, and in evaluating the effect of rehabilitation programmes.
As to the anaerobic components of muscular work, they are difficult to
assess accurately and are also of less significance than the aerobic ones in
relation to cardiovascular function and to the everyday activity of the aver-
age person.
CHAPTER 2

Types of Exercise Test

Different principles and various types of exercise have been employed in

work tests. The objectives of the testing programme are:
(I) to test the fitness for work, sport and other activities;
(2) to evaluate the functional status of the cardiovascular (and/or respi-
ratory) system in health and disease, including the diagnosis of present status,
the prediction of the probability of developing cardiovascular disease, and
the prognosis if the disease is already present; and
(3) to evaluate the effect of preventive, therapeutic and rehabilitation pro-
grammes, including the effects of medication, surgery, physical condition-
ing, and other means of improving health.
In addition, fitness tests have been used to reassure patients and motivate
them to improve their health. A recent evaluation of exercise testing
procedures can be found in Parmley et al. (1969).
Determination of the circulatory and respiratory recovery time follow-
ing completion of a standard work task has been widely used for studying
fitness for work, and is based on the principle that quicker recovery means
better fitness. For a given effort, the fitter the subject the lower his heart
rate; conversely, for a given heart rate, the fitter the subject the more intense
is the work he can perform. As early as 1889 it was observed that systolic
blood pressure and heart rate rose during exercise and gradually returned to
normal after exercise. In these early tests, blood pressure and pulse rate
were measured after an exercise and were compared with the pre-exer-
cise values. If these readings did not differ significantly the individual was
considered to have a normal myocardial function.
Schematically, two main classes of tests may be recognized:
(a) Recovery tests (measurements are taken during the recovery period
following exercise).
(b) Effort tests (measurements are taken during exercise).
It is now generally agreed that the most reliable information regarding
effort tolerance is obtained from physiological observations made during

-27-
28 FUNDAMENTALS OF EXERCISE TESTING

exercise. The main justification for the use of recovery tests in the past
was the difficulty of measuring physiological functions during exercise.
However, modern equipment has greatly facilitated such measurements and
it is no longer a problem to obtain accurate values for metabolic, circula-
tory and respiratory functions during exercise.

Recovery Tests
In 1929, Master & Oppenheimer introduced a standard "two-step test"
for the recording of blood pressure and heart rate responses to muscular
exercise. Subsequently, the test was used as a work-load for post-exercise
EeG recording (Master & Jaffe, 1941). In this test the load (in terms of
rate and duration of stepping) is adjusted according to the age, sex, and body
weight of the subject, and can be read off a table (Master & Rosenfeld,
1967); however, it is now widely recognized that the intensity of exercise
required in this test is rather low and that the adjustments made for differen-
ces of body weight are too large.
In spite of these shortcomings, the Master two-step test is widely used
Master & Rosenfeld (1967) summarized their experience and stated that
the test was simple and reliable and aided in the discovery and evaluation
of coronary heart disease and in the assessment of the coronary circulation
during exercise in those subjects with other forms of heart disease.
Among other step tests currently in use is the Harvard test, which was
introduced in the USA by Brouha et al. (1943). In this test the patient
was required to step on and off a bench 51 cm (20 inches) high at a fixed
rate (30/min) for five minutes or until exhausted. The heart rate was re-
corded three times (1-111, 2-2Yz and 4-4Yz min) after cessation of work and
was used together with the total performance time in the calculation of a
fitness index. A pack-test version had previously been worked out by
Johnson et al. (1942), mainly for the testing of military personnel; this
test involved carrying a rucksack proportional in weight to the weight of
the subject.
A simplified Harvard test has been introduced in Scandinavia (Ryhming,
1953); the height of the bench is 40 em, and only one heart rate is counted in
the recovery phase-namely, 1-111 minutes after cessation of work. This
count multiplied by two is termed the" test-pulse". Reference standards for
healthy males are available (Lange Andersen, 1955).

Effort Tests
So far as the intensity of effort is concerned, exercise tests may be clas-
sified as:
(a) Maximum tests (exercise of increasing intensity is performed until no
further increase of oxygen uptake occurs);
 TYPES OF EXERCISE TEST
29
(b) Submaximum tests (tests performed at lesser intensities of effort
than the maximum tests).
As to the loading, three principal patterns are in use (Fig. 11):

FIG.11
TYPES OF LOAD USED IN EXERCISE TESTS"

Single·level load Continuous or

J L almost continuous

MIill
increase in load

Discontinuous series
of increasing loads Continuous series of
with intermittent rest increasing loads with ~
periods an almost steady state
at each leve I
\\'H080223

"Each of these types of load may be applied in any of the following types of exercise: steps or bench,
upright bicycle, supine bicycle, and treadmill. (Reproduced with slight modification from the report of a
WHO Meeting on Exercise Tests in Relation to Cardiovascular Function, WId Hlth Org. techno Rep. Ser"
1968, No. 388, p. 10.)

Single-level load

Each individual performs exercise at a single constant level on a given

day. The level is either kept the same for all subjects or is adjusted accor-
ding to the health, age, sex, and physical fitness of the individual.
Discontinuous series of increasing loads
This type of test involves a series of exercises in which the load is in-
creased in steps, between which short rest pauses are allowed.

Continuous or almost continuous series of increasing loads

In this type of test the work-load is increased in an almost continuous
series of steps of variable short duration without rest pauses; the truly conti-
nuous increase of work-load is a special case of this procedure. An almost
continuous increase of load can be achieved with some forms of bicycle
ergometer and with the treadmill; it is also quite readily achieved in step
tests, particularly if an electrical metronome is used to increase the subjects'
pace.
In selecting the manner to apply the work-load, the following factors need
to be considered:

(a) With a single work-load it is difficult to develop a test procedure

which can be utilized in a population that is heterogeneous in respect of work
capacity, since a single work-load does not exert a similar cardiovascular
stress for even a relatively homogeneous sample with regard to age, sex, and
 FUNDAMENTALS OF EXERCISE TESTING
30
occupation. Also, a single work-load does not take into consideration the
advisability of a warm-up period before performing exercise and may danger-
ously overstress a patient. Multi-stage tests, on the other hand, can satisfy
these requirements but require more time.
(b) If a multi-stage procedure is to be used one needs to consider the
advantages of intermittent versus continuous increase in work-load. With
intermittent increases, there is the advantage of being able to obtain periodic
measurements during rest. With this procedure, however, the testing time
is substantially increased over the continuous method.
 CHAPTER 3

Types of Ergometer

Procedures for exercise testing vary widely. The simplest and least
standardized procedures involve knee-bending, flexing and extending the
arms, hopping and jumping, climbing stairs, or walking or running a prede-
termined distance. More refined techniques are described below.
Proper exercise testing requires either the measurement of oxygen con-
sumption or the performance of a measured amount of work by the subject.
This implies for a step-test accurate measurement of the height climbed,
and for a bicycle ergometer a simple and reproducible method of calibrat-
ing the instrument. It is also important that the test should be easily per-
formed by the subject and that the rate of work performed can be set at any
desirable level.
In addition to these basic requirements it is also essential, particularly
when testing cardiovascular responses, that the mode of exercise selected
should activate most of the larger muscles of the human body. Furthermore,
it is desirable that the test procedure should not involve any muscle activity
that requires special skill or co-ordination for its performance. A diffi-
cult and unfamiliar task may create anxiety and may lead to a discontinuous
and uneven work rate, with a consequent bias in the value of the physio-
logical parameters. In order to ensure co-operation, the exercise should
preferably be enjoyable to the patient, and both the immediate exercise
task and the general laboratory environment should not only be free from
hazard but should also appear so to him.
Several types of ergometers are suitable for routine exercise testing:
(1) Bicycle ergometer (upright or supine);
(2) Steps;
(3) Treadmill;
(4) Arm crank.
Each of these has its merits and disadvantages, and the type of work
task selected for a specific study depends upon its purpose and the nature of
the popUlation sample. The relative merits of the first three ergometers are
summarized in Table 3.

-31-

-..........--------------
32 FUNDAMENTALS OF EXERCISE TESTING

TABLE 3. RELATIVE MERITS OF EXERCISE TESTS'

Type of test
Criterion
Upright Supine Treadmill
Step bicycle bicycle

A. Ease of Performance

Familiarity with task required? +++ ++ - +++a

Ease of obtaining high oxygen uptake ++ ++ ± +++
Subject's performance to maximum
oxygen uptake + ++ + +++
Ease of instrument calibration b ++c
__ d ++c
__ d + or ±e
Ease of measuring applied power ++1 +++ +++1 9
Ease of recording or obtaining the
following during maximum test:
ECG ± ++ ++ ±
Blood pressure -- ++ +++ -±
Blood samples --- ++ +++
Respiratory volume and oxygen ± ++ ++ +
Need for providing for emergency
care h
Ease of breathing
+
+++
-
++
+++
+
---
+++
Ease of obtaining a nearly continuous
increase of efforth ± ++c ++c + + or ±e
+++d +++d

B. Freedom from Undesirable Features

Hazards +++ or + +++ --

±'
Need for skill + + - ++'
Occurrence of local muscle fatigue at
hig h exercise levels + - -- ++
Need for trained personnel ++ ++ ++ ±
Cost of equipment +++ ++c
__ d +c d
__ ---
Ease of maintenance (including need
for constant calibration) +++ ++c ++c ±
±d ±d
Freedom from noise +++ ± ± --
Bulk of equipment h +++ + -__ d ---
Ease of transporting equipmenth +++ ++c ±c, ---
±d
Needfor electricityh b ++c
__ d ++c
__ d ---
Need for neuromuscular-skeletal co-
ordination
Ease of rate controlh
-
.-- -_c +
_c --
+++
++d ++d

• This table is reproduced from the report of a WHO Meeting on Exercise Tests in Relation to Cardio-
vascular Function (Wid Hlth Drg. techno Rep. Ser., 1968, No. 388, p.11). Each olthe four types oltest is
evaluated according to the criteria listed in the first column. A grading of + + + indicates easiest, greatest
freedom from undesirable features, most advantageous, etc.; a grading of - - - indicates most difficult,
least freedom from undesirable features, least advantageous, etc. The intermediate point is represented
by a grading of ±. Throughout the table, therefore, the greater the number of plus signs (or the fewer
the number of minus signs), the fewer the problems presented by the test concerned.

a More difficult when the rate and slope are high.

b Unnecessary.
c Friction type.
d Electric type.
e Calibration easy for angle, less easy for rate.
1 Less easy at maximum power.
9 Can be estimated only.
h Less important factor.
Less at low stepping rate, greater at high rate.
 TYPES OF ERGOMETER 33

Bicycle Ergometers
Bicycle ergometers are of two main types, mechanical and electrical, and
they may be designed for work in the supine or the upright position, or
in both positions. For clinical purposes it is often necessary to carry out
exercise tests in the supine position, either because extensive ancillary inves-
tigations (such as cardiac catheterization) are being made, or because the
condition of the patient precludes exercise in an erect position, or because
the objective is to compare circulatory responses to exercise in the two posi-
tions.
In the usual mechanical type, a frictional force is developed on or within
the bicycle wheel and the work performed is proportional to the product of
the applied force and the total number of wheel revolutions. The source of
friction is normally a weighted leather belt applied to the outer surface of
the driving wheel, but models using weighted brake-shoes have also been
devised. In the simplest forms of machine, the frictional force is either
calculated from the difference between the applied weights and the reading
of a spring balance or is indicated by the position of a calibrated and weight-
ed lever; however, both procedures may lead to systematic error. More
sophisticated machines permit the direct application of the desired load.
Several problems arise in the use of the simpler machines:
(a) The belt becomes hot, altering the coefficient of friction, and it is
not easy to maintain a constant work-load.
(b) The system of belt, weights and levers forms a compound pendulum
and the spring balance or load indicator fluctuates wildly during vigorous
effort.
(c) Inexperienced subjects find difficulty in maintaining a constant
rhythm.
These problems are overcome in the Fleisch ergostat. A servo-mecha-
nism increases the loading automatically as the belt heats and a damping
system is provided to minimize oscillations of the belt. The number of pedal
revolutions is controlled precisely by a large pointer linked both to the drive
of the bicycle and to a synchronous motor through a differential gear.
These advantages are offset by a considerable increase in the weight, com-
plexity and price of the apparatus, and the necessity to provide an electricity
supply for the synchronous motor.
Electrically braked bicycles provide viscous resistance by moving a con-
ductor through a magnetic or electromagnetic field. In these bicycles the
conductor is an iron (or copper) band on the outer part of the wheel; a
permanent magnet is moved across the surface of this core as the test pro-
gresses, giving a continuous increase of work-load. Other machines transmit
the pedal force to a small dynamo. If the field coils of the dynamo are
energized from an independent source, it is possible to incorporate a

...........---------------
 FUNDAMENTALS OF EXERCISE TESTING
34
feed-back mechanism so that the total amount of external work performed
is independent of minor variations in pedal speed. The main disadvantages
of the electrical machines are the need for an electricity supply and their
complexity and cost. Calibration is also much more involved than for the
mechanical devices and can only be carried out in specialized biophysical
laboratories; unfortunately, the constancy of calibration depends upon the
magnetic properties of the core and this is commonly altered during the
journey to and from the calibrating laboratory.
The simpler types of bicycle with a mechanical braking system are
inexpensive, easy to maintain and can be built in any well-equipped mechani-
cal workshop to meet the specifications of the investigators.
Several types are commercially available. Fig. 12 shows one of the
most popular simple designs, that of Von Dobeln (1954). The calibration
is arranged so that a scale and pointer (Fig. 13) indicate the approximate
work (in kpm) performed by one rotation of the ergometer wheel. Accu-
rate calibration may be done through the application of a standard torque to
the pedals. The bicycle is connected to a revolution timer, which records
the number of ergometer wheel rotations during the test period, thus per-
mitting estimation of the total work output during the period.
FIG.12
THE VON DOBELN UPRIGHT BICYCLE ERGOMETER
 TYPES OF ERGOMETER
35
FIG. 13
SCALE AND POINTER USED IN CALIBRATION OF THE
VON DOBELN BICYCLE ERGOMETER

The bicycle should be so constructed as to allow the work rate (work per-
formed per unit of time, expressed in kpm/min or in watts)1 to be recorded
and to permit changes in the work rate while the pedalling rate is kept con-
stant. It should also have a large rate indicator from which the patient
can gauge his rate of pedalling, although some adults prefer to keep time with
a metronome. The pedal crank length should be 15-20 cm for adults and
appropriately less for children. The height of the bicycle seat should be
rapidly adjustable. The shape of the seat deserves attention; most people
prefer a narrow seat. The mechanically braked bicycle ergometer is por-
table and in its simpler forms requires no electricity so that it could be used
in field studies for testing the maximum aerobic power of primitive popula-
tions unfamiliar with this type of muscular activity (Lange Andersen, 1969).
If suitable calibration has been carried out, it is also possible to measure ac-
curately the external work performed or the power applied. Another advan-
tage that makes the bicycle, particularly the supine version (see below),

1 See page 74 and definitions in Annex 6.

36 FUNDAMENTALS OF EXERCISE TESTING

very valuable for clinical use is that the patient's trunk and arms are rela-
tively immobile, thus permitting complicated technical procedures such
as catheterization, blood pressure measurements, rebreathing procedures,
blood sampling, and the like to be performed. The mechanical efficiency
of effort is known rather more precisely than in other types of effort;
it varies little over a large range of work intensities and there is only a
small variation between individuals. Habituation and learning pose no
major problems.
The main drawbacks with bicycle ergometers are related to the occurrence
of weakness, fatigue, and pain in the quadriceps muscle and saddle discom-
fort, which may become intolerable in prolonged exercise, particularly if the
patient is untrained in bicycle riding. Strong contraction of the quadriceps
during cycling may be sufficient to impair blood flow to that muscle even
when exercise is performed at 50-60 % of maximum aerobic power. Evidence
for this hypothesis is the fact that the blood lactate level is higher during
bicycling than during stepping or running (Shephard et aI., 1968b).
Difficulties in maintaining the pedal rhythm may also be a problem, parti-
cularly in elderly and diseased subjects, and it is not easy for a patient with
various leads attached to dismount in an emergency. During vigorous
exercise, activity of the pectoral muscles may also impair the quality of the
ECG. Calibration should be checked regularly by applying a standard
torque. The calibration procedures suggested with commerical versions of
the Von Dobeln machine are not very accurate, and for serious scientific
study specialized calibration equipment must be borrowed or constructed.

Bicycling in the supine position

The initial attempts at bicycling in the supine position may be rather

clumsy since this is a totally unfamiliar experience and some practice is
usually necessary. It is essential that the subjects be fastened to the sup-
porting bench by appropriate shoulder straps. Furthermore, the feet
should be fastened to the pedals in order to prevent slipping during exercise
(Fig. 14).
The physiology of exercise in the supine position differs markedly from
that in the upright position. The maximum values for oxygen uptake
obtained in the supine position are lower than those attained in the upright
position. Saltin (1964) found an average of 4.47 litres/min in the upright
position, as compared with 3.85Iitres/min in the supine position; this
difference is surprising in view of the greater stroke volume when supine,
but may be due to the fact that only a limited muscle mass can be mobilized
in this position.
The haemodynamic responses are also different: there is a substantial
initial increase of stroke volume when exercise is performed in the sitting
posture, but relatively little change occurs when the subject is lying down.
 TYPES OF ERGOMETER
37
FIG. 14
SUPINE BICYCLE ERGOMETER"

'Figure kindly supplied by Richard Lauckner, Berlin.

Steps

Different authors have used steps differing greatly in height; single,

double, triple, and multiple steps all have their advocates. Sturdy construc-
tion is essential and the test is aided by bolting the steps to the floor.
A handrail support may be provided for older subjects. The desired height
is determined partly by the requirements of rhythm and partly by the require-
ments of work-load. A rate of less than 60 paces/min is uncomfortably
slow, and a rate of more than 180 paces/min leads to tripping. Fortunately
the requirements of most exercise tests are satisfied by the range 60-180
paces/min. A total height of 40-50 cm must be climbed during maximum
work in fit young sUbjects. A single step of this height is unfamiliar and is
uncomforta ble for prolonged use, so for most purposes a double step with
each of the two risers 23 cm (9 inches) high is suggested.
Steps should be at least 50 cm (20 inches) wide and 25 cm (or 10 inches)
deep. A metronome or a pendulum (a weight attached to a 150-cm length
of string may be satisfactory) aids in keeping the rhythm and pace. A
convenient staircase for exercise testing is illustrated in Fig. 15. This form
was evaluated by an international team of work physiologists in Toronto
 FUNDAMENTALS OF EXERCISE TESTING
38
in 1967 (Shephard et al., 1969). The apparatus is cheap and portable,
and requires no maintenance, calibration or electricity; in this respect it
has many advantages over the bicycle ergometer as a field procedure.
Stepping exercise is familiar to almost all people and can be performed easily
by subjects of all ages and varying levels of fitness. The intensity of exercise
can be readily changed by a simple adjustment of the metronome setting,
but some anxiety may arise from tripping at rapid rates.

FIG.15
SUITABLE STEPS FOR EXERCISE TESTING'

-1 I
I

-,--- \3 1
,
cO'l
=1
I
I
"<%> I

~~----
I

_1.
C'I
\
50cm -I

'From Shephard (1967a).

The main disadvantage of the step tests is a continuous movement of

the arms and head, which creates difficulties when taking physiological
measurements. Complicated technical procedures such as cardiac catheter-
ization and cardiac output measurements by rebreathing methods are prac-
tically impossible to carry out and even the measurement of blood pressure
by the indirect (cuff) method is difficult. However, ECGs of good quality
can be obtained during stepping, and oxygen consumption is readily
measured.

Treadmills
The motor-driven treadmill allows studies of the response of man to
walking and running (Fig.16). Treadmills are normally constructed so that
both speed and inclination can be varied.
 TYPES OF ERGOMETER
39
FIG. 16
MOTOR-DRIVEN TREADMILL

The treadmill "grade" or elevation is defined as the units of elevation

per hundred horizontal units; it is expressed as a percentage and is usually
set with the aid of a built-in" inclinometer". Speed is conveniently measured
in m/s or km/h. The treadmill should be supplied with a speedometer,
although for accurate work timing of the belt speed is essential.
Treadmills vary greatly in their size and power, from giant machines
able to reach 40 km/h (25 mi/h) to portable devices that may run at speeds
of 5-10 km/h (3-6 mi/h). Unless tests are to be performed on champion
athletes, a high speed is not essential; few patients can run up an 18%
slope at 10 km/h for any length of time, and this intensity of effort can
be developed on the simplest form of treadmill. Noise is an important con-
 FUNDAMENTALS OF EXERCISE TESTING
40
sideration; a poorly constructed or badly maintained treadmill can be an
annoyance not only to the investigator but to many of the other occupants
of the building.
A safety rail and emergency stop button are also mandatory. The
belt should be wide enough to avoid tripping, but not so wide that the
patient finds difficulty in grasping the safety rail and stepping to the side
platforms when exhausted. A safety mat at the rear of the treadmill is
required for maximum effort tests; however, a "safety harness" is probably
unnecessary for patients who will exercise at only moderate speeds. Al-
though walking and running are activities familiar to everybody, their perfor-
mance on a treadmill induces anxiety, since a certain danger of falling off is

FIG.17
HAND.CRANK ERGOMETER'

'Figure kindly supplied by Richard Lauckner, Berlin.

 TYPES OF ERGOMETER
41

present. Effects of learning and of habituation, assessed as improvements

in work efficiency, are therefore important and playa greater role in treadmill
exercise than in bicycling or stepping (Shephard et aI., 1968a).
Treadmills have the advantage that the rate of work is constant, is inde-
pendent of the motivation of the patient, and can be set to any desired
level by adjusting the speed and inclination of the belt. They are also
more suitable for producing a true maximum oxygen uptake than the other
ergometers. However, they are usually bulky, noisy and expensive, may
not be easily transported, and require electricity. For these reasons the
treadmill is best suited for use in a well-equipped laboratory and is not very
practicable for field work.

Arm Cranks
Two main types of arm crank can be mentioned: the "double-crank"
and the" single-crank" (Fig. 17).
The double-crank ergometer gives substantially lower values for maxi-
mum oxygen uptake than bicycle pedalling, but if a large single-crank is used
that activates the larger muscle groups of the upper part of the body, then
the results with regard to maximum oxygen uptake are comparable with
those obtained in other forms of maximum exercise.
German work physiologists have proposed that the length of the single-
crank should be one-third of a metre, and that the height of its centre above
the floor should be one metre. They also proposed that the cranking rate
should be such that:
0-100 watts is performed with 25-35 rev/min;
100-200 watts is performed with 35-45 rev/min;
200-300 watts is performed with 45-55 rev/min.
The arm crank has specific usefulness in the testing of patients with
impaired function of the lower limbs, and for this reason it deserves further
study. Owing to lack of sufficient information, details on the use of arm
cranks will not be given in this manual.
CHAPTER 4

Safety Precautions

No systematic investigation concerning the occurrence of complications

in connexion with exercise tests is available. Occasional reports and personal
communications disclose, however, that minor complications are not rare
and that serious cardiovascular accidents, in a few instances fatal, have been
observed. Vasovagal reactions seem to be quite frequent but, if injury is
avoided, are usually benign, while cardiac arrhythmias, especially those of
ventricular origin, are relatively rare but much feared. Acute cardiac failure
is a rare complication observed in severely ill patients with chronic valvular
heart disease, and sometimes occurs also in healthy subjects (Bruce et aI.,
1968). Angina pectoris is usually accepted as a limit to work-load increase
and is not regarded as a complication, except in status anginosus; if the ECG
is monitored throughout the test, angina occurs rarely.
Careful organization of safety measures is a good assurance against the
fatal outcome of the cardiocirculatory accidents that may occur during
exercise testing.
Emergency services and safety precautions are mandatory not only when
testing cardiac patients but also when testing healthy subjects. Since the
occurrence of ventricular tachycardia or ventricular fibrillation is possible in
apparently normal people, it is advisable that any team testing normal sub-
jects should be well prepared for emergency situations and that appropriate
equipment be available.

Operational Precautions

Requirements concerning personnel

Exercise testing is a highly specialized task and must be performed by well-
trained personnel. The measurement of physiological parameters and the
conduct of the experiments should be learned in an established laboratory of
exercise physiology.
Ideally, the testing team should include four persons: a qualified phy-
sician, two technicians, and a nurse. The physician should select the proper

-42-
 SAFETY PRECAUTIONS 43

loading pattern, watch the subject for signs and symptoms indicating that
exercise should be interrupted, and interpret the ECG and other results,
while the technicians and the nurse should take care of the various analyti-
cal procedures and calculations, prepare the ECG electrodes, perform the
expired gas collection, and take blood pressure, anthropometric, and other
miscellaneous measurements. However, if a simple exercise test is used
involving stepping or pedalling a bicycle ergometer, with determination
only of ECG wave-form, blood pressure and pulse rate, then one
experienced person can cope with the whole procedure; but a physician
should be at hand if the person in charge of the testing is not medically
qualified. With this precautionary measure, accidents due to exhaustion
may be prevented and possible emergency situations may be dealt with.
Exercises at low work-loads can in general be conducted by a single
individual, but this is not so in the case of the treadmill, which cannot, as
a rule, be stopped by the subject himself. Small accidents can have more
serious consequences if the patient falls on the treadmill.
The members of the testing team must have a basic understanding of
exercise physiology. They must be well acquainted with the testing proce-
dure and the risks involved in different methods of testing. They must be
able to recognize signs and symptoms of impending difficulties and be com-
petent to initiate appropriate therapy without delay. Each member should
be trained to recognize basic ECG abnormalities.

Safety features of equipment

Treadmills must be equipped with a handrail to prevent falling. Step-
tests and bicycle ergometers usually do not require handrail equipment,
although elderly subjects may welcome hand support in stepping. The sub-
ject must be able to discontinue the test at his will so as to minimize the
danger of falls and of exhaustion.

Monitoring equipment
ECG recordings and blood pressure measurements are usually an inte-
gral part of the exercise tests. Continuous ECG monitoring on a cathode-
ray oscilloscope is not obligatory in all subjects. However, it is recom-
mended particularly when testing cardiovascular patients.
Exertional hypotension has been recognized by many authors as an
inadequate and disadvantageous response to exercise; for this reason recor-
ding of the systolic blood pressure during exercise is recommended. Details
on blood pressure and ECG techniques are given in Chapter 7.
44 FUNDAMENTALS OF EXERCISE TESTING

Medical facilities

The room must be equipped with a couch where the patient may lie.
A defibrillator is one of the most important pieces of safety equipment.
A rubber balloon and face mask of the type used by anaesthiologists and an
airway device should also be available to assist respiration if necessary.
Emergency medicines must include drugs against arrhythmias (lidocaine or
procainamide and quinidine); against severe hypotension or shock (a pressor
amine); against angina pectoris (glyceryl trinitrate); against vasovagal
reactions (atropine); and against acute cardiac failure (digitalis). Glucose/
saline infusion sets should be available.

Clinical Precautions

Medical examination of subjects

Prior to exercise a thorough medical history should be recorded; physical

examination should include the cardiorespiratory system with competent
evaluation of a multi-lead ECG recording (see Chapter 7 for details).
During the exercise, continuous monitoring of the ECG increases the
safety of the test considerably by making it possible to stop it as soon as
any significant electrical anomaly appears. It also increases the validity
of the test by revealing ECG changes that appear only at the beginning of
the test, or disappear rapidly soon after the end of the exercise.

Contraindications for exercise testing

The test cannot be performed routinely if significant locomotor distur-
bances are present. Impaired neuromuscular function or skeletal abnorma-
lity may alter the subject's response to exercise, partly by decreasing his
mechanical efficiency (thus vitiating assessments of the cardiorespiratory
functions based on work rate) and partly by throwing an excessive strain
on specific muscle groups (thus leading to early accumulation of lactate).
Anxiety may decisively influence the circulatory response to exercise and
may also increase the heart's vulnerability to arrhythmias.
Manifest cardiac failure, symptoms and electrocardiographic signs of
impending or acute myocardial infarction and myocarditis, and aortic steno-
sis are all contraindications for exercise testing. Three months must elapse
between an acute episode of myocardial infarction and exercise testing.
Acute infectious diseases, unstable metabolic conditions, and the pro-
bability of recent pulmonary embolism are also considered as contraindi-
cations to exercise testing.
Special precautions must be taken when patients with the following con-
ditions are tested: arterial fibrillation or flutter, high degrees of atrioventri-
 SAFETY PRECAUTIONS 45

cular block, left bundle branch block syndrome, and the Wolff-Parkinson-
White syndrome.

Indications for stopping exercise

Discontinuation of the test should be considered as soon as (a) the sub-

jects starts complaining of increasing pain in the chest, severe dyspnoea,
severe fatigue, faintness and claudication, or (b) the subject shows clinical
signs suggestive of an impending emergency situation, including pallor,
cold moist skin, cyanosis, staggering, confusion in response to inquiries,
the facies of cerebrovascular insufficiency, and head-nodding.
The exact limit of increase of systolic blood pressure as a result of exer-
cise is unknown. An exaggerated increase in relation to age and to clinical
condition calls for stopping of the exercise test. Similarly, exertional hypo-
tension or lack of the normal pressure increase during exercise consti-
tutes a contraindication to continued effort.
The ECG should be watched throughout the whole period of the test
and if facilities are available an electronic signal average is most helpful.
The exercise should preferably be halted if the following ECG changes
occur: paroxysmal supraventricular and ventricular arrhythmias, ventricular
premature beats appearing before the end of the T-wave, conduction
disturbances other than a slight atrioventricular block, and ST depression of
horizontal or descending types greater than 0.2 mV. Arrhythmias frequently
become more marked immediately after stopping exercise, and if in doubt the
investigator should always haIt the test.
Some authors maintain that, if no abnormalities occur, the exercise may
proceed even up to the attainment of maximum oxygen uptake. Others,
who are more conservative, recommend cessation of the exercise when the
heart rate reaches the following values:
Age Upper limits
(years) (beats/min)

20-29 170
30-39 160
40-49 150
50-59 140
60 and over 130

Measurements during recovery period

The frequency of both minor and major complications, including arrhyth-

mias, is probably greater during the recovery period than during the exercise
itself. Postural hypotension may develop immediately after exercise, and
this can also provoke arrhythmias. Rapid cooling of the body may further
 FUNDAMENTALS OF EXERCISE TESTING
46

increase the heart's susceptibility to arrhythmias. Unless it is specifically

necessary to make recovery observations, the exercise should be gradually
tapered off and subjects should be seated in a semi-reclining chair to minimize
postural problems. Neither cold nor hot showers should be allowed imme-
diately after the completion of exercise.
A continuation of EeG recording for at least six minutes after exercise
is recommended to detect anomalies that may appear only at a late stage or
become accentuated during the post-exercise period.
 CHAPTER 5

Environmental Specifications and Preparation

for Testing

Careful control of environmental conditions and of the state of the sub-

ject is essential if the results of exercise tests are to be reproducible
and comparable from one laboratory to another. Points to be considered
include the following: influence of the time of day; environmental tempera-
ture; diet; medication and drugs, including tobacco and alcohol; preliminary
rest; anxiety and previous experience of the laboratory; clothing; medical
history; and anthropometric measurements.

Time of Day
Many of the functions commonly measured during exercise tests, such
as pulse rate and body temperature, show a pronounced circadian rhythm
(Mills, 1966). During waking hours a variety of factors also tend to
have a harmful effect on human performance. In many populations of
the world an increasing dose of tobacco particles and nicotine is taken into
the body and leads to bronchospasm, tachycardia, and reduced peripheral
blood flow; and in certain occupational groups the tendency to broncho-
spasm is further enhanced by dusts encountered at work. Again, many
subjects spend their working day standing, and this can lead to peripheral
pooling of fluid with an increase of extracellular water and a reduction of the
central blood volume. For all these reasons the time of day when the
measurements are made is of some importance. Unfortunately this factor
is often determined by hours of employment and is thus outside the control
of the physician. Nevertheless, the time of examination should always be
recorded and, whether an individual is being compared with himself or with
another, every effort should be made to carry out the test at the same time of
day.
Environmental Temperature
A high environmental temperature diverts an increased proportion of
the cardiac output to the subcutaneous vessels during rest and submaximum

-47-

-------....--------------
48 FUNDAMENTALS OF EXERCISE TESTING

exercise, so that predictions of maximum oxygen intake based upon the pulse
response to a given submaximum load fall into error. Brief exposures to
moderate heat have less effect on the maximum oxygen uptake (Saltin,
1964), perhaps because skin blood flow is already maximal. More prolonged
exposure to heat leads to reduction of the central blood volume owing to
sweating and peripheral pooling of fluid; thus, if the patient is tested at the end
of an unduly hot day his maximum oxygen intake may be poor.
The critical range of environmental temperature is from 20°C (68°F) to
30°C (86°F); at 20°C almost all the cutaneous vessels are fully constricted,
and at 30°C almost all are fully dilated. The influence of environmental tem-
perature becomes less as the intensity of exercise is increased, since the exer-
cise itself tends to demand full dilatation of the cutaneous vessels. The
heat-load imposed by a given air temperature depends also upon the radiant
heat, the relative humidity, the air speed, and the nature of the clothing worn
during the test. If radiant heating is avoided, the relative humidity is less
than 60%, and the air is still, then the laboratory temperature should be
kept in the range 18-22°C (64-72°F). The upper limit can be increased by
about 2 deg C if the effective temperature is reduced by the use of a large fan.
Exercise tests are not normally conducted in a cold environment, and
testing should be discouraged if the room temperature is below 10°C (50°F).

Dietary Prerequisites

Both heart rate and ventilation are increased for an hour or more after a
heavy meal, and attempts at intensive exercise can lead to vomiting. On the
other hand, a complete fast leads to a low blood-sugar level and this also can
depress performance. A compromise is thus necessary. On the day before
the test the diet is changed as little as possible, while on the test day the sub-
ject is permitted a light breakfast (toast or bread, fruit, and a bland drink
such as milk or orange juice).

Drugs

The patient should not be allowed to take any unusual drugs on the day
of testing, and in circumstances where maintenance therapy must be conti-
nued (for instance, in a person under digitalis treatment) details of dosage
must be specified.
The taking of stimulants--coffee, tea, nicotine and alcohol-is undesirable
on the day of investigation, but in the case of out-patient investigations it is
difficult to ensure that the patients adhere to the desired regimen. A preli-
minary one-hour period of observation is thus important not only in permit-
ting the patient to rest, but also in stabilizing the dosage of habitual stimu-
lants.
 SPECIFICATIONS FOR TESTING 49

Preliminary Rest
The importance of adequate preliminary rest is well appreciated by ath-
letes, few of whom would consider volunteering for physiological investiga-
tion for several days prior to an important contest. The main adverse effects
of previous activity are a peripheral sequestration of fluid leading to a reduc-
tion of central blood volume (Lundgren, 1946) and stiffness of the affected
muscles. The capacity for prolonged work may also be reduced by exhaus-
tion of muscle glycogen stores.
Ideally the average subject should have a week of rest before the testing,
but this is difficult to obtain. However, unusually strenuous exertion and
non-essential physical work should be avoided on the day prior to testing.
On the day of examination walking and/or driving to the laboratory can be
permitted, but no other strenuous activity should be undertaken. The rest
period before the test itself should be specified, and should preferably be of
at least one hour's duration.

Anxiety
Anxiety on the part of the patient is a greater problem in submaximum
than in maximum exercise. The pulse rate and the respiratory quotient at a
given submaximum load are both increased by anxiety, and the validity of
the usual procedures for interpretation of submaximum test data is compro-
mised. Further, the threshold of various important symptoms, such as
angina and dyspnoea, is lowered and depression of the ST segment of the ECG
occurs much more readily in an anxious patient than in one who is com-
pletely at ease (Dimond, 1961).
Anxiety must thus be kept to a minimum. Where possible, tests should
not, for example, be scheduled on the day before a directors' meeting or ten
minutes before the departure of the last bus. The atmosphere of the labo-
ratory and the temperament of the staff should be quiet and reassuring.
The number of personnel and the quantity of apparatus in the examination
room should be kept to a minimum, and extraneous conversation and street
noise should be eliminated as far as possible. Time should be taken to
explain the test procedures to the patient and allay any specific fears that he
may have. It is sometimes helpful to allow a nervous individual to watch
the testing of a previous patient, but this is not advisable if the test involves
maximum effort or the taking of blood samples. The effects of anxiety can
be overcome quite readily by habituation, i.e., by simple repetition of the
entire test procedure at a second visit.

Clothing
The deep body temperature can rise as much as 1°C within a few min-
utes of continuous submaximum exercise. Free loss of heat from the body
50 FUNDAMENTALS OF EXERCISE TESTING

is thus important to avoid the occurrence of unduly high pulse rates during
the final minutes of exercise. The maximum surface of skin should thus
be exposed, light gymnasium shorts being worn where possible.
The subjects should wear their normal shoes, provided these are com-
fortable and suitable for performing the test. When exercise is performed
barefoot or in gym-shoes with low heels and poor ankle support, the chances
of a sprained ankle or of an injury to the Achilles tendon are substantially
increased.

Medical History

Prior to testing, the medical history of the subject should be recorded

with particular regard to the cardiocirculatory and respiratory systems.
Such a record would provide: (a) necessary clinical data for proper planning
of the test and for evaluation of the results, and (b) indications for safety
precautions to be taken (see Chapter 4).

Anthropometric Measurements

The basic measurements recommended prior to exercise testing are the

following:

Standing height
This is measured once, to the nearest 0.5 cm. The patient stands with-
out shoes and with his back against the wall-measure; the eyes should be
directed straight ahead (the visual axis is horizontal when the top of the ex-
ternal auditory meatus is level with the inferior margin of the orbit), and
a set-square should rest on the scalp and against the measure.

Weight
This is measured once, with a lever balance, to the nearest 100 grams;
the patient should be clad in light undergarments, without shoes. The weight
of the clothing worn by representative individuals is also measured, and the
data corrected to a nude weight, except in the case of the step test, where the
work calculation must be based on the clothing worn during testing. The
balance should be calibrated before and after each study.

Subcutaneous skin/olds
These are measured with calibrated calipers that exert a pressure of
10 g/mm 2 , independent of jaw width. There is a convenient and accurate
method for calibrating the jaw pressure at different caliper openings, and
evidence exists that a variation in jaw pressure of 1 g/mm 2 in the average
skinfold bite affects the skinfold thickness by no more than 0.2 mm (with a
Harpenden caliper). Great care should be taken in locating the skinfold
 SPECIFICATIONS FOR TESTING 51

and in picking it up, since inaccurate procedures may strongly vitiate the
measurements.
Firm pressure must be applied with the fingers in lifting the skin fold and
supporting it during measurement. A fold comprising skin and subcu-
taneous tissue should be grasped. If the patient complains of pain, it means
that only the dermis is being pinched; a firm grasp of the entire skinfold is
usually painless.
The skinfold is grasped about 1 cm above the prescribed site of measure-
ment. The vertical distance from the crest of the fold to the point of mea-
surement should be approximately the same as the thickness of the fold itself.
It is desirable to record two measurements and employ their mean for ana-
lysis.
Results show considerable observer bias, and it is therefore preferable
for one well-trained technician to perform all measurements. If readings
are to be interpreted in an absolute sense, the observer should be checked
against subjects of known fat thickness. Three skinfolds (triceps, subsca-
pular, and supra-iliac) have been recommended for international standardi-
zation.
(a) Triceps skinfold. This is measured on the back of the bare pendant
right arm at a level midway between the tip of the acromion and the tip of the
olecranon (the mid-point is marked with a skin pencil). The skinfold is
lifted parallel to the long axis of the arm, and measurement is made to the
nearest 0.5 mm.
(b) Subscapular skinfold. This is measured to the nearest millimetre
on the bare chest just below the tip of the right scapula, with the subject
standing in a relaxed position.

(c) Supra-iliac skinfold. This is measured to the nearest millimetre just

above the right supra-iliac crest in the lateral line.

The values for all three skinfolds should be tabulated individually, though
they may be amalgamated later on.
The following additional measurements may be of interest:

Arm circumference
This is measured with a snugly applied tape-measure, in duplicate, to the
nearest millimetre, on the bare right arm, relaxed and pendant, midway
between the tip of the acromion and the tip of the olecranon.

Sitting height
This is measured once, in the same manner as standing height except that
the patient is seated on a stool of standard height.
 FUNDAMENTALS OF EXERCISE TESTING
52

Shoulder girdle diameter

This is measured in duplicate with obstetric calipers at the level of the
acromion processes. The patient stands erect against a wall with the shoul-
ders relaxed. Firm pressure is required to measure the exact dimensions.

Pelvic girdle diameter

This is similarly measured in duplicate; the maximum diameter between
the external margins of the iliac crests is recorded.

Bone size
This is measured in duplicate, using obstetric calipers and a steel tape-
measure, at the maximum diameters and circumferences of the right hum-
eral and femoral condyles.
Circumference of chest, abdomen, thigh and calf
These measurements are made only in investigations concerned with the
detailed distribution of tissue masses, prediction of body-fat content, or
changes in body dimensions. A steel tape-measure is used: readings are
taken with the patient standing and are recorded to the nearest centimetre.

Standard methods of procedure are as follows:

(a) Chest circumference. This is measured in men on the bare chest at
the level of the nipples, at the end of a normal expiration.
(b) Abdomen circumference. This is measured on the bare abdomen at
the level of maximum girth.
(c) Thigh circumference. This is measured on the bare right thigh at
the level of maximum girth.
(d) Calf circumference. This is measured on the bare right calf at the
level of maximum girth.
CHAPTER 6

Proposed Clinical Procedures for

Submaximum Exercise Tests

It is widely accepted that the best over-all criterion of cardiorespiratory

health is an individual's maximum oxygen uptake, (VO,)mm and it is also
held that the maximum oxygen uptake should be measured directly.
The direct measurement of maximum oxygen uptake requires that the
subject be exposed to strenuous and exhaustive exercise. This can be done
on athletes, but medical, ethical and other reasons make it impossible to carry
out such exercise tests on every subject in a population, and it would be
most dangerous to expose a sick person or a patient under rehabilitation to
such an exhaustive effort. This procedure cannot, therefore, be recommen-
ded for routine or for clinical use.
Since this manual is intended as a practical aid in the exercise testing of
cardiac patients, children and population groups in general, rather than in
testing for sport purposes or for research in exercise physiology, neither maxi-
mum exercise tests nor the direct measurement of (V02 )max will be dealt with
here.
For clinical purposes a progressive exercise test at increasing submaxi-
mum work intensities is safer, easier to perform and yields adequate infor-
mation. The test should start at a low intensity and the work-load should be
increased at regular intervals, usually every four minutes, until a defined
limit is reached. It is important that each exercise step should last long
enough to establish a steady state with regard to oxygen uptake and usage.
If heart rate is monitored continuously it may be used as a guide to determine
when the steady state is reached, depending on the age and degree of fitness
of the patient. At least four minutes' exercise should be allowed at each
load, and physiological measurements should be taken in the last minute of
each period.
The ECG should be monitored continuously, e.g., by using an oscillo-
scope, and it is also helpful to display an averaged ECG signal. The patient
should be observed continuously in order to detect signs and symptoms indi-
cating that exercise should be stopped (see Chapter 4).

- 53-
54 FUNDAMENTALS OF EXERCISE TESTING

The maximum oxygen uptake can be directly estimated on the basis

of submaximum measurements as described in Chapter 8. Furthermore,
the measurements taken during the steady state provide information as to
whether the circulatory and respiratory response patterns are" normal" or
not. In this way, "abnormal" reactions can be found and related to the
level of work at which they occur. ECG abnormalities can be used in the
diagnosis and prognosis of ischaemic heart diseases, and the parameters may
be used to throw light on the current functional status (see Chapters 9 and 10).

Mode of Performance

Bicycle test

A bicycle ergometer with a mechanical braking system is recommended.

Performance should include the following steps:
(a) Safety precautions, preparation of the patient, and adjustment of the
environment should be carried out as laid down in Chapters 4 and 5.
(b) The height of the saddle pillar should be adjusted to the size of the pa-
tient so that his legs are almost fully extended at the knee-joint when the ball of
the foot is applied to the pedals and one pedal is at its lowest position.
The patient warms up for four minutes by pedalling at a very low, fixed load
(e.g., 10 watts or 60 kpm).
(c) A pedalling rate of 50-60 rev/min! should be used in all tests since
this is the most comfortable rate for people of average fitness. The pedal-
ling rate should be kept constant with the aid of a tachometer, but a metro-
nome or similar device may be used to help the patient maintain the approp-
riate rhythm. The patient should always remain seated and not be allowed
to lift his body. The exercise proper then begins by setting the work-
loads at the predetermined values as described below.
(d) The loading for sub maximum work depends on the age, fitness, and
body weight of the patient. Suggested loads, to be maintained for at least
four minutes, are:
Children: Starting at 150 kpm/min, increasing to 300-450-600 kpm/min,
etc.
Adult males: Starting at 300 kpm/min, increasing to 600-900, etc. (With
athletic subjects the starting load can be 600 or 900 kpm/min.)
Adult females: Starting at 150 kpm/min, increasing to 300-450-600, etc.
(With athletic subjects the starting load may be 500 kpm/min.)

1 This is also the rate where oxygen uptake is minimal.

 PROCEDURES FOR SUBMAXIMUM TESTS
55
In general, it is advisable to be guided by the pulse response to the first
load rather than adhere to a rigid schedule. The aim should be to produce
four evenly spaced pulse readings over the range 40-80% of aerobic power.
The heart rates are recorded at each work-load and will be used for the
estimation of maximum oxygen uptake and maximum work output as des-
cribed in Chapter 8. Alternatively, the graph in Fig. 18 may be used as a
guideline to establish the final loading that should be attained as a function
of age, sex, and body weight. As an example, a 20- to 29-year-old man
weighing 74 kg should be exercised up to 1050 kpm/min, whereas a heavier
man (90 kg) in the same age bracket should be exercised up to 1300 kpm/min;
in both instances, if the subjects are of average fitness, the heart rate should

FIG. 18
LOADINGS FOR BICYCLE ERGOMETER IN SUBJECTS OF DIFFERENT
AGES AND BODY WEIGHTS'
240, - ___

--- -- --------
230{
220 -
1300
~
210

200t '"I
1200

190>
llOO -
180

170
1000
160

iii 150
~
,E 900
E
~140
0
~ I ~800
130 0
~

120

110

100

90

. I
80

70

----'-----------1------'-----.-...L~_~____L_ _.L_~ ----f',---o'c-~---c"!

Ib llO 120 130
L __ ~_~ __ ~ __
kg 50 60
140
~ __ WEIGHT
70
_
150 160 170 180 190 200 210 220
BODY ~ __ ~_~ __ ~ __ ~ __ ~
80 90 100
Ib 80

kg 40
100 110
I

120
!

130 140 150 160

BDDY WEIGHT
•
170
L
180

~---.L------1----L __ --L _ _ -l._---.L. __ ~ ___I _ _ J

50 60 70 80
J
1902DO

90

'Graph drawn from data in Shephard (1969a). All loads correspond to 75% of maximum aerobic
power in a person of average cardiorespiratory fitness. If a subject attains a heart rate 10 beats/min lower
than expected, he is of above average fitness; conversely, if his heart rate is 10 beats/min higher than
expected, he is unfit. The heart rates corresponding to average fitness in the various age-groups are shown
in parentheses (see also Table 6). Cycling was assumed to have a net efficiency of 23%.
56 FUNDAMENTALS OF EXERCISE TESTING

attain about 160. A 50- to 59-year-old woman weighing 55 kg should be

exercised up to only 420 kpm/min and her heart rate should be 145 (see
also data on pulse rates at 75% of maximum aerobic power in Table 6,
page 82).
Elderly persons (above 70 years of age) and convalescent subjects should
follow the procedure recommended for women. All patients must be indi-
vidually monitored and those who are more seriously ill must, obviously, be
given special, continuous attention.

Step test

If the steps illustrated in Fig. 15 are used, the mode of performance of

the test is very simple.

TABLE 4. LOADINGS FOR STEP ERGOMETER IN SUBJECTS OF DIFFERENT AGES

AND BODY WEIGHTS'

Body weight Age-group (years)

(kg)
I (Ib) 20-29
I 30-39
I 40-49
I 50-59

Women: Load in ascents/min a

(167) (160) (154) (145)
36 80 16 16 14 10
41 90 17 16 14 10
45 100 17 17 14 10
50 110 17 17 15 10
54 120 17 17 15 10
59 130 18 17 15 10
63 140 18 17 15 10
68 150 18 18 15 10
72 160 18 18 15 10
77 170 18 18 15 10
81 180 18 18 16 10
86 190 18 18 16 10
91 200 18 18 16 10

Men: Load in ascents/min a

(161) (156) (152) (145)
50 110 20 18 16 13
54 120 20 19 16 13
59 130 20 19 16 13
63 140 21 19 17 13
68 150 21 19 17 13
72 160 21 19 17 13
77 170 21 19 17 14
81 180 21 19 17 14
86 190 21 19 17 14
91 200 21 20 17 14
95 210 21 20 17 14
100 220 21 20 17 14

• The loads correspond to 75% of maximum aerobic power in a person of average cardiorespiratory
fitness. Stepping was assumed to have a net efficiency of 16%. (Based on data from Shephard, 1969a.)
a The figures in parentheses atthe top of each column representthe pulse rates (beats/min) correspond-
ing to average fitness in the age-groups in question. If a person has a pulse rate 10 beats/min lower than
expected, he is of above average fitness; conversely. if his pulse rate is 10 beats/min higher than expected
he is unfit.
 PROCEDURES FOR SUBMAXIMUM TESTS 57

The pattern of ascent and descent is first demonstrated to the patient

and the metronome is then set at the desired rate. A suitable starting
rhythm for a submaximum test on a young and relatively fit man would be
60 paces (10 ascents) per minute. The patient exercises at this rate for four
minutes. He is then asked to increase his speed and the rhythm is increased
to 90, 120 and ISO paces/min at 4-min intervals. In a less fit man or a female
patient, the starting rhythm is 48 paces/min and the increase may be limited
to 72, 96 and 120 paces/min.
The total number of ascents and the actual time should be recorded. In
order to calculate the work performed it is necessary to count the total num-
ber of ascents and multiply this by the body weight; normally the patient is
paced by a metronome. It is vital to ensure that the subject stands erect on
the top step after each ascent and places both heels firmly on the ground after
each descent. The steps may be bolted to the floor to avoid movement; a
padded hand-support is also valuable in giving confidence to older subjects.
Table 4 may be used as a guideline for appropriate loading.

Treadmill test
Prior to the test the patient stands straddling the belt and grasping the hand-
rails. At a given signal he jumps on to the tread and releases his hand grasp
when he is moving confidently. The speed of the treadmill must be checked
while the subject is on the belt; if the mill is horizontal the speed may be
slowed by the weight of the subject, while if there is a steep incline some
acceleration may occur. The choice of speed and slope for a given subject
is rather more arbitrary than for step and bicycle ergometer work, but nomo-
grams are now available that permit approximate predictions of the oxygen
cost of effort. Suggested loadings are:
(a) Horizontal level, variable speed: starting speed 6 km/h, increasing to
8 km/h, 10 km/h, etc.
(b) Constant speed, increasing inclination:
Walking: speed 6 km/h, slope increasing in steps of 2.5%;
Running: speed 10 km/h, slope increasing in steps of 2.5%.
Lower speeds may be used for subjects with cardiovascular disease.

-------....-------------
CHAPTER 7

Techniques for Collection and Evaluation of

Cardiovascular and Respiratory Data during Exercise

Cardiovascular Parameters

Analysis of the more fundamental haemodynamic parameters requires

measurement of cardiac output, heart rate, pressures in the systemic and
pulmonary circulations and electrocardiograms. Some of these measure-
ments can be taken only in specialized hospital laboratories. In particular,
the risk involved in heart catheterization should limit such studies to those
where the measurements must be taken for medical reasons, or when the
investigator himself serves as an experimental subject.
Some circulatory parameters, such as heart rate, brachial artery pressure
(by the cuff method) and EeG, are easily obtained. Others, such as cardiac
output, may also be performed with bloodless procedures and can thus be
conducted in the field laboratory by properly equipped and staffed teams.

Heart rate
The heart rate is easily counted during exercise by palpation of the carot-
id artery or by auscultation of the heart sounds. The procedure is facili-
tated by counting the time occupied by 10 heart beats, i.e., by starting a stop-
watch at 0 and stopping at 10. Heart rate is then calculated according
to the equation:
60
fh = - x 10,
t
where "fh " is the heart rate and "t" is the duration of 10 beats. Stop-
watches are commercially available on which the heart rate may be read
directly from the dial.
It is preferable, however, to record the exercise heart rate by means of an
electrocardiograph. The EeG makes an important contribution to the
safety of a test. It also gives a permanent record and reduces the chances of
error. Telemetry systems for EeG transmission could prove very valuable
in that they would free the exercising subject from the encumbrance of wires

- 58-
 COLLECTION OF DATA DURING EXERCISE 59

and cables. There are now several types commercially available. Details
on the choice of leads and on ECG recording techniques are given below.
The heart rate may be conveniently found by measuring the distance be-
tween 7 R-waves (6 intervals) and applying the following formula:
b
fb = - x 6,
a
where" a" is the distance between 7 beats and" b" is the distance travelled
by the paper in one minute.
The approximate heart rate during exercise may also be monitored by
means of cardiotachometers. Several reliable types are commercially
available. The use of cardiotachometers is helpful in determining when a
relative" steady state" has been reached, and when any determined heart-
rate ceiling has been reached in progressive tests.

Blood pressure
The pressure in the larger vessels and in the cavities of the heart can be
measured by means of catheterization techniques, using either catheter-tip
manometers or, less precisely, liquid transmission along the catheter length.
However, the use of such techniques is limited to well-equipped and properly
staffed hospital laboratories and they should be carried out only when there
are medical indications.
Reference is made to a handbook dealing with catheterization techniques
and direct blood pressure measurement (Sjostrand, 1967). Both systolic
and diastolic pressures can be measured and the approximate mean pres-
sure is usually indicated by the measuring instrument itself.
The brachial artery pressure may be measured by the conventional cuff
method, which, however, has certain disadvantages when used during exer-
cise. Only the systolic blood pressure can be assessed reasonably well
during exercise, and readings of 300 mm Hg and more have been recorded
without any apparent discomfort or hazard to the patients concerned.
Exertional hypotension seems to be recognized by many as an inadequate
and disadvantageous response to exercise. For this reason, recording of the
systolic blood pressure during exercise is recommended as a safety measure
(see Chapter 4). Attempts to measure the diastolic pressure are generally
regarded as unsatisfactory. For details on the technique of indirect blood
pressure measurement see Rose & Blackburn (1968).
The mean arterial pressure may be calculated from measurements of
systolic and diastolic pressure according to the equation:
Mean arterial pressure = diastolic pressure +t pulse pressure.
The pulse pressure is the difference between the systolic and the diastolic
pressure.
60 FUNDAMENTALS OF EXERCISE TESTING

Electrocardiogram

Choice of leads
Before exercise, the classic 12-lead recording is essential as well as the
recording from the lead that will be used during the exercise test.
Various methods of recording during exercise have been suggested.
Certain bipolar or transthoracic leads increase the QRS amplitude and the ST
depression, others seem little sensitive to changes in the electrical position
of the heart, while still others are less sensitive to extraneous interference
(Blackburn & Katigbak, 1964; Blackburn, 1969).
Various possible ways of recording have been proposed. If four leads
can be used, they should be I, II or aVF (aVF electrode and reference elec-
trode placed at the base of the spine, level with the iliac crests), V 2 and V5;
the CH leads (reference electrode placed on the forehead) may also be used.
A good solution is a 7-cable lead, with the limb leads placed below each cla-
vicle distally and in the flank above the iliac crest, chest positions being
V4 , Vs and V6 • It is then possible to record I, II, aVF, V4 , Vs and V6 ,
which contain all the information available from 12 leads (Blackburn, 1969).
If a bipolar lead system can be used, preference should be given to the
lead exploring point V5; the reference electrode should be placed at the
symmetrical point on the right hemithorax (C5-C5R) or on the manubrium
sterni (CM5). The neutral electrode may be placed on the back of the neck,
the forehead, or the right arm, as convenience dictates.
Mter exercise, the leads that were used during the test should be supple-
mented by leads I, II and III, a VL and a VF.

Recording technique
Correct preparation of the skin, which should be reddened by rubbing
with ether, and the choice of electrodes are important in order to obtain a
readable ECG tracing during the test. Various types of special electrodes
have their advocates; as a rule preference should be given to electrodes
avoiding direct contact between the skin and the metal by the interposition
of a special paste. However, good results can be obtained from standard
suction cups if these are carefully applied.
Continuous recording during exercise considerably increases both the
safety of the test, by making it possible to stop it as soon as any significant
electrical anomaly appears, and its validity, by revealing changes in the
ECG that appear only at the commencement of the test or disappear rapidly
after the end of exercise (Bellet & Muller, 1965). A continuation of recor-
ding for at least six minutes after exercise is desirable, to detect anomalies
that may appear only at a late stage or become accentuated during the post-
exercise period (Abarquez et aI., 1964). A comparison of ECG recordings
during bicycle and step tests has been reported by Folli et ai. (1965).
 COLLECTION OF DATA DURING EXERCISE 61

Cardiac output
Cardiac output may be measured by either "bloody" or bloodless
methods. The "bloody" methods require indwelling catheters in the syste-
mic and pulmonary arteries and should be performed only in well-equipped
hospital laboratories and on medical indication. Catheterization tech-
niques should be learned only in specialized laboratories and they will there-
fore not be dealt with in this manual (for further information, see Sjostrand,
1967). Both the" bloody" and the bloodless methods of cardiac output deter-
mination require highly trained personnel, expensive equipment, and com-
plicated analytical procedures. Only outlines of the techniques will be
described here; further details may be found in Degre (1968).

" Bloody" methods

Fick principle. The oxygen content is measured in mixed venous blood
(sample taken from pulmonary artery) and in arterial blood, and the arterio-
venous oxygen difference is calculated. If the oxygen uptake is mea-
sured simultaneously, the cardiac output can be calculated according to the
following formula:

In cases of congenital malformations, with communication between the

pulmonary and systemic circulations, blood may be shunted from one cir-
culation to another. This affects the oxygen content of the blood sampled
from the different parts of the system and analysis of these differences may
permit the diagnosis of such shunts.
Indicator dilution technique. If a known quantity of indicator substance
(either a radio-isotope or a dye) is injected into the circulation at one place
and samples are then drawn sequentially at another place, the concentration
of the indicator at the sampling site will be lower than that at the injection
site. A dilution curve can thus be drawn and the blood flow passing the
sampling site may be calculated.
According to Degre (I968), if "ill" is the injection rate of the indicator
and" C/' is the concentration of indicator at the sampling site at time" t",
then the cardiac output at time "t" is given by the formula:

. m
Qt=-·
Ct
The time interval between injection and the first appearance of indicator
substance at the sampling site is termed the appearance time. The concen-
tration thereafter increases quickly to a maximum, and then decreases in
an almost exponential fashion. Before the concentration reaches zero a
62 FUNDAMENTALS OF EXERCISE TESTING

new increase occurs as a result of recirculation. Recirculation of the indi-

cator substance makes it impossible to determine the passage time directly.
Since disappearance is exponential, the concentration curve may be plotted
against time on semilogarithmic paper and the passage time can be found by
extrapolation to zero concentration. The mean concentration of indicator
substance at the sampling site is determined by dividing the area of the graph
(total amount of substance) by the passage time.

Bloodless methods
Inhalation of a foreign gas. A foreign gas (e.g., acetylene) with a known
blood solubility coefficient is inhaled from an air or oxygen mixture. The
uptake of the foreign gas is measured over unit time and from this figure and
the solubility of the foreign gas in the blood, the cardiac output can be cal-
culated.
The method was introduced by Grollman (1929) and further worked out
by Christensen (1931).
The acetylene method has been considerably refined in recent years by
shortening the rebreathing period to a maximum of 7 seconds (thus avoi-
ding significant recirculation); by using lower concentrations of acetylene
(maximum 1%), whit:h are subjectively more acceptable and avoid danger of
explosion; by mOle accurate determinations of the solubility of acetylene;
and by the development of modern techniques of acetylene analysis (gas
chromatography, infra-red analysis, mass spectrography). The main disad-
vantages of the method are the need for regular and deep breathing (60 breaths
per minute, which is unnatural except during heavy exercise) and the assump-
tion that gas mixing in the lungs is adequate. As with most other techniques
for the measurement of cardiac output, trained personnel are needed to
take carefully timed gas samples, and the necessary analytical equipment is
quite expensive.
CO 2 - rebreathing procedure. The arteriovenous CO 2 difference and the
CO 2 output are measured, and the cardiac output is calculated according to
Fick's principle:
Q= VC02
Ca , C02 - Cy-, cO 2

The content of CO 2 in mixed venous blood is measured by one of two

possible rebreathing procedures (Campbell & Howell, 1960; Defares, 1958).
The content of CO 2 in arterial blood can be derived in various ways (see
Klausen, 1965; Lambertsen & Benjamin, 1959; Magel & Lange Andersen,
1968; Bar-Or et aI., 1969).
Reference must be made to a standard CO 2 dissociation curve, and
this creates problems in many clinical disorders. As with the acetylene
method, regular and deep breathing is required together with adequate gas
mixing; the equipment is also expensive and the arteriovenous CO 2 difference
 COLLECTION OF DATA DURING EXERCISE
63
is too small to permit accurate measurements at rest. None of the blood-
less procedures has yet reached the point where it can confidently be recom-
mended for general use. However, in view of the many disadvantages of
catheterization, including time, cost, disturbance of the patient's basal meta-
bolic state, prescription of sedative medication, and inherent risks, the use of
bloodless rather than "bloody" techniques for the estimation of cardiac
output is preferable.

Other cardiovascular parameters

Oxygen pulse

The oxygen pulse is defined as the oxygen uptake divided by the heart
rate, and is calculated accordingly:

Oxygen pulse (mljbeat) = V~ .

fh
The oxygen pulse is a function of the stroke volume and of the arterio-
venous oxygen difference.
Stroke volume

When cardiac output and heart rate are measured, the stroke volume can
be calculated:
Q.
Qs (m!) = -
fh
Arteriovenous oxygen difference
When oxygen uptake and cardiac output are measured, the arteriovenous
oxygen difference can be calculated:

C•. 02 - CV• 02 (mljlitre) = ~02.

Q
Left ventricular work
When cardiac output and mean blood pressure in the aorta are measured,
the work rate of the left ventricle (WI) can be calculated:

WI (kpmjmin) = QX BPmean •
Several authors calculate an indirect index of left ventricular work from
measurements of arterial blood pressure (by an indirect method) and heart
rate.
Ritmeester & Boutkan (unpublished report, 1956) propose the following
equation:
 FUNDAMENTALS OF EXERCISE TESTING
64

where "Wh " is the work of the heart ' "f"

h is the heart rate ' "PS,a "is the
systolic pressure, and "PD,a" is the diastolic pressure. Hellerstein et al.
(1967) recommend the use of the following index:

Resistance and conductance

A pressure gradient between two areas in a vessel causes blood to flow
from the high pressure area towards the low pressure area, while resistance
impedes the flow. This can be expressed mathematically as follows:

. ilP ilP
Q= - or R = -
R Q'
where "Q" is the blood flow (litres/min), "ilP" is the pressure gradient
1
(mm Hg), and "R" is the resistance.
Resistance cannot be measured directly; it can only be calculated from
the above formula. "R" is expressed in arbitrary units or in dynes sec/em S
(see also Table 1).
Since the pressure in the right atrium is close to zero, the total resistance
in the systemic circulation is:

Rtotal (in arbitrary units) = BP~ean

Q
or
Rtotal (dynes sec/ems) = BP~ean x 1.333 x 60.
Q

Conductance is the reciprocal of resistance: C = .!.

R .

Heart size
Heart volume is measured by standard X-ray techniques, using frontal
and lateral films. A focus to film distance of 2 m and an object to film
distance of 10 em for the sagittal film and of 20 em for the transverse film
are recommended. The films are taken at the end of an ordinary inspiration
and no synchronization between exposure and phase of the heart cycle is
necessary.
Details of the technique are given in several publications to which
the reader is referred (J onsel, 1939; Ammundsen, 1959; Reindell et ai.,
1967).

1 In arbitrary units.
 COLLECTION OF DATA DURING EXERCISE 65

Total haemoglobin and blood volume

The total blood volume (TBV) is defined as the sum of the cells and
plasma within the vascular system. The methods available for measuring
TBV are based on dilution procedures. A known amount of an indicator
substance (a radioisotope or a dye) is injected into the blood; after a given
time, blood is withdrawn and the final concentration of indicator is deter-
mined and used to calculate the red cell volume (RCV) and/or the plasma
volume (PV). Sjostrand (1948) has worked out a method for determining
total haemoglobin, and hence TBV, by introducing a known quantity of
carbon monoxide into the blood through inhalation and subsequently
measuring the concentration of carboxyhaemoglobin in the peripheral
blood. Reference is made to this paper for details.

Blood lactate
Capillary blood sampled from the finger-tip (or ear-lobe) after warming
of the hand by immersion in water at 45°C may be used for the deter-
mination ofblood lactate.
Either the photometric method, originally described by Barker &
Summerson (1941) and later modified by Stram (1949), or the micro-method
described by Scholander & Bradstreet (1962) may be used.
Enzyme methods have also been described (for references see Shephard
et aI., 1968a).

Respiratory Parameters

It is desirable that at least the following respiratory measurements

be taken:
(1) Respiratory minute volume (gas volume expired per unit time);
(2) Respiratory frequency (with subsequent calculation of tidal volume);
(3) Respiratory gas exchange, including oxygen uptake, carbon dioxide
output, and respiratory gas exchange ratio.
The use of an open-circuit system is recommended for taking these
measurements. Closed-circuit systems suffer from several important defects,
namely:
(1) Erroneous results can arise from displacement of the end-tidal
position or alterations of thoracic blood volume.
(2) Volume errors can arise from temperature changes, particularly
at high metabolic loads.
(3) The performance of the available apparatus is inadequate in terms of
resistance and inertia at high metabolic loads .
66 FUNDAMENTALS OF EXERCISE TESTING

(4) Leakage, for which both systems should be checked before use,
has a much greater effect on the results in a closed than in an open system.
All determinations of respiratory gas exchange require careful analytical
work. Techniques of measurement should preferably be learned in a refe-
rence laboratory to avoid systematic errors.

Collection of expired gas

Expired gas may be collected in bags (Douglas bags) or spirometer

tanks. Several types of Douglas bags made of vinyl plastic or heavy-duty
polyethylene are commercially available in various sizes (100-250 litres). It
is important to select a broad-necked design. A flexible side-arm tube for
direct sampling of gas is sometimes provided, but it is preferable to collect
from the tube leading to the spirometer after the bag has been partially
emptied. When using Douglas bags in the collection of expired air, leakage
of CO 2 due to diffusion is unavoidable; however, the effects of such diffusion
may be minimized if the bags are filled almost to the limit of their capacity,
and if they are sampled and emptied through a gas-meter as quickly as
possible after collection.
If a conventional bell spirometer is used instead, problems may arise from
filling resistance, inertial overshoot, and changes in expired gas tempera-
ture. The first two problems may be largely overcome by using a light-
weight bell or dry plastic spirometer of sufficient size (bell capacity of at
least 100-150 litres). The use of a bell spirometer has the advantage that the
respiratory movements can be recorded by means of a conventional recording
drum. Several dry gas-meters (respirometers) are available that meter the
expired gas volume immediately and allow aliquot air samples to be drawn
for further analysis. However, in general, they have too high a resistance
and too Iowan accuracy for on-line use. The portable Max-Planck
respirometer is designed for field use and for measurements of light effort;
it will not accommodate the gas volumes encountered in heavy exercise
testing.
Face masks are difficult to use in exercise tests owing to problems of
dead space and leakage. A conventional nose-clip and a broad-flanged
mouthpiece fitted to a low-resistance (less than 5 cm H 2 0 pressure at a
flow of 300 litres/min), low-dead-space (preferably below 50 ml) respiratory
valve is recommended. The opening pressure of the wet valve should not
exceed 2.5 cm H 2 0 pressure.
Connecting tubes and stopcocks should have a smooth internal bore,
with a diameter of at least 30 mm, and sudden angulation of the air-stream
should be avoided. Non-corrugated flexible hose should be used with as
short a length as possible (about 1 m). The total expiratory gas line should
be free to move in two directions, perpendicular to one another. The
 COLLECTION OF DATA DURING EXERCISE 67

system should have a resistance to air flow not exceeding 1.5 cm H 2 0 at a

flow rate of 200 litresjmin.
The three-way stopcock connecting the patient to the Douglas bag or
spirometer should be opened at the end of an expiration when exercise
starts and closed, also at the end of an expiration, when exercise stops. The
time during which the collection is made must be noted accurately and is
used in the calculation of the results.
Mouthpieces should be washed with soap and water and, if they will
withstand boiling, it is recommended that they be sterilized in boiling water
for 3-5 min. When boiling is impossible, the use of a standard bactericide
at the recommended dosage is advised. Nose-clips need not be sterilized
except after they have been used on a subject with nasal secretions or a
superficial skin infection. Valves and connexions should be washed with
soap and water after use. Even when using the open system, washing of the
tubing past the expiratory valves is desirable as bacteriological studies
have shown that micro-organisms can regurgitate past one-way valves.

Recording of breathing frequency

The breathing rate (breaths per minute) can be counted simply by obser-
ving the patient; if a spirometer is used the respiratory movements are
recorded by the writing device and recording drum. Several other more
complicated systems have been designed to indicate breathing frequency.
The tidal volume (VT), in ml, is calculated from the measurement of
respiratory minute volume eVE) and breathing frequency (fR) according
to the following formula:

Gas metering

Either large bell spiro meters or some type of gas-meter, either wet or
dry, can be used to measure gas volumes. Dry gas-meters are handy
instruments in field studies but they require frequent calibration. When
dry or wet gas-meters are used it is important not to exceed the specified
rate of operation in order to secure accurate measurements. Various
flow-meters are also available. These may be used in metering gas volume,
but in general they are more expensive and offer little advantage.
After the expired air has been collected in bags it is metered by passing
it either into a bell spirometer or through a gas meter. Various arrange-
ments, such as air pumps and other control devices, may be employed to
secure standard operation and to facilitate the procedure.
The temperature of the collected gas must be recorded with an accuracy
of 0.2deg C. This can be done by inserting a thermometer in the exit part
68 FUNDAMENTALS OF EXERCISE TESTING

of the gas-meter or at the top of the spirometer bell. It is important to

allow time for equilibration of temperature between the thermometer,
air and water, and this is one rather serious drawback to on-line measure-
ments of gas volume.
The barometric air pressure must be recorded to the nearest mm Hg,
using an accurate barometer (preferably a mercury barometer).
The expired gas volume should be expressed under STPD (standard
temperature and pressure, dry gas) conditions, using the appropriate factors.
Alternatively, a small desk-top computer may be programmed to carry out
the necessary calculations.

Gas sampling

Aliquot gas samples may be collected in glass syringes (50 ml or larger),

in small bags within an air-tight metal or glass container, or in traditional
mercury sampling tubes. The gas samples should preferably be analysed as
quickly as possible, although their composition remains unchanged for at
least six hours in well-greased syringes or mercury sampling tubes.
If glass syringes are used they should be initially dried and cleaned,
and then lubricated carefully with a compound that does not absorb CO 2 ;
ethylene glycol is recommended.

Gas analysis

Either chemical or physical methods may be employed, and an accuracy

within ±0.05% should be obtained. Chemical methods require less expen-
sive apparatus and have slightly greater precision if employed by well-
trained personnel; however, they are more time-consuming than the physical
methods and periodic checks of technique should be made against known
gas mixtures if serious errors are to be avoided.

Chemical methods
Haldane gas analyser (Haldane & Priestley, 1935). Carbon dioxide
is absorbed in potassium hydroxide solution, and oxygen is subsequently
absorbed in a solution of either pyrogallic acid or of anthraquinone (which
gives a faster reaction). The remaining gases in the sample are normally
inert, nitrogen making up the major portion. This method being a volu-
metric one, the initial sample volume must be recorded and the percentage
of carbon dioxide and oxygen in the dry mixture calculated from respective
decrements of gas volume in the two absorption chambers.
An accuracy of ±O.02% is claimed. The analysis takes from five to
ten minutes to perform, depending on the design (original Haldane or
Lloyd modification) and the rate of the oxygen-absorbing reaction.
 COLLECTION OF DATA DURING EXERCISE 69

Scholander O.5-ml gas analyser (Scholander, 1947). This method is

also volumetric. It uses a 10% solution of potassium hydroxide as CO 2
absorber and a solution of sodium anthraquinone-ji-sulfonate as oxygen
absorber. It has the same accuracy as the Haldane method but is rather
more liable to systematic error. It requires a smaller air sample (0.5 ml is
sufficient) and an experienced analyst can perform a single analysis in
6-8 minutes.

Physical methods
There are several physical methods of carrying out gas analysis. The
apparatus required involves a substantial capital outlay, but in a busy
laboratory may ultimately prove cheaper than a team of well-trained
Haldane analysts. In order to operate the physical analysers with sufficient
precision, careful and frequent calibration is necessary; a supply of gas
cylinders of known composition is thus required. Details of the various
techniques have been described by White (1958), but an outline of the
methods more frequently used is given below.
Thermal conductivity method. This method is based on the principle that
when the resistance wire is heated in the path of a gas stream, the heat
generated by the wire is conducted away at a rate proportional to the thermal
conductivity of the particular gas. A hot filament, when heated by a
constant power input, has a well-defined resistance to electrical current
at any given temperature. As heat is conducted away differentially from
the hot filament by different gases the temperature of the filament changes;
this causes a change in its electrical resistance that can be converted elec-
tronically into a current signal.
Thermal conductivity methods provide a reliable, although rather slow,
means of analysing the CO 2 content of respiratory gas. They have occasion-
ally been used for the measurement of oxygen concentrations, but this
is not to be recommended since the effect of varying O2 concentrations on
thermal conductivity is slight.
Paramagnetic oxygen analysis. The partial pressure of oxygen influences
the forces developed in a magnetic field, and this principle is utilized in the
construction of paramagnetic oxygen analysers. These instruments give
reliable measurements of oxygen tension, which can be converted to concen-
tration (%v/v of dry gas). The instruments can be calibrated manometri-
cally and are well suited to respiratory gas analysis in the laboratory.
Infra-red carbon dioxide gas analysers. Carbon dioxide and many
other hetero-atomic gases absorb light strongly in the infra-red region of
the spectrum; this principle is utilized in the infra-red CO 2 gas analysers.
Several instruments suitable for respiratory gas analysis are commercially
available.
 70 FUNDAMENTALS OF EXERCISE TESTING

Calculations : Oxygen uptake and respiratory gas exchange ratio

Since all gas volumes must be corrected to STPD it is essential that gas
temperature and barometric pressure be recorded. One convenient way
of converting gas volumes that are collected and metered at ATPS (ambient

FIG. 19
NOMOGRAM FOR DETERMINING STPD FACTORS FOR REDUCTION OF SATURATED
GAS VOLUMES TO DRY VOLUMES AT OoC AND 760 mm Hg*

44-
B o

:1
~
43 {)

42-
-I
-2
c
., -3
600/

r
41
--4
10-1 590
40 -5 20 -)

39
--6
--7 ,0-1 -.BOO
600

:J
l
-8
313
-9 10

-10
;.-620

l::
-:II~
36 >- ,
cr:
:::>
-13 <.0 630
cr:
-14 w
.700-
-15
-16 -,900
'"
"-
0
40

-17

60
.--20
2'>
\ -21 ...J
2&- ...J 670
-22. cr:
27 - -23
.--24
:: J 0
f-
<.0 '"=" 680

:1~'1
-25
« -00 w
800- LL
1.000 cr: 690
--26 :::>
2<>
[ --27 '"
Q. ~

2
-28 t; w
cr: 700
2
21- --
[--29
30
-31
CL

'"
cr:
710

r --32
f-
UJ

'"cr: 720

'I','~:
80 0

-'~oo

{;
«
00 730
-35
-)0
-36 .900-
--20
-37 -'0
740
-38

:;
-40

:~
1-39 750

rf--:~
I
-'0

-42
"
'0
80 760

7-
--43 '0-
80 _
"
~-_ :200 770

-
-44
6 -45 '0-
5- 1000 -
4-
--46
)0 "
40
7eo

r
47 >0
3
-48 '0
2
-49 "
o -50

• From Consolazio et al. (1963).

 FIG. 20
NOMOGRAM FOR CALCULATING RESPIRATORY QUOTIENT (GAS EXCHANGE RATIO)
AND TRUE OXYGEN FROM ANALYSES OF EXPIRED AIR'

D B

""
0 .,
W
Z 1800
~
a::
w
I-
w 300
0
W
0 ,- ;0

""
X
0
0
"'-
Q:- ""z 0
W
z
Z f2 w
~
0
en ;: '-"
>-
X
a::
w
a:: Q: 0 <00 I-
cot: w
u tJ
Q:-
w 0
::J
a:: z
I- w
'-"
>-
X
0

;00

c,

'From Consolazio et al. (1963).

72 FUNDAMENTALS OF EXERCISE TESTING

temperature and pressure, saturated with vapour) to STPD volumes is to

multiply the ATPS volume by the STPD factor shown in Fig. 19 (Consolazio
et al., 1963). The observed gas temperature is plotted on scale A or B, and
the ambient barometric pressure on scale C. A line is drawn between the
two points, and the STPD factor is read off scale D or E respectively. An
alternative and even simpler procedure is to programme a small desk-top
computer to convert ATPS to STPD values.
In order to calculate oxygen uptake ("Vo,) from measurements of expired
air volume (at STPD), Consolazio et al. (1963) introduced the term "true
oxygen". True oxygen is defined as the factor by which the expired air
volume (at STPD) should be mUltiplied in order to calculate the oxygen
uptake.
The true-oxygen factor is calculated according to the formula:
True oxygen = % N2 in expired air x 0.265 - % O 2 in expired air.
The respiratory gas exchange ratio (R) is calculated according to the
following formula:
R = % CO 2 in expired air - 0.03
True oxygen
True oxygen and R may be read off a nomogram, such as that shown
in Fig. 20. In this nomogram, the observed values (in % dry air) for the
CO 2 and O 2 concentrations in the expired air are plotted on scales A and
B respectively. A line is drawn between the two points, and the "true
oxygen factor" and the respiratory gas exchange ratio (R) are read off
scales D and C respectively. Alternatively, these values may be calculated
on small desk-top computers, thus eliminating observer errors in the reading
of charts.
Examples of protocols for the tabulation of data where the results are
calculated without the aid of a computer (A) and with a desk-top computer
(B) are given opposite.
The machine prints out: (VE)BTPS (litresJmin)
(VE)STPD (litresJmin)
(V0 2 )sTPD (litresJmin)
R
 A. WITHOUT COMPUTER

Ventilation Expired air

Sampling Gas STPD Oxygen
temp. BTPS'
time factor factor uptake
(oC) litres True (Iitres/min)
ATPS
I
litres/min
STPD
I
litres/min
BTPS"
%0 2
I C0
% 21
R
I O2 ("')
ot""
t;;
I I 1 1 1 I I I I I I ("')
j
~
I I I I I I I I I I o
J_ 1 1
1
"!'j

o
I I I I I ~~ - - 1 ___ -' - - - 1
~
" Body temperature and pressure, saturated with vapour.
o
~
B. WITH DESK-TOP COMPUTER ~
trI

Spirometer Gas temp. Water vapour Barometric pressure 02 CO 2 ~

reading
I (oC) (mm Hg) (mm Hg)
I (%)
I (%) ("')
gj
I I I I I
1 1 I 1- ---

-l
W
CHAPTER 8

Expression of Results: Maximum Work Output and

Maximum Oxygen Uptake

The physiological data obtained during submaximum work may be

expressed in the following ways:
(1) in relation to work rate, e.g., at 300-450-600 kpm/min, etc.;
(2) in relation to metabolic load, e.g., at 1.0-1.5-2.0 litres/min oxygen
uptake, etc.; and
(3) in relation to a percentage of the maximum oxygen uptake, e.g., at
25%-50%-75%.

Maximum work output (Wmax) and maximum oxygen uptake (Vo 2)max-i . e.,
the amount of work performed and oxygen consumed at maximal heart
rate-are the most important criteria for assessing physical fitness in general
and cardiorespiratory function in particular (see Fig. 22).

Work Output

In bicycling and in stepping, the work output is usually expressed in

kilopond-metres (kpm) or kilogram-metres (kgm), which are equivalent in
unit gravitational field, whereas work rate is expressed in kpm/min, kgm/min,
or watts.
The conversion of kpm/min into watts, or vice versa, can be made
according to the equation: I watt ="= 6 kpmjmin, or 1 kpmjmin ="= 0.167 watt.
The ordinate axis of the graph in Fig. 18 may be used as a nomogram for
the interconversion of watts and kpmjmin.

Bicycle test
The net mechanical efficiency of bicycle riding has been assessed III
many laboratories and averages about 22% ±4%.

-74-
 EXPRESSION OF RESULTS 75

The total work output (W,) during the whole testing period "t" can be
calculated as follows:

where "w" is the work (indicated in kpm on the machine scale) performed
during one rotation of the ergometer wheel, and "a" is the number of
rotations of the wheel in time "t", which is indicated by the revolution
counter.
The work rate Win kpm/min would therefore be: W,/t.
An example of a protocol for calculating the work rate on a mechanical
bicycle ergometer is given below.

Exercise periods 1 2 3

Duration (t) of each exercise period, in minutes

------
Loads (w) on ergometer wheel in kpm

Number (a) of wheel rotations in time t

Work output in time t (WI = wxa) in kpm

------
Work rate eN = Wtlt) in kpm/min

Step test

The mechanical efficiency of effort in stepping is lower and a little more

variable than that on the bicycle ergometer (16%, as compared with 22%).
However, it is still quite practical to equate work performed and oxygen
consumed, if facilities are not available for oxygen analysis. A load of
700 kpm/min on the step test is approximately equivalent to a load of
1000 kpm/min on the bicycle ergometer.
If care is taken to ensure complete ascent and descent, the work per-
formed in time "t" (W,) can be estimated with reasonable accuracy from the
step height, body weight and number of ascents according to the formula:
W, (kpm) = body weight (kg) x height of steps (m) x number of
ascents in time "t".

1 If a standard torque is applied to the pedals for calibration, then the torque factor "k" should be included
in the calculation: WI = k x w x a.
 FUNDAMENTALS OF EXERCISE TESTING
76

Treadmill test
The work output cannot be directly calculated in activities such as
walking and running. All measurements, and in particular oxygen uptake
(see below), must therefore be related to inclination and speed.

Maximum Oxygen Uptake

The oxygen uptake and the net mechanical efficiency of sub maximum
"steady state" exercises should be calculated and expressed in relation to
work output. Maximum oxygen uptake can be determined in various
ways:

Direct methods
These involve performing muscular exercise at increasing intensities
and establishing the level of work rate above which a further increase in
work output does not bring about any increase in oxygen uptake. This
"plateauing" of oxygen uptake is the best single criterion that the maximum
value has been reached (Fig. 21). Subsidiary criteria are a blood lactate
level of over 100 mg/lOO ml (Fig. 21), a gas exchange ratio higher than
1.15, and a pulse rate in excess of the predicted maximum.

FIG. 21
DIRECT DETERMINATION OF MAXIMUM OXYGEN UPTAKE:
OXYGEN UPTAKE IN RELATION TO WORK OUTPUT ON BICYCLE ERGOMETER AND BLOOD
LACTATE LEVEL 4-6 MINUTES AFTER CESSATION OF EXERCISE'

4.0,...-------------------------

c
/~~~rna~ _______ _
100
~ 3.0 -
~
~

w - 60 ~
~ 2.0 w
e- e-
o.. <C
:::J
40 t;
z: <C
W ...J
~ 1.0
x
co
20 :sco
J 0
05
600 900 1200 1500
300
WORK PERFORMED (kpm. min)

• __• Oxygen uptake

0 - - 0 Blood lactate
'Submaximum exercise for 6 min; maximum exercise for 3 min. The maximum oxygen uptake corres-
ponds to the level of work where a further increase in work output does not result in any higher oxygen
uptake. (Figure kindly supplied by Professor K. Lange Andersen.)
 EXPRESSION OF RESULTS 77
Indirect methods

Fitting of a linear regression line

This method is based on the establishment of the linear relation (see
Fig. 2) that exists between heart rate and oxygen uptake measured when the
metabolic rate, circulation, and respiration have reached a "steady state"
response to submaximum work, and subsequent extrapolation to "maxi-
mum" heart rate (Fig. 22).

FIG. 22
INDIRECT ESTIMATION OF MAXIMUM WORK AND OF MAXIMUM OXYGEN UPTAKE.

200

---- -Milximum
-- -- heart rate
- - - --71
./' I
Extrapolation ~" I
j
E

150
.,/'/ ~!
. '~I

100
/ -gl
:1
.",gl
I
I
J~_----,---_ i
300 600 900 1200 1500
Work rate (kpm/ min) I
I t
0.5 1.5 2 2.5
Oxygen u~take (Iitres/ min)

·Redrawn from Lange Andersen & Smith Sivertsen (1966).

The procedure involves making the subject exercise at several work-

loads (see Chapter 6) and measuring oxygen uptake and heart rate when
a steady state response is reached at each load. The heart rates are plotted
against the corresponding values of oxygen consumption and a straight
line is fitted, either by eye or by the method of least squares. This line is
extrapolated to the predicted maximum heart rate; the corresponding
oxygen consumption, CVOz)max, can then be read off. Since the maximum
heart rate is age-dependent (see Fig. 1), the value needed for the extrapola-
tion should be previously obtained from the graph in Fig. 23. It is advi-
sable that a graph of this type be constructed relative to the population
group to which the subjects under study belong. Some authors avoid this
complication by extrapolating to heart rate 170 instead of the maximum
and using, therefore, (V02) 170 instead of (VoJrnax .
78 FUNDAMENTALS OF EXERCISE TESTING

FIG. 23
RELATION BETWEEN MAXIMUM RATE AND AGE'

200~~--~~--------~----------~-----------'

-;;- 190
E
?
! 180
'"ro
i 170 ----I--
5E I
'x
:l¥ 160 I

150 - -+ --
I
I

30 40 50 60 70 80
Age (years)

'Figure kindly supplied by Professor K. Lange Andersen.

FIG. 24
RELATION BETWEEN WORK RATE AND OXYGEN UPTAKE IN BICYCLE TESTING'

300 600 900 1200 1500 1800 2100 2400

Work rate (kpm/ min)

'Figure kindly supplied by Professor K. Lange Andersen.

This indirect method may be simplified by establishing the linear rela-

tionship between heart rate and work performed (instead of oxygen uptake),
with subsequent extrapolation to maximum (or 170, if so preferred) heart
rate. In this way, the maximum work rate (W'max)--or, alternatively, W'170-
 EXPRESSION OF RESULTS 79

can be evaluated (see Fig. 22). Maximum oxygen uptake can then be
more accurately estimated by using the relationship between work rate and
oxygen uptake shown in Fig. 24. Table 5 exemplifies mean values of
(V02)max.

TABLE 5. TYPICAL MEAN VALUES OF MAXIMUM OXYGEN

UPTAKE (ml/min/kg body-wt, STPD)*

Age-group Men Women

(years)
I I
20-29 44 36
30-39 42 34
40-49 39 33
50-59 36 29
60-69
70-79
32
27
--

* Norwegian population sample (unpublished data supplied by Professor K. Lange Andersen).

The fitting of the line requires at least three, and preferably four, points
ranging from a heart rate of 110-120 to one of about 150-180, depending
upon the age of the subject. The main disadvantage of this approach is that
the fitting of the linear regression line gives an excessive weight to the lowest
points on the line and these points are rather readily distorted by anxiety
and an increase in environmental temperature. Empirically established
age-dependent mean maximum values of oxygen uptake for a given popula-
tion are often used as an approximation for the maximum heart rate of an
individual.

Use of a nomogram
Astrand & Ryhming (1954) have proposed nomograms for the evalua-
tion of oxygen uptake during stepping or cycling submaximum exercises.
Pulse rate is measured at one or more submaximum loads, together with
the corresponding oxygen consumption or work rate. The maximum oxygen
uptake is then estimated directly from the nomograms.
In using either of these nomograms corrections should be made for
variations in maximum heart rate with age. Fig. 25 shows the Astrand-
Ryhming nomogram.
With the aid of this nomogram it is possible to compute the maximum
oxygen uptake from the heart rate measured after a 6-minute step test at
the rate of 22 steps per minute. The step height is different for males and
females. This nomogram can also be used with a bicycle ergometer.
Maximum oxygen uptake can be extrapolated as follows: (1) draw a hori-
zontal line through the body-weight scale "b", in the case of a step test,
or the work-level scale" a", in the case of a bicycle test, and read the corre-
sponding oxygen consumption on scale 1. (2) Draw a line through this
80 FUNDAMENTALS OF EXERCISE TESTING

FIG. 25
ASTRAND-RYHMING NOMOGRAM FOR ESTIMATION OF
MAXIMUM OXYGEN UPTAKE FROM STEP TEST OR BICYCLE TEST'

Heighl "
step cm:
1'1 cf V02(Ii",,/ mio), ST P 0
33 40

b. wt. Work level on bicycle

fh ( kgm/ min)
r! rr
170
.
V0 max
lP
1.1
1.2 !.OJ
2 1.6
166 1;3
162 172 1.'.
600
158 168 1,5
15'+ 16~ 1,6
1,7 100
150 160
1~6 156 1,8

1.2 152 1,9 BOO

1]8 1.8 2.0

134 I .... 2.1 !lIlO

130 1'00 2,2

126 \36 2.J

\000
III 132 2,'

128 2,5
@ ~6 1100
12.
!20 2;

® DO
~
0
0
2,B 1200
2,9
0
~o
'" 00 3,1
I.lOO
~ ®
CD
"Redrawn from Flandrois (1968).

last value and the exercise heart rate value on scale 2 and read (V 02)max
on scale 3. The nomogram was constructed on the basis of measurements
taken on young adults. For persons of 25 years and over, the estimated
value for (V 02)max must be multiplied by the appropriate correction factor,
as shown in the following table (Astrand, 1960).
Age (years) Correction factor

25 1.00
35 0.87
45 0.78
55 0.71
65 0.65

Another nomogram for evaluating (VO)max from step tests was published
by Margaria et al. (1965).
 EXPRESSION OF RESULTS 81

In activities such as walking and running on a treadmill, the work output

cannot be directly calculated. The oxygen uptake must therefore be related
to slope and speed. In the case of walking the relation is not linear, the
rate of oxygen requirement increasing markedly at higher speeds. The
oxygen cost of running bears a more nearly linear relationship to speeds,
so that it is most efficient to walk at slow speeds and run at faster speeds.

FIG. 26
NOMOGRAM FOR CALCULATING THE GROSS OXYGEN COST OF
TREADMIL RUNNING'

55

50

45
o 0

40

C>

~ 35
=00
.~

>.
B 30
!2
-;0.
"E
~
'"
~ 25
8'" 8 5
~
ID
00
>-
; 20
(:j
10

15 II 7

12

10

'Redrawn from Shephard (1969b).

82 FUNDAMENTALS OF EXERCISE TESTING

Shephard (1969b) has constructed a nomogram that gives the energy

requirements of running at various speeds and slopes (Fig. 26). Data on
the energy requirements of treadmill exercise have also been published by
Bobbert (1960).

Use of an arbitrary formula

Von Dobeln et al. (1967) have recently devised a formula relating
maximum oxygen uptake to age and heart rate during sub maximum exercise
on the bicycle ergometer. Their equation is:

( V) = 1.29) L e - O,00884T
O 2 max f -60 '
h

where "L" is the bicycle ergometer load in kpm/min, "fh" is the heart rate
after six minutes' exercise at this load, and "T" is the subject's age in years.
This new formula is claimed by the authors to give a more accurate estimation
than the Astrand-Ryhming nomogram; the method of calculation implies
an increase of efficiency with an increase of maximum oxygen uptake, since
(Vo,)max varies as the square root of L.

Accuracy of methods
The accuracy of the various methods for estimating the maximum
oxygen uptake is not greater than ± 10% (Lange Andersen & Smith
Sivertsen, 1966; Shephard et aI., 1968a). Hence, the optimum approach
for future standardization might well be to report all data-oxygen consump-
tion, work-load and EeG findings-at pulse rates corresponding to a fixed
fraction of aerobic power; 75% seems a convenient arbitrary level, since it
is below the threshold for substantial anaerobic work. A suitable table
of pulse rates for this purpose is presented in Table 6.

TABLE 6. APPROXIMATE PULSE RATES (BEATS/MIN) AT SELECTE D PERCENTAGES

OF MAXIMUM AEROBIC POWER'

Age (years)
Percentage
of aerobic
power
20-29 I 30-39 I 40·49 I 50-59 I 60-69
Men I Women Men I Women Men I Women Men I Women Men I Women

40 115 122 115 120 115 117 111 113 110 112
60 141 148 138 143 136 138 131 134 127 130
75 161 167 156 160 152 154 145 145 140 142
100 195 198 187 189 178 179 170 171 162 163

• Data from Shephard (1969a).

 CHAPTER 9

Evaluation of Results:
Diagnostic and Prognostic Value of Exercise Tests

Physical training brings about local changes in the muscles, improved

neuromuscular co-ordination of activities, and a series of more general
cardiorespiratory changes, as follows:
(1) an increase of maximum respiratory minute volume in exercise;
(2) possibly a slight increase in oxygen diffusing capacity;
(3) 10-30% increase of maximum oxygen intake (depending on initial
fitness);
(4) an increase in stroke volume and maximum cardiac output;
(5) an increase in volume of the heart shadow;
(6) an increase in total haemoglobin and blood volume.

While all the above values are higher in physically fit subjects, the
following are lower:
(I) heart rate at rest and at a given effort;
(2) systolic pressure at a given effort;
(3) lactic acid level in blood at a given effort.

The following parameters usually remain unchanged, regardless of the

degree of physical fitness:
(1) total lung volume (although the vital capacity may be increased by
exercises strengthening the thoracic musculature);
(2) the oxygen consumed by the left ventricle (more work is performed
for a given myocardial oxygen consumption; this reflects the fact that
external work is only a small component of total myocardial work).

All the variables may undergo very rapid changes with alterations of
activity pattern, and this is one reason why the so-called "normal" values
found in the literature are often discordant. It is also why it is advisable
that each investigator elaborate his own set of standard values relative to
the type of patients or to the population group he is studying. A few
weeks of total inactivity are enough to decrease the fitness of a subject,

-83-
 FUNDAMENTALS OF EXERCISE TESTING
84
with deterioration of many physiological functions; on the other hand,
physical training can quickly improve the work capacity of a sedentary
individual. This is true not only of healthy subjects but also of sick people.
If the end-points of exercise testing are Wmax and (Vo)max (see Chapter 8),
the cardiorespiratory fitness of an individual can be assessed according
to Fig. 27, which is self-explanatory. As an example: if Wmax and (Vo 2)max
are higher (or lower) than the mean for the population group to which the
subject belongs, then the subject's fitness is above (or below) average; or,
in the case of a patient (coronary or otherwise) who has undergone a certain
treatment or a rehabilitation programme, the improvement of his health and,
consequently, of his physical fitness can be assessed by comparing the
post-treatment Wmax and (Vo2 )max values with the pre-treatment ones: if the
former are higher, it means that cardiorespiratory fitness has improved.

FIG.27
RELATION BETWEEN OXYGEN UPTAKE, WORK RATE AND HEART
RATE IN FIT AND UNFIT SUBJECTS'

Fit

c
E 3 Unfit

~
';;N 1
.> OL-~ __~~-L-L--~~
o 300 600 900 1200 1500 1800 Work rate (kpm/ min)

Fit

300 600 900 1200 1500 1800 Work rate (kpm/ min)

0.5 1.5 2 2.5 3.5 t

WHO 00689
Va, (litres/ min) (Vo,lmax

'Redrawn from Lange Andersen (1968), copyright Academic Press.

Alternatively, if the method illustrated in Fig. 18 is used, and the end-

point is therefore heart rate, physical fitness can be assessed by comparing
the subject's heart rate at the work-load corresponding to his age, sex, and
body weight with the average heart rate of the population group to which he
belongs (values in parentheses in the figure; see also Table 6); if his exercise
 EVALUATION OF RESULTS 85

heart rate is 10 beats/min higher than expected, he is unfit; if it is less than

expected, he is of above average fitness.
Exercise tests are of special value in the diagnosis of coronary diseases
for they enable the clinician to detect coronary insufficiency in a patient
whose resting ECG is normal, to assess the coronary vascular status of
a subject whose resting ECG is already abnormal, and to help interpret a
pathological resting tracing in a patient in whom coronary disease is doubt-
ful because of age, case-history or clinical data.
In labile arterial hypertension and in neurocirculatory asthenia, the
exercise test may also be of diagnostic interest. In other cardiovascular or
pulmonary diseases the exercise test has no value from the strictly diagnostic
viewpoint, but many be of considerable aid in defining the functional status
of the patient with a view to determining his work capacity, establishing a
rehabilitation programme or deciding whether an operation is indicated.

Types and Intensity of Exercise in the Diagnosis

of Cardiovascular Diseases

The bicycle ergometer advocated for a long time by Scandinavian authors

may have some advantages in coronary cases, mainly because (a) the same
position can be maintained afterwards, which is highly desirable for correct
interpretation of the ECG record, and (b) if a supine version is used, safety
is also increased owing to the position of the subject (it is difficult for a
patient fitted with various leads to dismount from an upright bicycle ergo-
meter in an emergency).
The relative value of the different exercise tests remains debatable;
although Master's step test (or one of its variants) has the advantage of
simplicity, the bicycle ergometer test in the upright position makes it possible
to attain high heart rates gradually and under conditions that may offer more
comfort and safety to a patient who is unwell. Changes in the ECG
tracing may also be followed with the patient in the same position during
exercise and recovery periods if the. bicycle is used.
The Master test has been much utilized in the diagnosis of coronary
insufficiency (Master & Rosenfeld, 1967). Usually the technique advocated
by Master and the tables drawn up by him are applied; however, some
authors consider that Master's tables, which take weight into account, add
a personal factor to the test instead of eliminating it. In any case, the Master
test calls for some criticism: recording of the ECGs during exercise is
easy enough, but the tracing recorded during the test has to be compared
with tracings recorded in the supine position before and after exercise; the
heart rate reached during the test is not usually very high and does not
represent a sufficiently large fraction of the theoretical maximum rate
according to the age of the subject (it is estimated that the rate reached during
86 FUNDAMENTALS OF EXERCISE TESTING

exercise should, apart from contraindications, attain about 75% of the maxi-
mal theoretical rate based on the age of the patient); and the test causes
considerable variations in heart rates between individuals.
Variants of the Master test have been suggested to overcome the above
drawbacks: gradual increase in the number of "ascents"; a single step of
variable height; carriage of a load by the patient; etc.
The increasing-load treadmill has also been suggested, i.e., a treadmill
test with a gradual increase in speed and slope; this exercise makes it possible
to increase the heart rate up to its maximum limit, if no other factor arises
to interfere with the test. However, the inherent logistic and operational
difficulties limit the use of a treadmill to a well-equipped laboratory.
As to the intensity of the tests, it is desirable that the effort be of gradually
increasing intensity so as to raise the heart rate as much as possible. In this
way the diagnostic validity of the test is increased, since the percentage of
negative tests in confirmed coronary cases decreases without an undue
increase of false positive tests. The occurrence of negative tests in confirmed
coronary cases drops from 80% in the single Master test to 45% in the more
strenuous double Master test, to 10% if the test is continued until the symp-
tom of angina develops, and to almost zero if the test is prolonged up to
the maximum heart rate (Bellet & Miiller, 1965; McAlpin & Kattus, 1966).
Similarly, the percentage of ischaemic ST segments reported in a population
clinically free from cardiovascular complaints increased from zero in the
single Master test, to 3% in the double Master test, to more than 7% if the
test was continued until heart rate reached 150 beats/min, and to more
than 10% for exhaustive exercise (Abarquez et aI., 1964). The diagnostic
limitations of the Master two-step test have been described by Master
& Rosenfeld (1967).

Coronary Complaints

ECG criteria of coronary insufficiency during exercise

Depression of the ST segment
A change in the ST segment is the essential element in the exercise
EeG of coronary cases. Study of this criterion calls for the accurate
measurement of an ST depression equal to about 0.01 or 0.02 mV, and
therefore it requires the definition of a stable reference line based on cardiac
cycles rigorously situated on the same horizontal level. This reference line
can be constructed by using a small transparent plastic rule to join either
several PR segments or several points of junction located between the PR
segment and the QRS complex or the PQ junction (Q-Q base-line). Alter-
natively, a series of 16-32 cycles may be averaged by electronic devices;
such procedures are essential if significance is to be attached to measurements
of 0.01 mV.
 EVALUATION OF RESULTS 87

In any case, care must be taken to avoid error due to the interference of
a negative T-wave of auricular repolarization (Ta-wave) with the commence-
ment of the ST segment, particularly if the PR space is short and the Ta- wave
is long, as is the case in tachycardia. The following cases must be taken
into consideration:
(a) Depression of the ST segment of ischaemic type. To be indicative
of ischaemia, the ST segment must be either a horizontal straight line
(Fig. 28, A) or a straight, or slightly convex, line sloping downwards and
bending upwards in the form of a sickle (Fig. 28, B). At present the
ischaemic ST is regarded by many authors as the essential criterion and by
some even as the only valid diagnostic criterion of myocardial ischaemia
(Sheffield & Reeves, 1965).
FIG. 28
ISCHAEMIC ST DEPRESSIDN"

B R

T
J - - - - - - .-- .-
1'1110 00692 Q X I

I:' QxjJ
A. Horizontal type.
B. "Sickle" type .

• Figure kindly supplied by Professor H. Denolin.

(b) Depression of the ischaemic ST segment at its origin. Before it can

be regarded as significant, the ST depression, according to some authors,
should exceed 0.05 mV or even 0.1 mV, especially in the presence of tachy-
88 FUNDAMENTALS OF EXERCISE TESTING

cardia. Although some writers do not assign diagnostic value to the extent
of ST depression, all nevertheless stress its prognostic importance (Robb &
Marks, 1967). The displacement can, if necessary, be divided into three
categories of depression: 0.01-0.09 mY; 0.1-0.19 mY; 0.2 mY and above.
(c) JST depression. Depression of the J point with a rapid and almost
vertical climb towards the isoelectric level generally has little significance,
especially in the presence of tachycardia. Its appearance may be due to (a)
interference from the Ta-wave or a normal type of electric repolarization
connected with the increase in effort and in heart rate, (b) to the inter-
vention of the autonomous nervous system, or (c) to hyperventilation and an
associated respiratory alkalosis. Deep inhalation and the administration
of parasympatholytic or adrenolytic drugs, as well as decubitus, may restore
a more "normal" appearance to this complex. However, certain authors
feel that a considerable JST displacement during exercise (exceeding 0.2 mY)
or a gradual climb towards the base-line may have a certain ischaemic
significance (Fig. 29).

FIG. 29
DEPRESSION OF "JST" TYPE WITH LOWERING OF POINT J AND RAPID RETURN
OF THE ST SLOPE TO THE BASE LINE (POINT X)'

At high heart rates T and P

cross over in this ale,1

• Figure kindly supplied by Professor H. Denolin.

(d) Duration of the ST depression. This should be greater than 0.08 sec.
This criterion makes it easier to separate ischaemic ST depression from the
JST aspect.
(e) QXj QT ratio. If the duration of QX (interval between the com-
mencement ofQRS and the point where the depressed segment returns to the
base-line (see Fig. 28, B) exceeds half the QT duration (i.e., if the QXjQT
ratio is more than 50), there may be ischaemia, even if the ST slope towards
the base-line is reminiscent of the JST aspect and the drop beneath the line
is less than 0.2 mY. This criterion, however, is strongly debated.
 EVALUATION OF RESULTS 89

(f) Rise in the ST segment. When occurring alone, a rise in the ST segment
may be found in normal subjects as well as in ischaemic cases; under resting
conditions it may appear saddle-shaped, with the concavity directed upwards
and sometimes exceeding 0.2 mV in the left precordial leads, and it may
disappear momentarily during exercise. However, a rise in the ST segment
accompanied by a depression in the opposite leads always indicates serious
ischaemia, with a risk of acute complications in the corresponding sector
of the myocardium.

Changes in the T-wave

An isolated T-wave change during exercise is, in general, hardly specific.
Continuous 24-hour ECG recordings have shown that in 30% of "normal"
subjects (i.e., those with no cardiac complaints) transitory changes in the
T-wave may occur, an increase in amplitude being twice as frequent as
a decrease. These T-wave variations are brought about by tachycardia,
nervous excitation, effort, mental activity, change of position, eating a meal,
coffee, tobacco, etc.
However, the appearance of a pointed and elevated T-wave in V4 with
three times the amplitude (or more than 0.5 mV) always indicates serious
myocardial ischaemia. It may be accompanied by a decrease in the ampli-
tude of the R-wave or a rise in the ST segment. Some authors believe that
a 25% decrease in the T-wave during or after exercise, as compared with the
resting value, is suspect and that a 50% decrease probably signifies coronary
insufficiency. Moreover, a flattening of the T-wave after exercise is seen
more often among sedentary subjects in their forties than among heavy
manual workers. The value of these various changes has not yet been
defined precisely (Puddu et aI., 1965).
The significance of the return to positive value in exercise of aT-wave
inverted as a result of an old myocardial lesion is also debated. Such a
return of negative T-waves to positive voltages has been observed in healthy
subjects (Master & Rosenfeld, 1967).
As to frank but isolated inversion of the T-wave, whether constant
or only post-extrasystolic, this is sometimes regarded as pathological or at
least suspect if it exceeds 0.2 mV and shows a lengthened QT in the presence
of a normal electrolyte balance. Certain authors, however, feel that it is
only in association with an ischaemic ST that the T-wave inversion becomes
of pathological significance and represents a factor aggravating the prognosis
(Mattingly, 1962; Blackburn & Katigbak, 1964).

Changes in the TU segment and the U-wave

A TU displacement is always pathological, both during rest and during
exercise, whether or not associated with an ischaemic ST. A negative
U-wave is generally regarded as pathological in the resting subject, except in
aVR and in III, if T is negative. During exercise an increase or decrease in
90 FUNDAMENTALS OF EXERCISE TESTING

the amplitude of the V-wave, dependent in particular on the heart rate, may
be normal. On the other hand, inversion of this wave is always pathological
(Bruce et aI., 1956).
Other changes
The amplitude of the P-wave may triple during exercise; this is not
pathological. The PR space may shorten during exercise both in the normal
subject and in coronary cases; it is said to shorten always in chronic pul-
monary patients with marked dyspnoea.
A large change of amplitude, i. e., a reduction of R to at least 60% of its
resting value as well as a variation in the QRS axis during exercise exceeding
+ 30° or - 20°, or a variation in the T axis, can be regarded as pathological.
Transitory disturbances of conduction, possibly proceeding as far as a
block of the left or right branch, may also reveal coronary ischaemia (perhaps
localized to the septal tissues), but it may also be merely the result of an
increase in heart rate beyond a critical threshold value. Lengthening of the
duration of intraventricular conduction has not yet any well-defined meaning.
Ventricular or auricular extrasystoles should be regarded as possibly
pathological only if they are numerous and multifocal. As to attacks
of arrhythmia during or after exercise (auricular fibrillation, ventricular or
supraventricular tachycardia), their significance is a matter of controversy.
At present it is impossible to come to any definite decision as regards the
ischaemic specificity of these attacks which, according to prolonged and
continuous dynamic checks, may occur from time to time in normal subjects.
The possibility of such accidents, however, calls for the continuous moni-
toring of exercise tests, and also the immediate availability of means for
rapid defibrillation.

Exercise tests in the determination of coronary capacity

By measuring the heart rate at the end of exercise and comparing it with
the theoretical maximum heart rate for the age of the subject, the rate of
reduction of coronary capacity in the subject under test can be evaluated
(Sheffield & Reeves, 1965).
For the functional assessment of a patient with a confirmed but stabilized
coronary condition-to determine his physical fitness, for example-the
ECG should be monitored continuously at gradually increasing levels of
exercise. The presence of alterations in the resting ECG does not consti-
tute a contraindication to the test since the aim is evaluation and not diagnosis.
Exercise capacity is defined as the metabolic level just below that where
well-marked ischaemic changes develop, such as increasing pain without
change in the ECG, supraventricular or paroxysmal ventricular arrhythmia
or ventricular extrasystoles occurring before the end of the T-wave, distur-
bance of conduction, or depression of the ST segment of ischaemic typt'
 EVALUATION OF RESULTS 91

It should be noted that the ingestion of drugs may influence the changes in
the ST segment, so that the test should be repeated not less than two or
three weeks after such medication has ceased.

Exercise tests in the diagnosis of non-specific repolarization anomalies

It is becoming increasingly evident that healthy subjects may present

"non-specific" changes in the ST segment and the T-wave that cannot be
explained by a heart condition or any apparent medicinal, metabolic or
electrolytic cause. These anomalies are not exceptional (1-5% of cases
according to some authors) and are sometimes difficult to diagnose. Various
tests have been proposed to reveal the non-coronary origin of such anomalies:
the recording of the EeG in decubitus and while standing; hyperventilation
test; recording on an empty stomach and after a meal; potassium test.
However, the exercise test is of particular value in that it can cause resting-
state EeG anomalies to regress or disappear.

Validity of exercise tests

It should be remembered that" false negative" cases exist-i.e., subjects

with a heart condition in whom exertional anginal pain develops without any
specific change occurring in the EeG; there are also coronary patients
whose resting EeG is highly abnormal but who do not present any additional
changes during exercise, or even during an attack of angina. Furthermore,
it should be mentioned that there are also a number of "false positive"
cases, i. e., clinical conditions that in the absence of any organic pathological
coronary changes may bring about or accentuate EeG changes during
exercise. The following may be mentioned in particular:
(1) relative or functional insufficiency of coronary output (e. g., left
ventricular hypertrophy, mitral stenosis);
(2) electrolyte imbalance (e. g. , diuretics);
(3) hormone imbalance (e.g., adrenal hyperfunction);
(4) haemoglobin deficit or blocking (e.g., severe anaemia, increased
level of carboxy haemoglobin) ;
(5) impairment of oxygen transport (e. g. , hypoxia);
(6) various drugs (e. g., epinephrine, digitalis, quinine, nicotine);
(7) meals (post-prandial hypokalaemia, probably caused by insulin
action);
(8) hyperventilation (changes of intracellular potassium concentration
as a result of respiratory alkalosis): on the other hand, this may sometimes
prevent or improve ST changes due to neurocirculatory asthenia, left
ventricular hypertrophy, pericarditis or saturation with digitalis;
92 FUNDAMENTALS OF EXERCISE TESTING

(9) orthostatism;
(10) neurocirculatory asthenia.
Many of these conditions, probably as a result of the hypokalaemia that
they bring about (Kwoczynsky et a!., 1961), may accentuate ECG anomalies
accompanying mild exercise even in the absence of coronary insufficiency.
This applies in particular to digitalis which, because of its influence on the
transmembrane ionic transport or on the permeability of the cell mem-
brane, renders the interpretation of ECG anomalies during exercise subject
to considerable difficulty.

Other measurements taken during exercise

Changes in the ECG during exercise not only make it possible to reach
an accurate diagnosis in coronary heart patients when the resting ECG is
normal, but also permit assessment of the coronary capacity in a patient whose
coronary insufficiency is already apparent while resting, or in a patient
recovering from myocardial infarction. However, there are non-coronary
causes for apparently ischaemic ECG changes. Thus, where there is lack
of agreement between the ECG findings and the clinical data, a thorough
analysis of the context must be made, with a search for possible alternative
causes of the ECG changes and perhaps recourse to other tests.
It is probable that these alternative causes depend on the same cellular
mechanism as hypoxia itself, and that the presence of an ischaemic ST
appearance gives no absolute diagnostic certainty ofthe ischaemic nature of
the anomaly or of the nature of the causal heart condition.
Additional haemodynamic measurements may contribute useful informa-
tion, for although the change in the contour of the ECG is of considerable
value from the diagnostic and prognostic viewpoint, it does not by itself
enable the work capacity of a patient to be determined precisely; the lack
of relationship between the resting ECG and functional capacity should
be remembered here. Haemodynamic tests carried out on coronary heart
cases may possibly reveal a hypo kinetic state, with a reduction of cardiac
output and of stroke volume at a given work-load. The oxygen consumption
and change of heart rate, in addition to the changes in the shape of the ECG
tracing, are important factors in defining the clinical condition of the patient
at a given work-load.
Study of the relationship between haemodynamic or metabolic behaviour
and certain morphological data may also reveal pathological changes in
functional status and the degree of cardiac compensation (for example,
relationship between the maximum oxygen pulse and the volume of the
cardiac shadow).
For additional information on ECG in exercise testing, see: Sandberg
(1961); Folli et a!. (1965); Blomqvist (1965); Riva et a!. (1967); Berkson et
a!. (1966); Bruce et a!. (1966); Areskog et a!. (1937); Blackburn (1969).
 EVALUATION OF RESULTS 93

Arterial Hypertension

As was mentioned in Chapter l, normal subjects always show elevation

of the mean peripheral arterial pressure at the beginning of effort. There is
an almost linear relationship between loading and increase in mean periphe-
ral blood pressure; if the effort is prolonged, the arterial pressure may
show a slight decrease in comparison with the initial exercise value. Age
has a marked influence, the systolic pressure increasing much more markedly
in older people.
Information regarding changes in central (aortic) blood pressure during
exercise is still scanty and controversial. In a hypertensive subject at rest,
cardiac output is usually normal while peripheral vascular resistance is
increased; however, in young hypertensive subjects cardiac output may
sometimes be increased while vascular resistance remains normal, and in
older hypertensive subjects the cardiac output may decrease. In some
instances the initial phase of hypertensive disease is represented by a state
of hyperkinesis and normal resistance that progressively evolves towards
a state of hypokinesis with higher resistance.
During exercise, cardiac output may be lower in hypertensive than in
normal patients and the arteriovenous difference may be greater, even at
low work-loads. The systemic arterial pressure is always higher in the
hypertensive than in the normotensive subject during exercise, but the
difference is particularly marked in older patients. However, the exercise-
induced increase of arterial pressure is proportionally the same in hyper-
tensive and normotensive patients. Vascular resistance is usually higher
even in the young hypertensive, but the reasons for this are not yet clearly
defined.

Diagnostic interpretation of arterial pressure changes

Diagnosis of hypertension
The elevation of blood pressure that is observed during effort in known
hypertensive subjects does not yield any significant diagnostic information.
In cases oflabile hypertension, i.e., when the resting blood pressure reverts
to normal after a few days of rest, the response to effort is similar to that
observed in permanent hypertension, the vascular resistance becoming
abnormally high. Since exercise provokes hypertension, it may be useful
in disclosing labile hypertension and in indicating the need for hypotensive
treatment. In other conditions (such as mitral stenosis and aortic stenosis)
arterial pressure falls during exercise; this indicates a low myocardial reserve
and is a sign of severe disease.
Some works worthy of study in connexion with blood pressure changes
in exercise are those by Logan & Bruce (1958), Bruce et al. (1959), Carlsten
94 FUNDAMENTALS OF EXERCISE TESTING

& Grimby (1966), Sannerstedt (1966), Eich et al. (1966), Amery et al. (1967),
BelIet & Roman (1967), and Hamer (1968).

Diagnosis of myocardial status in hypertension

Detection of latent coronary insufficiency in hypertensive subjects is
particularly important. The prevalence of ECG abnormalities under effort
is much higher in hypertensive subjects, and is more marked as the arterial
pressure increases. This is probably related both to the increased work of
the left ventricle and to the presence of a coronary disease, and it has impor-
tant diagnostic and prognostic significance.

Work of the left ventricle

Analysis of this parameter, and, consequently, of certain symptoms (e.g.,
crises of angina) or of the effect of certain drugs, requires a knowledge of
the relationship between arterial pressure, cardiac frequency, and other para-
meters. Measurements of blood pressure are therefore indispensable not
only in assessing the performance of effort tests but also in evaluating the
status of the myocardium.

Valvular and Congenital Diseases

Exercise tests have little diagnostic value in valvular disorders and con-
genital malformations. Nevertheless, they aid in the assessment of effort
tolerance better than the anamnesis or the clinical examination can do and,
therefore, they may yield useful information regarding fitness for work or
the advisability of surgical treatment.
In such cases less weight is given to changes in the ECG and the arterial
pressure, and more emphasis is placed on the assessment of myocardial
adaptation and of valvular obstacles either at the pulmonary level (pulmonary
hypertension, dyspnoea, changes in respiratory function) or at the peripheral
level (metabolic derangements secondary to a poor adaption of cardiac
output or augmentation of arterial desaturation).

Mitral stenosis

Of the various valvular ailments, mitral stenosis has been studied the most
extensively. The following parameters are commonly considered:
(a) Oxygen consumption. The" on-transient" (adaptation phase) is
protracted, and although steady state values are usually normal during
sub maximum efforts, CYo)max may be markedly reduced (Den olin et aI.,
1953; Blackmon et aI., 1967).
(b) Ventilation in relation to oxygen consumption. Hyperventilation
often occurs in mitral stenosis as a consequence of insufficient cardiac output
 EVALUATION OF RESULTS 95

or of changes in pulmonary function and brings about an abnormal eleva-

tion of the ventilatory equivalent for oxygen. Hyperventilation is often
accompanied by a fall in the arterial CO 2 tension.
(c) Heart rate. This increases excessively in relation to effort, partic-
ularly in severe cases. The maximum oxygen pulse is markedly reduced
(Frick, 1968).
(d) Cardiac output. In spite of marked tachycardia, cardiac output
increases only slightly owing to the lack of increases in stroke volume.
(e) Lactic acid. The blood lactate level during and immediately after
exercise increases disproportionately as a consequence of inadequate
peripheral blood flow.
(f) Pulmonary arterial pressure. This increases disproportionately
with progression of the disease. In the early stages, it increases moderately
under effort, and this increase parallels that seen in the left ventricle and the
pulmonary capillaries. As the disease progresses, however, the pulmonary
arterial pressure increases disproportionately relative both to left ventricular
and capillary pressures and to the increase in cardiac output. At this
stage there are thus secondary alterations in the pulmonary arterial system
that lead to an increase of resistance. Such changes indicate also that the
disease is progressing. More elaborate indices of the performance have
been proposed, such as the fitness index of Bruce et al. (1956); however,
these methods of expressing data do not appear to offer any diagnostic
advantage.
The simplest and most sensitive tools for assessing the severity of
mitral stenosis during effort are the determination of ventilatory equivalent
for oxygen and heart rate at specified fractions of aerobic power. The
measurement of pulmonary arterial pressure during effort in either the sitting
or the supine position contributes to assessment of the degree of stenosis
and may be indispensable in surgical diagnosis. Tests based on the deter-
mination of heart rate are still applicable in the presence of auricular
fibrillation.
The responses discussed above are not specific to mitral lesions. They
simply indicate impaired function of the left ventricle. All other diseases
that reduce left ventricular output during exercise may give rise to the
same cardiorespiratory effects.

Mitral insufficiency, aortic stenosis and aortic insufficiency

These and other more complex valvular lesions have not been studied so
extensively. In general, the haemodynamic and respiratory effect of
valvular lesions is the failure of the left ventricular output to increase during
effort.
96 FUNDAMENTALS OF EXERCISE TESTING

Congenital malformations
Maladaptation to effort will manifest itself as an inability of the heart
to supply enough oxygen to the peripheral tissues, mainly because the
resistance of the pulmonary vasculature is increased, thus preventing
an adequate increase in cardiac output. Other reasons may be the appear-
ance or the enhancement of a right to left shunt accompanied by desaturation
of the arterial blood and, more rarely, insufficient adaptation of the left
ventricle.
The effort tests for congenital malformations are the same as those
used for the general assessment of work capacity. In children who are old
enough to ride a bicycle, the simple measurement of the heart rate during
progressive effort is perfectly practicable. The simple cardiorespiratory
tests may be supplemented by measurements of arterial oxygen saturation. A
decrease in oxygen saturation during effort may mean either development
of a shunt or reversal of an intra- or extra-cardiac shunt. The changes in
right ventricular and pulmonary arterial pressure and in the vascular resis-
tance of the lungs indicate the degree of maladaptation to effort, and may
help in medical and surgical diagnosis.
In patients with congenital malformations, as in those with acquired
valvular disease, aptitude for effort does not correspond closely to the
haemodynamic changes; physical capacity is also influenced by body
weight, age, and degree of physical training. Better assessments of the
severity of the disease can sometimes be achieved by comparing the results
of the exercise tests with the cardiac volume or with the total haemoglobin.
If, for instance, the working capacity is poor in relation to heart volume, this
may imply substantial right ventricular hypertrophy due to pulmonary
stenosis or pulmonary hypertension; if, on the other hand, the physical
working capacity is poor but the ratio of working capacity to heart volume
is normal, the patient merely lacks training. For more information on
exercise testing in congenital heart diseases, see Jonsson et al. (1957) and
Frick et al. (1966).

Neurocirculatory Asthenia
This ailment is characterized by poor vasomotor regulation and by a
lower degree of contraction of the resistance vessels. Venous tone is reduced,
and an abnormal proportion of blood is peripherally distributed. The
resting cardiac output may also be increased, usually with an increased heart
rate rather than an increased stroke volume.
Exercise tests are often useful in the diagnosis of neurocirculatory
asthenia. They may reveal an abnormally high heart rate and cardiac
output in moderate work, with deficient circulation to the peripheral muscles,
a high lactic acid level in the blood, and a lower work capacity. ECG
abnormalities may also appear both during and after exercise.
 EVALUATION OF RESULTS 97

Changes in work performance are particularly apparent when cardiac

volume and total haemoglobin level are related to the pWC 170 • However,
if the test is carried through to maximum effort, it is found that the ratio of
work performed to heart volume is essentially normal, although the aerobic
power is poor. In contrast, patients with myocardial disease have a de-
creased ratio of work performed to heart volume in heavy and maximum
effort (Holmgren, 1967).

Chronic Pulmonary Diseases

It would be impossible to review here all the alterations of respiratory

physiopathology that may occur in different pulmonary diseases. The
mechanisms involved are so complex and the tests proposed for the assess-
ment of pulmonary function are so varied that we shall deal only with some
parameters that permit (a) assessment of ventilatory function under effort,
and (b) detection of possible respiratory insufficiency. Suggested references
are: Denolin et aI., 1964, 1966; Sadoul et aI., 1966; Armstrong et aI., 1966;
McIlroy, 1968; Anderson & Shephard, 1968.

Ventilation
If the respiratory frequency becomes too high, it suggests that respira-
tory function is abnormal. This is particularly true if the heart rate remains
within the limits anticipated for a given work-load. However, several
chronic pneumopathies (particularly those of obstructive type) do not give
rise to an excessive respiratory frequency, while certain cardiac ailments
may give rise to a disproportionately high respiratory frequency and to
poor physical capacity as a consequence of secondary pulmonary insuffi-
ciency. An abnormally high minute ventilation may also occur in some
pulmonary diseases, more commonly in restrictive than in obstructive
ailments. This is demonstrated by calculation of the respiratory equivalent
for oxygen: RE02 = (V02)STPDj'VBTPS.
The respiratory equivalent does not normally exceed 30, even during
relatively strenuous effort.
As with respiratory frequency, the increase in ventilation volume is not
specific to pulmonary ailments but is observed also in hyperthyroidism,
anxiety, heart disease, etc.
The dyspnoea index has been proposed by some authors as a more sensi-
tive tool in diagnosis. It is defined as 100xVE/MVVlOO (%), where "VE"
is the expiratory minute volume and "MVV100" is the maximum voluntary
ventilation at 100 breaths/min. In a normal subject under heavy effort
the value of this index is less than 50%, but in chronic pneumopathies,
and particularly in obstructive ailments without hyperventilation, it increases
markedly since the MVV100 is small. The MVV is normally measured
98 FUNDAMENTALS OF EXERCISE TESTING

at rest, although recent work shows it to be increased somewhat by exhaust-

ing exercise.
A progressive increase of ventilation during moderate effort may also
indicate some pulmonary abnormality. In this respect, the study of the
expiratory minute volume eVE) would be useful. Bonjer (I968a) introduced
the concept of a ventilation performance index, which is similar to the
Leistungspulsindex (oxygen pulse) but indicates how much VE increases at
each load increment, and compares actually measured data with normal
values for subjects of the same sex and body build.
The French school has developed the criterion of maximum tolerated
power (puissance maximale supportee), which corresponds to the most
intense "steady state" effort that can be sustained for 20 minutes (i. e.,
when ventilation between the 10th and the 20th minute of effort remains
constant to within 5%, with a ventilatory equivalent of less that 30 and a
respiratory gas exchange ratio of less than 1). This test is of particular
interest for the assessment of chronic pneumopathies of occupational
origin. A steady state work-load of 720 kpm (120 watts) should be sus-
tained by a healthy adult male. Unfortunately, as in other tests, a poor
performance is not specific to pulmonary syndromes but may occur also as
a consequence of heart disease.

Blood gases
The following values may be considered as normal:
At rest At 75% o/maximum effort

S.,02 (%) 93-98 Same

p.,o, (mm Hg) 83-100 Same
Pa , C02 (mm Hg) 36·47 Slightly less
Arterial pH 7.35· 7.45 Lower (- 0.03 at bicycle
ergometer load of 720
kpm or 120 watts)

If the resting values are normal and the effort values are abnormal
(e.g., lower Sa,02 or P a,02' markedly lower pH, marked increase or decrease
in P a,C02)' it suggests that pulmonary function is impaired. However,
alteration of the blood gas values is not specific to pulmonary diseases.
For instance, a fall in P a,C02 is simply a consequence of alveolar hyper-
ventilation, regardless of cause. Similarly, P a ,02 and Sa,02 may decrease
markedly in congenital malformations with a right-left shunt. Metabolic
acidosis is observed in all cases of peripheral circulatory maladaptation,
whether due to insufficient cardiac output or to insufficient distribution
of output to the active muscles, as in neurocirculatory asthenia and patients
with poor physical fitness.
Excessive CO 2 retention is probably the most specific sign of insufficient
alveolar ventilation; when it is accompanied by oxygen desaturation of the
 EVALUATION OF RESULTS 99

arterial blood it indicates a combination of ventilatory insufficiency and

pulmonary disorder or congenital heart disease.
Assuming that there is no cardiac malformation, then an increase of
Pa,coz in association with a decrease of Sa,Oz suggests a disorder of obstruc-
tive type, such as bronchitis or emphysema; if marked hyperventilation is
associated with a fall in Pa,oz while the Pa,coz remains normal, this suggests
pulmonary fibrosis.

Diffusing capacity or transfer factor

It is generally admitted that measurement of the diffusing capacity is
useful in the assessment of pulmonary function. It is also generally admitted
that diffusing capacity increases during effort, but there are many differences
in the techniques used and in the way of expressing results, so that a standard,
practical application of this parameter cannot be envisaged yet.

Haemodynamic parameters
It is commonly held that determinations of exercise heart rate are of no
interest in the diagnosis of a chronic pulmonary ailment or in the assessment
of physical fitness in a patient suffering from respiratory insufficiency. As
noted earlier, oxygen uptake depends more on cardiac output than on
alveolar ventilation, and the heart rate during effort may follow a normal
pattern even in serious pneumopathies. It seems that there is no relation
between changes in heart rate and changes in pulmonary arterial pressure.
The effort ECG may be useful in the detection of a myocardial or
coronary ailment, but for the diagnosis of chronic cor pulmonale it is of
little value.
Another important parameter to be taken into consideration is the pul-
monary arterial pressure during effort. If this increases during effort while
the capillary (wedge) pressure remains the same, it implies that pathological
lesions are present in the arterial and arteriolar system. The appearance of
pulmonary hypertension disproportionate to the imposed work-load (i.e., a
mean pressure higher than 25 mm in young subjects undergoing efforts of
moderate intensity, or higher than 35 mm Hg in subjects over 50 years old
and in young subjects undergoing an exhaustive effort) is of particular
interest (a) in the diagnosis of vascular complications secondary to pulmonary
disease, (b) in prognosis, and (c) in the assessment of permissible physical
activity (to prevent overworking and consequent failure of the right ventricle
induced by pulmonary hypertension).

Differential Diagnosis of Cardiovascular Disease and Poor Physical Fitness

The poor performance of an exercise test, by itself, does not tell whether
the subject is sick or is simply unfit. Training of a cardiac patient may
100 FUNDAMENTALS OF EXERCISE TESTING

indeed elicit the same physical reactions as those of sedentary but otherwise
healthy subjects; intolerance to effort (dyspnoea, EeG abnormalities, etc.)
may also diminish. In other words, both lack of physical fitness and cardiac
disease may produce the same physiological effects, so that a poor aptitude
for exercise may be due either to lack of physical training or to disease of the
cardiocirculatory system. A poor exercise performance by itself cannot
discriminate between these two possibilities, and is not specific evidence of
a pathological state. As is often the case in chronic diseases, the effects
of cardiac insufficiency and of poor physical fitness may compound one
another, making it difficult to assess the real degree of invalidism.
Exercise tests do not permit differentiation between pulmonary and
cardiac illnesses, or between different cardiovascular diseases. Interpretation
of the results is made more difficult by differences in the degree of physical
fitness between patients. Even the most specific tests may be invalidated by
training. For instance, functional EeG abnormalities typical of neuro-
circulatory asthenia and signs of coronary insufficiency may both regress
under the influence of repeated, regular muscular exercise.
Other factors that influence results are genetic characteristics, body
build, environmental conditions, motivation, etc. The results should there-
fore be interpreted in relation to mean values for the population to which the
patient belongs, taking account of the type and degree of habitual physical
activity, sport activities, and physical fitness of the patient in the months
preceding testing. The Swedish and German schools have tried to set up
some systems for differentiating between the effects of training and of
diseases, but the complexity of the equipment needed, the relative scarcity
of results, and the lack of reference values make them unsuitable, so far,
for general application.

Prognostic Value of Exercise Tests

During the past ten years some authors have suggested that the exercise
EeG obtained with either the double Master test or a gradually-increasing-
load test could be used, in the interests of preventive medicine or life insu-
rance, to detect the subjects in a population who are likely, in the future, to
show a high morbidity and mortality from coronary disease.
The results seem to be conclusive, particularly in the middle-aged male
population and provided that the presence of an ST ischaemic response is
taken as the only positive criterion. This seems the only statistically
valuable index. The frequency ofST depression shows the expected increase
proportional to age and to the intensity of effort; on the contrary, the fre-
quency of T-wave abnormalities does not change with age or intensity of
effort.
 EVALUATION OF RESULTS 101

Value of a positive test

Subjects who show an ST change of ischaemic type during or after an
exercise test seem to have a higher probability of dying from coronary
disease than subjects who show no such change. The magnitude of the
ischaemic ST depression during and after exercise is directly correlated
with the severity of coronary disease. An ST depression of less than 0.1 mV
(in maximum or near-maximum effort) corresponds to a coronary disease
mortality rate twice the probable figure for the age-group in question.
A depression of 0.1-0.2 mV at the same intensity of effort would bear a
5-fold increase in mortality rate, while a depression of more than 0.2 mV
would bear a 20-fold increase. On the average, the probability of coronary
death in subjects with ST ischaemic depression is four times higher than in
subjects showing no such change. In vivo coronary arteriography confirms
the association between ST changes and coronary occlusion.

Value of a negative test

As far as the Master step test is concerned, a negative result-i.e., lack
of ST depression-does not exclude the presence of coronary disease. It may
simply mean that, at the time of testing, the obstructive lesions of the
arteries had not progressed to such a state as to cause coronary insufficiency
at the relatively light effort involved. In other instances, a previously
established positive response during exercise may decrease and disappear,
with the development of collateral circulation and improved perfusion of the
heart. In general, the Master test leads to an inadequate increase of heart
rate; a treadmill test or a bicycle test, which allow gradual increase of the
work-load and, consequently, progression to a higher heart rate, could
disprove the negativity of a Master test. In yet other instances, a Master
test may be reported as negative because the ECG is not continuously
monitored during the exercise or is not monitored long enough (up to six
minutes) afterwards.
The relatively limited prognostic value of the Master test as compared
with other fixed-intensity tests or with progressive-loading tests (bicycle or
treadmill) appears evident when the percentage frequency of ischaemic ST
changes in a population clinically free from cardiovascular symptoms
(males over 30 years of age) is studied. It was shown that when maximum
exercises were performed by a progressive-loading test, 10% of the population
sample under study showed positive ECG changes of heart ischaemia; in
sub-maximum exercises the percentage of positive signs was 7%. But when
the double Master test was used only 3% of the population showed ischaemic
ST changes, while the standard Master test was altogether unable to elicit
any significant ST depression.
 Annex 1

EXERCISE TESTS IN REHABILITATION PROGRAMMES

A programme of progressive physical training has a favourable influence

on the future physical fitness of the majority of patients with cardiac disease
and, probably, also influences favourably the development of the disease.
However, the intensity, duration and surveillance of such training pro-
grammes are not yet well defined. This is due in part to a lack of programme
standardization in relation to the individual clinical conditions. As far as
myocardial infarction is concerned, sufficient experience is available for
certain general directions to be drawn up; for other heart conditions (congen-
ital and valvular abnormalities, arterial hypertension, sequelae of heart
surgery, etc.) the available information is still too scanty. Even in the case
of myocardial infarction, however, specific problems must be individually
considered.
Three stages must be considered in myocardial infarction: the acute
phase, the phase of hospital care, and the convalescent phase. After the
acute phase is over (i. e., when the resting ST segment has returned to normal,
inflammatory signs have disappeared and symptoms are no longer present) a
rehabilitation programme may be undertaken provided there are no contra-
indications. Proposals for such a programme have been presented by a
WHO Working Group (1968).

Surveillance of training during hospitalization

During the hospital phase the exercise constitutes both treatment and
test. The following parameters should be checked carefully and no further
increase in effort allowed if:
(1) the heart rate during exercise increases by more than 30 beats/min,
or decreases by more than 10 beats/min;
(2) disturbances of rhythm and of conduction appear during or immedi-
ately after exercise;
(3) dyspnoea, angina or fatigue appears during or at the end of the test;
(4) pallor, hypotension with bradycardia, or faintness appears.

-102-
 ANNEX 1 103

Tests for establishing intensity of rehabilitation programme during

convalescence
After three or four weeks, if the evolution of the disease seems favour-
able, the patient may undergo a more strenuous rehabilitation programme,
either individually at home or collectively in a specialized centre. Mo~t
programmes involve rhythmic exercises (marching, cycling, etc.) of about
30 minutes' duration, repeated at least three times per week. The above-
mentioned WHO Working Group (1968) proposed a progressive programme
for patients recovering from myocardial infarction (between the third week
and the return to work) according to whether they do or do not visit a
rehabilitation centre. From time to time, starting preferably during the
third or fourth week of a normal convalescence, physical fitness should be
tested and the results of the fitness tests should guide the future course of
participation in the programme. Heart rate is the most important and
simplest guide in establishing the intensity of the exercise programme.
The WHO Working Group suggested that for a constant-load exercise of
30 minutes' duration, training heart rate should not increase beyond the
resting heart rate by more than 60% of the difference between the heart rate
during maximum exercise and the resting heart rate. This criterion may
be criticized on the grounds that a heavier load is thus imposed on elderly
than on young patients. It would be better to take as the upper limit
of the training heart rate: fh,rest+t(fh,max-fh,rest).
Alternatively, the following limits could be imposed:
(1) heart rate should not increase by more than 50% of the resting value;
(2) heart rate should not increase beyond 120 beats/min or, if no severe
subjective symptoms appear, beyond 150 beats/min;
(3) heart rate should be no more than 70% of the difference between
maximum heart rate and resting heart rate;
(4) oxygen consumption should be between 60% and 70% of the aerobic
power as calculated from the Astrand nomogram;
(5) oxygen requirement should not exceed 50% of the maximum aerobic
power, defined here as the aerobic power that can be maintained stable for
3-5 min.
All these possible limitations to the intensity of the rehabilitation
programme are rather empirical, and procedures (1) and (2) again penalize
the older person. Nevertheless, most of them have been used and since the
average coronary population is relatively homogeneous in respect of age
they usually yield fairly comparable results. In general, the limits proposed
seem safe; however, no centre has yet had experience with more than about
500 patients and there is need for further study, especially of older patients.
Appearance of SUbjective symptoms during exercise should also be watched.
104 FUNDAMENTALS OF EXERCISE TESTING

Interpretation of EeG changes varies with the investigators: some believe

that ST depression of more than 0.2 m V indicates that exercise must be
stopped, whereas others believe that as long as there are no symptoms of
intolerance, ST depression or disturbances of rhythm should be disregarded.
Suggested sources of information concerning exercise tests in the training
and rehabilitation of cardiovascular patients are: Heller stein & Hornsten
(1966); Naughton et aI. (1966); Kellerman et aI. (1967); Konig (1968);
Blackburn (1969).
 Annex 2

EXERCISE TESTS IN CHILDREN AND ADOLESCENTS

The measurement of physical effort in children and adolescents by means

of exercise tests has become of increasing importance in recent years. In the
fields of social paediatrics and public health, physicians are commonly faced
with the problem of deciding whether the physical performance capacity of a
child is adequate for his stage of development and, if it is not, of advising on
a physical education programme involving sport and other forms of physical
work in school as well as outside.
In the field of therapeutic medicine and particularly in the treatment of
children with chronic disease, a knowledge of the development of physical
ability is important. It is necessary, for instance, to determine the physical
capacity of children with diabetes or obesity if one wants to adapt and
direct their patterns of daily activity (Sterky, 1963). The same applies to
children with serious physical handicaps (such as blindness), who are often
physically inactive.
Children with congenital or acquired heart disease represent another
medical field where testing of physical performance capacity can guide the
physician to evaluate the effect of surgery (Adams & Duffie, 1961 ; Bengtsson,
1956b; Duffie & Adams, 1963).
The objective of testing programmes in children is usually to answer the
following questions:
1. Does the physical performance capacity of the child under study
correspond to that expected for his age-group?
2. Does the development of physical performance capacity correspond
to his physical and anatomical development?
3. How does the physical performance capacity of the child relate to the
standard value for young adults?
The first question may provide sociological information if a group of
children should fail to meet the expected values; the second is helpful in
assessing what can be expected from the individual healthy or sick child
relative to his size (expressed per unit of body length or body weight) and (if
performance falls outside the rather broad range of "normality") what
is necessary as a training stimulus to improve his development; and the third

-105-
106 FUNDAMENTALS OF EXERCISE TESTING

provides information on whether the adolescent can be treated in the same

way as an adult with respect to sports and work requirements.
Regular medical examination of schoolchildren is obligatory in many
countries. In these examinations one usually obtains, in addition to the
clinical findings, data on body weight and height; it was found, a long time
ago, that in children without symptoms of disease functional development
can be assessed rather simply from the height and body-weight increase,
while the most important dimensions of the heart/lung system show an
age-curve that is identical with the growth-curve (Scammon, 1930).
However, these findings are not decisive, and in school-age children the
values for physical working capacity are so diverse that individual develop-
ment cannot be forecast even in a group with the same body height and
body weight. Because the indirect methods for the estimation of maximum
oxygen uptake do not require complex equipment, these seem the best suited
to regular school examinations. Such examinations are even more desirable
in adolescence, and an assessment of working capacity is prescribed as
part of the ILO prophylactic examination of adolescent workers. In this
way a physician can decide whether the health of an adolescent would be
endangered by a given type of industrial work. Decisions are too commonly
based simply on measurement of body mass and on clinical examination,
although such observations have only a limited bearing on the physical
working capacity and maximum oxygen uptake. Measurement or predic-
tion of the maximum oxygen uptake provides the only means of deciding
what would be a tolerable work-load for an adolescent (Hubac et aI., 1968).
As regards children and adolescents under physical training, ergometric
methods are of great importance. Astrand et aI. (1963) showed that adoles-
cents who are under training have a considerably higher maximum oxygen
uptake than those of similar body weight but not under training. This
increase in working capacity is associated with an increase of heart volume
and total haemoglobin, as well as with an alteration of functional lung
capacity. All these factors revert relatively quickly to previous values when
training is interrupted (Eriksson et aI., 1968).

Types of exercise
Exercise tests such as those proposed in Chapter 6 are commonly used in
paediatrics to measure maximum oxygen uptake and related respiratory
and circulatory functions.
Treadmill running has been extensively used in the exercise testing of
children, and reference is made to the work of Robinson (1938), Morse et
aI. (1949), and Astrand (1952). Bicycling has been used in children of
5 years and above by several investigators (Rutenfranz & Mocellin, 1968;
Adams et aI., 1961; Astrand et aI., 1963; Berven, 1963; Bink & Wafelbakker,
1968; Hollmann et aI., 1965; Macek, 1968; Lange Andersen, 1966; Bengtsson,
 ANNEX 2 107

1956a; Shephard et aI., 1969b). Stepping has also been successfully employed
by some authors (Lange Andersen, 1966).
Most of these investigations are related to the age-groups from 10 to
18 years. The youngest ages where ergometric methods have been applied
are 5 years on a bicycle (Rutenfranz & Mocellin, 1968) and 4 years on a
treadmill (Astrand, 1952). In order to examine children of less than 4-5
years of age, ergometer techniques have to be altered, with appropriate
regard for body mass and with exact measurement of effort at quite low
intensities of work (e.g., commencing at 10 kpmjmin); an optical pedometer
adapted to the level of a child's understanding is useful, and there is a need
for greater adaptability of the saddle height and the length of the pedals.
It would be useful if children's toys, such as bicycle automobiles, were con-
verted into ergo meters (Klimt, 1965) or used on a treadmill belt.

Methods of measurement
The direct measurement of maximum oxygen uptake is also easily
performed in very young children. But since this approach requires a well-
equipped laboratory with a specially trained staff, it is-for clinical pur-
poses-more practical and perfectly valid to use an indirect method. It is
preferable to establish the relationship between heart rate and oxygen uptake
at different sub maximum work-loads and to assess the maximum oxygen
uptake by extrapolation to the empirically established mean value for
maximum heart rate (see Chapter 8, p. 77).
As discussed in Chapter 1, the oxygen uptake values should be related
to body weight or height (Astrand, 1952; Lange Andersen, 1966; Ruten-
franz & Mocellin, 1968), to total haemoglobin (Astrand, 1952), to heart
volume (Reindell et aI., 1967), or to lean body mass (Parizkova, 1968).
The following parameters must be determined for this purpose:
(1) the regression coefficient relating heart rate and load ( a);
(2) the initial load (L), which must be individually selected for every child
(~ 1 W per kg body weight);
(3) the corresponding pulse frequency (fh,L) ;
(4) the maximum pulse frequency (fh ,max) for the particular age-group; and
(5) the oxygen consumption per unit of work characteristic of the ergo-
meter and the technique used.
The indirectly measured maximum oxygen uptake is then calculated as
follows (for continuously increasing effort):

(VO,)max = [L + 60 (fh.maxa- fh'L)] x K

plus basal metabolic rate.

108 FUNDAMENTALS OF EXERCISE TESTING

The factor 60 must be used in order to change the kpm/sec into kpm/min,
because "a" has the dimension min -1 /kpm sec - 1.
In the measurements of Mocellin & Rutenfranz (unpublished data, 1968)
with continuously increasing effort, the factor "K" was 0.001846; this
corresponds to an oxygen intake of 185 ml/IOO kpm/min.
Total oxygen transport can also be calculated as W170 (work rate at
heart rate 170). One can obtain this in children either by graphic extra-
polation of at least three constant-effort tests in a relative steady state
(Wahlund, 1948; see also Fig. 22) or by calculating it from a continuously
increasing effort. The calculation is similar to that for the indirect measure-
ment of the maximum oxygen uptake (Rutenfranz, 1964):

W170 = L + 60 (fh , 170 - fho L) •

a

Unless standard techniques are used in all laboratories (see, for example,
the recommendations of the International Biological Programme (IBP)
working party (Shephard et aI., 1968a), differences in both the directly
measured and the predicted maximum oxygen consumption may occur.
The mean values for maximum oxygen uptake in some groups of children
aged 10-18 years are presented in Tables 7 and 8, which show that the maxi-

TABLE 7. MAXIMUM OXYGEN UPTAKE AS A FUNCTION OF AGE IN SCHOOLCHILDREN:

INDIRECT DETERMINATION"

Boys Girls
Age
(years) Maximum oxygen uptake a Maximum oxygen uptakea

(Iitres/min) I (ml/min/kg body-wt) (litres/min) (ml/min/kg body-wt)

I 1.22
9 1.51 50 40
11 1.93 50 1.49 39
13 2.35 50 2.03 43
15 3.17 53 2.02 38
17 3.70 54 2.19 38

• Data from Rutenfranz & Hettinger (1959).

a Pulse rate 195.

mum oxygen intake (in ml 02/min/kg body-wt) is practically constant and

independent of age between 10 and 18 years in boys, while it is smaller in girls
at the beginning of puberty and decreases until the age of 15-18. 1 The values
obtained by indirect methods correspond in their magnitude and trends to
those obtained by direct methods. As to W170, values for one sample of

1 In early childhood, maximum oxygen uptake is almost the same in boys and girls (see also Chap-
ter 1, p. 25).
 ANNEX 2 109

TABLE 8. MAXIMUM OXYGEN UPTAKE" AS A FUNCTION OF AGE IN SCHOOLCHILDREN:

DIRECT DETERMINATION

Boston a Stockholm b Cologne C Lapland d Leiden e

Age-group
(years)
~ I ~ ({ I ~ ({ ~
({ I ~ ({ I ({

10-11 52 - 56 52 - - 53 51 - -
12-13 - - 56 50 45 - 53 48 51 -
14-15 47 - 59 46 48 -- 55 44
42
50
52
--
16-18 53 - 57 47 45 53

" In ml/min/kg body-wt.

a Robinson (1938).
b Astrand (1952).
C Hollmann (1963).
d Lange Andersen et al. (1961).
e Bink & Wafelbakker (1968).

children in relation to age, body length and weight have been given by
Rutenfranz & Mocellin (1968). Useful information on the assessment of
physical performance capacity in children and adolescents may be found
m Geubelle (1938), Howell & MacNab (1938), Mocellin & Rutenfranz
(1970), and Shephard (1970).
 Annex 3

EXERCISE TESTS IN POPULATION STUDIES

Exercise tests may be successfully included in many epidemiological

surveys as a tool for evaluating the cardiorespiratory function, the work
capacity and, in general, the physical fitness of population groups as a
function of their health status and physiological characteristics. Risk factors
may also be assessed through exercise testing. For instance, abnormal
ECG response to exercise has proved to be a risk predictor of a high order
(i. e., it has great specificity and sensitivity!) in forecasting the possible
occurrence of myocardial infarction. Abnormal ECG responses to exer-
cise can be easily measured and may serve as an objective, although non-
specific, sign of insufficient blood flow to the heart muscle during effort.
It is important to study the prevalence, incidence and distribution of these
abnormalities within and between population groups, particularly in relation
to health criteria and other physiological parameters.
The predictive power of exercise responses other than ECG in relation
to health and disease on a population basis has not yet been thoroughly
investigated. It is desirable that such studies be undertaken in the near
future, that is, before the physical fitness of populations changes drastically
as a result of increased urbanization and industrialization.
Intercultural comparisons are particularly needed at the present time,
since many of the more interesting small and racially pure "primitive"
tribes are rapidly becoming incorporated, socially and genetically, into the
melting-pot of urban society. Many scientists would like to initiate longi-
tudinal studies of the fitness of such communities as they pass from the active
rural life of the hunter to the sedentary existence of the city dweller, and such
studies form an important objective of the human adaptability project of
the IBP. Accordingly, much of the initial effort of the IBP has been devoted
to the standardization of methodology.
Some important problems that may be investigated by means of exercise
tests in population surveys are the following:
(I) the relationship between growth and development of physical per-
formance;

1 For definition of sensitivity and specificity, see Rose & Blackburn (1968).

-110-
 ANNEX 3 111

(2) the effect of aging;

(3) natural acclimatization to altitude;
(4) the effect of evolution in contrasting climates (tropical versus arctic,
etc.);
(5) the effect of various degrees of habitual physical activity at work and
during leisure time;
(6) the effect of air pollution;
(7) the effect of dietary differences (under-nutrition, over-nutrition,
malnutrition);
(8) the effect of endemic diseases (parasitic or other) on the work
performance; and
(9) genetically determined differences.
Some problems may be tackled by a comparative approach, e.g., by
measuring and subsequently analysing data from contrasting populations,
while other problems may best be studied by prospective investigations.

Choice of exercise test

When respiratory gas exchange is measured, any type of exercise described
in this manual can be recommended, and the choice of ergometer depends
upon the experience of the investigator and the type of population under
study. The mechanically braked bicycle ergometer and the steps are the
instruments of choice for both laboratory and field use, particularly when cost,
lack of electricity and of specialized personnel for maintenance and cali-
bration, and transportation problems are limiting factors-a situation
frequently encountered in field studies in developing countries. As described
in Chapter 3 and illustrated in Table 3 (see page 32), the mechanical bicycle
ergometer and the steps easily fulfil most of the requirements in respect
of transportation, maintenance, calibration, task familiarity, relatively low
cost, and subject's optimum performance at high V02 •
A 4- to 6-minute exercise period at submaximum work rate is recommend-
ed, since this allows measurements to be taken in the" steady state" condition.
If maximum exercises are performed, the exercise should last for at least
three minutes.

Standardization of procedure
The findings of a population survey must be reported in such a way that
other investigators, even if not involved in that particular survey, may also
make use of the results and compare them with other studies. This requires
a carefully standardized procedure in exercise testing.
For the sake of standardization it is suggested that the basic recommen-
dations for exercise testing as laid down in this manual be followed. Never-
112 FUNDAMENTALS OF EXERCISE TESTING

theless, the individual investigator may need to prepare a protocol of his

own, according to the specific requirements of the survey and taking into
consideration the type and size of the population, the type of physiological
parameters to be studied, the availability of funds, etc. All this would
influence the choice of ergometer, the duration of the exercise, and the
complexity of the test.
Instruments require careful and frequent calibration and overhauling.
Access to a proper workshop is therefore important. The repeatability and
validity (see Rose & Blackburn (1968) for details) should be established by
each team before a population survey is conducted.
Types of population group suitable for exercise testing
Because of its relative complexity, exercise testing will rarely be appli-
cable in broad population surveys. The best results will be obtained with
well-defined population groups, such as schoolchildren, military personnel,
athletes and occupational groups. The investigating capacity of an exercise
test survey is rather limited since, if respiratory measurements are to be
taken, a team of three persons cannot study more than ten subjects a day.
By using a simple bicycle test with no respiratory measurements, personnel
requirements may be reduced to only one well-trained technician, who can
study up to 15 subjects a day. Exercise testing should therefore be res-
tricted to only random samples or cluster samples of the population groups.
Instead of the customary 3- or 4-stage testing procedure described in Fig. 22,
a quicker, 2-stage procedure may be used in certain circumstances, such
as when examining a large number of subjects with the simple bicycle ergo-
meter test, the initial information obtained being used as a basis for drawing
appropriately weighted subsamples for more detailed testing.
The quantity of data collected in a population study may indeed be large,
and computerized data-processing becomes essential. The primary data
should therefore be coded and recorded on a transfer sheet, and the infor-
mation subsequently transferred to punch-cards.
The results should be reported according to the recommendations of
Rose & Blackburn (1968).
 Annex 4

EXERCISE TESTS IN ASSESSMENT OF

FITNESS FOR JOBS AND WORK ACTIVITY

The patient recovering from a severe illness will inevitably inquire about
desirable living habits for the near and more-distant future and will especially
want to know whether he will be able to resume his original work and, if
not, for what kind of work he will be eligible.
Healthy subjects may be interested in the types of sport and games for
which they can be considered as apt on the basis of their physical fitness.
Military authorities may want to make sure that their candidates for
special missions are likely to meet the physical requirements.
In all these cases, and probably in many others, it is unsatisfactory
for the medical officer to give recommendations or to formulate statements
that are built purely upon a physical examination at rest.
Submaximum tests will enable the physician to give a functional evalua-
tion of the subject's physical working capacity, and comparison with
similar data obtained in healthy subjects of the same sex, age and body build
would permit evaluation in terms of percentage of normal values. Sub-
maximum tests can also yield the necessary information for estimating
maximum oxygen uptake. However, it is the maximum tests that yield
the most valuable information on physical working capacity, in that they
allow the direct measurement of (Vo)max.
As far as results are concerned the maximum aerobic power, directly
measured in maximum tests, and the maximum aerobic power estimated from
submaximum tests could be looked upon as being comparable, but the
accuracy is definitely lower in the submaximum measurements than in the
direct measurements. As has been indicated in Chapter 4, it may happen that
an exercise test has to be stopped because of abnormal changes in the EeG or
other pathological responses to exercise. The oxygen uptake at that level
of exercise is called the "relative maximum aerobic power"; in principle this
value could be regarded as a maximum but, unlike true maximum values, a
higher fraction of it may be accepted for prolonged efforts. It is well
established that the results of a short-lasting high-level exercise test can be
translated into terms of physical capacity for longer periods. As methods
are available for measuring the energy requirements of professional and

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114 FUNDAMENTALS OF EXERCISE TESTING

non-professional activities, it is now possible to match capabilities and

requirements and to formulate recommendations for work and other
activities on a quantitative basis.

Matching job requirements to subject's physical working capacity

In order to assess whether the work task to which an individual is
exposed is properly adjusted to his physical performance capacity, or whether
it is too heavy, Bonjer (1962) introduced the concept of "relative degree of
loading". This is the ratio Mt/Ap where "M/' is the mean energy require-
ment for a given job during a given time" t", and "At" is the individual's
"acceptable" oxygen consumption for the same time period. Both M t and
At are expressed as litreslmin of oxygen consumption, and their determi-
nation is described in the following two sections.
(a) Energy requirements of job. Assessment of professional and non-
professional physical activity should always be based on a description of
the type of activities and the time involved. Such a description can be
obtained by direct observation, by a diary kept by the subject himself or
by inquiries made by a trained observer. The purpose is to indicate how
many minutes per day are spent on activities of different energy expenditure.
The sum of the products (kilocalories per minute x time in minutes for each
category of activities) shows how many kilocalories are spent throughout
a 24-hour period, and the average value per minute can be obtained by
dividing the total by 1440. The average for 24 hours is not always the
most relevant thing to study. In healthy workers it may be sufficient to
know the mean professional energy expenditure (M t), whereas in the case
of rehabilitation of cardiac patients it seems to be of interest to take into
account all activities connected with the work, including transportation,
change of clothing, washing, etc.
Tables have been published that give the caloric expenditures for many
different types of activity according to body weight (Passmore & Durnin,
1955; Spitzer & Hettinger, 1964). Other investigators have collected data
from the literature and analysed them in terms of movements of the trunk
and of the upper and lower extremities, paying attention, at the same time,
to the forces to be exerted or the weights to be borne (Bink, Bonjer & Van
der Sluys, 1966).
In spite of all efforts the accuracy of such assessments remains limited.
To a certain extent direct measurements are preferable, but these also have
their limitations. Studies of the heart rate will always suffer from the
fact that not only physical activity but also the physical and psychological
environment will influence the final result. Miniature tape-recorders are
certainly promising for the purpose, but do not seem to be developed com-
pletely as yet, and the systems for a rapid "play-back" are extremely
expensive. An event-marking system is desirable. Heart beat totalizers
 ANNEX 4 115

have been developed recently, but they give no information about the
relationship between heart rate and time.
More valuable for the assessment of energy expenditure are the measure-
ments of oxygen uptake. Douglas bags and mechanical or electrical
portable gas-meters have been used for many years, but these methods are
inconvenient and for that reason the observation time is restricted. This
means that many samples should be taken to eliminate variations. Face
masks have proved to be less inconvenient than mouthpieces and nose-clips,
and recent developments of instruments for the continuous measurement
and analysis of expired air, combined with the use of masks, have solved some
of the problems (Bleeker & Hoogendoorn, 1969; Bonjer, 1969). Whereas
earlier studies always had to be directed to single and steady activities, it is
now possible to extend the studies to longer periods of time and to follow
changes in energy expenditure produced by changing activities. It is also
possible to study peak loads, as, for instance, in staircase climbing. (For
further details, see Bonjer, 1971).
(b) Evaluation of physical working capacity for part-time or full-time
work from results of short, high-level exercise test. Physiological (VO,)rnax
and" acceptable" (VO,)rnax' For obvious reasons, the maximum level of
energy expenditure over a full day's work cannot be assessed directly for
each individual by having him perform an 8-hour exercise test. It must
therefore be extrapolated from the results of a standardized, short test.
It should also be borne in mind that the average level of energy expendi-
ture, like other physiological functions, is lower the longer the working
time. In other words, the mean oxygen uptake during a day's work is
expected to be a fraction of the maximum value as determined during an
exercise test. Investigations carried out on large numbers of industrial
workers have suggested a ratio of 3 to 1 between the maximum oxygen
uptake and the "acceptable" average oxygen uptake (At) over 8! hours.
As shown in Fig. 30, the acceptable average energy expenditure of a worker
(A) whose (V02)rnax in a short exercise test is 3.0 litres/min should be 1.3litres/
min, when considered over a 240-min (4-h) period, and 1.0 Htres/min when
considered over a 510-min (8!-h) period.
Over a 1440-min (24-h) period, the acceptable (VoJrnax would be approxi-
mately 0.6 litre/min or 2.7 kcal/min. A daily energy expenditure of 1440 x
2.7, i.e., 3900, kcal is indeed a realistic figure for a young man doing heavy
muscular work (Bonjer, 1968b).
The figures mentioned above agree with the recommendations formulated
by German work physiologists (Lehmann, 1962). The proposed 3:1 ratio
or 33% of the maximum oxygen uptake for 8! hours fits well with findings of
Michael, Hutton & Horvath (1961), whose subjects could walk for 8 hours on
a treadmill without undue fatigue if the energy cost did not exceed 35%
of the maximum oxygen uptake. Astrand (1967) found 39% in a study of
116 FUNDAMENTALS OF EXERCISE TESTING

building industry workers. Fig. 30 shows that, in the case of workers B

and C (V02)max of2.1 and 1.8Iitres/min, respectively), the At values at 4 and
8t hours are 0.9 and 0.7 litre/min and 0.8 and 0.6 litre/min respectively.
Acceptable oxygen uptakes (At) at various working times (t) can gene-
rally be extrapolated from the graph in Fig. 30 by constructing a line in the
following way: (1) plot the value for (V02 )max obtained in a 4-min exercise

FIG. 30
ACCEPTABLE OXYGEN UPTAKE AS A FUNCTION OF WORKING TIME
IN THREE SUBJECTS'

500
·~r\-
400 \ ,
300
\
\
\.
240 \\\ .
200
\\
\ '
\\
\ '
100
90
80
\
\
\,
70
.~ 60 \\
\ '
.~ 50
on
~
\
\
\,
~ 40
'" 30
\\ \.
20
\\ \'
\ \
\ ,
\\ \,
10

:\ \8
\\ \
\

At 51 0 minutes the acceptable oxygen uptake is one-third of the maximum oxygen uptake.
'Redrawn from Bonjer (1968b).
 ANNEX 4 117

test (A4) on the graph in correspondence with 4 minutes; (2) take one-third
of this value and plot it in correspondence with 510 minutes (8t hours);
(3) connect the two points.
Alternatively, At values can be derived from the formula:

A=A 3.76 - log t

t 4 3.16

This formula was derived from the system:

At = log t - 3.756
a
0.602 - 2.708
a = -----:---
A4 - t A4
where 3.756 is the logarithm of the intercept (which is the same in all cases),
"a" is the slope (negative), 0.602 is log 4 (i.e., the 4 minutes of exercise
needed to determine A4 ), and 2.708 is log 510 (i.e., 510 minutes = 8t hours
at which At is t A4 ).
The ratio Mt/A t should never exceed unity. In the practical work
situation the value should range from 0.7 to 0.9 (Bonjer, 1962). Analysis
of values exceeding 1.0 always revealed undesirable situations. A common
finding in the case of worker A in Fig. 30 would be: M S10 = 0.8 litre/min;
AS10 = l1itre/min; MSlo/Aslo = 0.8. If worker B were to work part-
time at a M 240 of 0.8 litre/min, his relative degree of loading would be
0.8/0.9 (= 0.89), whereas for the same job worker C would have to employ
his full capacity at 240 minutes (0.8/0.8 = o.

Peak loads
Particular attention should be paid to peak loads. Maximum values are
important in these cases, since there is no relation to working time. Any
effort exceeding the maximum oxygen uptake and/or lasting more than
four minutes will cause exhaustion and should always be avoided. Shorter
and more strenuous efforts can be met by anaerobic processes, but the inci-
dental excess of job requirements must be compensated later on by reduction
of activities in the following period of time. Any excess of maximal physical
working capacity must be avoided, even for short periods, if ECG changes,
exceedingly high blood pressure, or other pathological responses that would
call for the stopping of a usual exercise test are likely to arise. This is
particularly important in the case of cardiac subjects.
Checking correctness of recommended professional activities
After a person has been tested for his physical capacity and the work has
been analysed as to its requirements, the final success of the job placement
118 FUNDAMENTALS OF EXERCISE TESTING

should always be checked even if the relative degree of loading seems to be

acceptable and no peak loads are endangering the well-being of the subject.
Such a check can be carried out in different ways. It may be sufficient for
a patient who has returned to work after rehabilitation to see the doctor
responsible for the placement periodically after completion of a working day.
More sophisticated methods involve the continuous recording of the heart
rate and/or EeG throughout the working day. It may be found that
environmental or psychological factors play a role, which could not be
foreseen during the preliminary assessments.
 Annex 5

COMPARABILITY AND STANDARDIZATION OF EXERCISE TESTS

It is apparent from Chapters 2 and 3 that many forms of exercise test are
currently used in different laboratories and in different parts of the world.
This is unfortunate, because much data is collected annually, and if some
measure of standardization could be achieved, interesting comparisons would
be possible between groups of people differing in physical activity, diet, and
other features of culture and environment in relation to health and disease.

Oxygen uptake in different types of exercise

The direct measurement of the maximum oxygen uptake provides a
reference standard against which other exercise tests may be judged. Young
men are quite readily pushed to their maximum aerobic power, but more
difficulty is encountered in the very young, the elderly, and female subjects
generally. When large-scale surveys are contemplated, the logistic require-
ments in terms of medical supervision become prohibitive. Nevertheless,
it seems likely that within any given population there will be an adequate
number of individuals who are able and willing to perform the (V02 )max
test, thereby providing a reference standard against which secondary and
more widely applicable tests may be calibrated.
A comparison of maximum oxygen uptake measured in the same
subjects (healthy young men) by three different types of ergometer was
carried out in Toronto in 1967 by an international team of work physiolo-
gists; the data obtained are presented in Table 9 (Shephard et aI., 1968a).
The results show that the terminal pulse rates and arterial lactate levels two
minutes after exercise are very similar for step, bicycle and treadmill exercise,
but the maximum oxygen uptake in the treadmill test is 7% greater than that
in the bicycle ergometer test while the step test (Vo)max values are intermediate
between the treadmill and bicycle ergometer values. Similar results have
been obtained in other studies (Lange Andersen, 1968; Wyndham et aI.,
1966; Astrand & Saltin, 1961; Glassford et aI., 1965). Comparisons on
women, children, and older subjects have yet to be carried out.
The differences between the three types of exercise with regard to
maximum oxygen uptake is not so great that values obtained from the
three types of exercise cannot be compared; which means that any of them
can be used if warranted by the circumstances of a particular experiment.

-119-
120 FUNDAMENTALS OF EXERCISE TESTING

TABLE 9. MAXIMUM OXYGEN UPTAKE (MEAN, SO AND RANGE)

IN THREE COMMON FORMS OF EXERCISE TEST"

{I;02),nax Pulse rate Lactate level

Test (beats/min)
(litres/min STP D) (mg/100 ml)

Treadmill 3.81±0.76 190±5 122± 21

(2.54-5.84) (178-197) (78-166)
Bicycle 3.56±O.71 187±9 112±15
(2.57-5.23) (167-207) (89-143)
Step 3.68±0.73 188±6 105±26
(2.66-5.59) (170-195) (45-165)

" Data from Shephard et al. (1968a), obtained on 24 healthy, young Canadian men.

However, allowance should be made for the systematic discrepancy between

the treadmill and the bicycle ergometer in the interpretation of results.
The stability of an individual's (Vo,)max for a given mode of exercise is
largely a matter of good technique; however, discrepancies have sometimes
been encountered in tests carried out in different laboratories (Bobbert, 1960;
Bonjer, 1966; Cumming, 1968)-a fact that emphasizes the need both for
a handbook of standard methodology and for a panel of approved reference
laboratories where the correct technique can be mastered.
The differences in maximum oxygen uptake between step, bicycle, and
treadmill exercise, although statistically significant, seem sufficiently small
for interconversion of data, using appropriate scaling factors, to be contem-
plated. The main weakness of such a mathematical manipulation of the
data is that the point of exhaustion is not the same for the steps, treadmill,
and bicycle. If, for instance, performance of bicycle ergometer exercise is
seriously limited by weakness of the quadriceps muscle, then the extent of
the weakness-and hence the discrepancy from treadmill and step test
results-may vary with the training of that muscle.

Mechanical efficiency as a function of learning and habituation

It is commonly held that the bicycle ergometer provides a unique method
of performing a known amount of work with a constant mechanical efficiency.
If this were true, it would give the bicycle ergometer an important advantage
over other forms of exercise in that measurements of oxygen consumption
would not be necessary for field testing.
In practice, it is hard to document this advantage. The coefficient of
variation in efficiency of cycling is between 3% and 5% when experienced
subjects exercise under optimum conditions, and can be as great as 8-10% in
subjects who are unaccustomed to cycling (Shephard et aI., 1968b); com-
parable figures for the step test are 5-6% in the experienced and 9-12% in the
inexperienced. Although the bicycle is a little better than the step test, in
both cases the prediction of oxygen intake can be made only very approxi-
mately, and oxygen consumption should be measured directly if reliable
values are to be obtained.
 ANNEX 5 121

The work performed during treadmill running cannot be measured

accurately, but nomograms are available to predict the approximate oxygen
cost; these are accurate to 10-14%.
There is some tendency for the efficiency of exercise to improve with
repetition of all three forms of test; the change produced by a week of
submaximum testing is equivalent to a 3-4% decrease in the oxygen cost
of step and bicycle exercise, and a 7% decrease for treadmill exercise.
Most procedures for the interpretation of submaximum tests are based
on the assumption that the pulse rate is constant at a given fraction of the
individual's aerobic power. The accuracy of such procedures is thus
limited by non-metabolic increases in pulse rate such as those due to anxiety.
Anxiety diminishes with repetition of the test, this being a form of
negative conditioning sometimes described as habituation (Glaser, 1966;
Shephard, 1966, 1967b). The greatest effect of habituation is seen on the
second day of testing.
Habituation is a function of the central nervous system, and it can be
difficult to distinguish from the regulatory aspects of physical training,
which also lead to a decrease in pulse rate for a given submaximum work-
load.
Continuous and discontinuous tests
Two practical problems are posed by a series of discontinuous tests:
fitness may change while the measurements are being made, and busy
subjects may not be willing to return to the laboratory on the three or more
occasions required for testing. Fortunately, the results obtained by a
continuous test, where the load is increased every 30 seconds (or every 1 or
2 min), are closely comparable to those obtained in discontinuous exercise
(Wyndham et aI., 1966; Pirnay et aI., 1966; Bonjer, 1966; Shephard et aI.,
1968a); indeed, if the correct loadings are chosen, the continuous test can be
less exhausting and a slightly higher VImax may be reached.
Subjective and practical considerations
In the case of intense effort the following considerations should be kept
in mind.
Towards the end of treadmill exercise, subjects tend to complain of
nausea, breathlessness and chest pain. They look intensely cyanosed, and
may become unsteady on their legs, partially losing consciousness. Local
pain in the legs is rarely described. On the other hand, when the bicycle
ergometer is used, weakness or pain localized to the quadriceps muscle may
give rise to complaint. A few subjects may report breathlessness, but the
facies of circulatory exhaustion is not seen. Stepping exercise occupies a
position intermediate between treadmill and bicycle exercise in this respect.
Some subjects complain of weakness or pain in the leg muscles, while others
are limited by dyspnoea or loss of co-ordination.
122 FUNDAMENTALS OF EXERCISE TESTING

On clinical grounds, it would thus seem that treadmill exercise is limited

by a central exhaustion of the cardiovascular system, while bicycle exercise
is limited by fatigue of local muscle groups.
Comparative investigations on 24 young subjects (Shephard et al., 1968 a)
have shown that the main complaints against the treadmill are lack of any
opportunity to rest, and the need to keep in one position on the belt. Some
subjects also may find the belt rather slippery. The main problem with
the bicycle is saddle discomfort. A few subjects may complain of difficulty
in keeping the pedal rhythm; this would probably present more of a problem
to older people. Some people may feel that they would achieve a greater
effort by standing on the pedals; however, body heaving of this type would
seem unacceptable as a standard form of exercise. As to stepping, the
46-cm step required for maximum exercise may be found rather high by
some subjects, and would probably be too difficult for older people. There
is also a tendency for tripping to occur as the subjects become exhausted.
Certain other practical considerations may be noted. Complicated
technical procedures such as cardiac catheterization and even the measure-
ment of cardiac output by rebreathing methods are difficult to carry out on a
running subject, and almost impossible on one who is climbing steps.
Also, the selection of four, evenly spaced work-loads is rather difficult in
the case of the treadmill, because the relationship between speed of walking
or running and oxygen consumption is not very consistent.
Many considerations enter into the choice of an optimum exercise test.
Some questions can be answered only by the individual physician concerned
with the observations. Is it planned to measure the maximum oxygen
uptake directly, or will a prediction be made from the response to submaxi-
mum exercise? Will extensive ancillary investigations, such as cardiac
catheterization, be required? Is emergency care likely to be needed? Will
tests be conducted in a well-equipped laboratory, or in a simple field station?
Will a physician and trained technical staff be available at all times? Will
electrical power be available?
It is obvious that with such varied requirements, one test is unlikely to
meet the needs of all investigators. However, it is possible to state the ideal,
and then match available tests against this criterion. The exercise should
be familar to the subject and require little skill. A difficult and unfamiliar
task creates anxiety, exaggerating pulse and ventilatory responses to sub-
maximum exercise, it also leads to rapid learning, so that it is difficult to
estimate oxygen consumption from the work performed. The subject
should enjoy the exercise, in order that his co-operation be ensured, and the
task should not only be free from hazard but should also appear so to
him. It should be easy to estimate the work performed by the subject; this
implies a simple and reproducible method of calibrating the instrument,
and a consistent relationship between the energy expenditure of the subject
and the work performed on the machine. The loading of the apparatus
 ANNEX 5 123

should be readily adjustable to give a nearly continuous increase of effort

if desired. If used for maximum effort tests, the apparatus should be
capable of driving a subject to general exhaustion rather than to local
muscle fatigue. Finally, the cost should be reasonable, the noise involved
in testing minimal, the maintenance requirements (including recalibration)
few, and the apparatus itself compact and readily transportable.
As expected, all testing procedures present problems of various kinds and
none of them can be chosen as the optimum one. The treadmill, however,
despite its suitability for maximum exercise, seems the least desirable form of
submaximum exercise. The apparatus is bulky, noisy, and expensive, and
requires careful maintenance. The task is unfamiliar and somewhat
frightening to the average subject, and in the first few days of testing the
pulse rate may vary considerably with habituation (a lessening of anxiety)
and learning (increased efficiency of exercise). It is not easy to select
suitably spaced work-loads. The quality of the ECG is often poor, and if
the condition of the subject demands rest, time is needed to transfer him to
a couch. The choice for submaximum exercise thus lies between a step
test and a bicycle ergometer.
The main advantages of the bicycle ergometer are (a) that variations in
pulse rate due to habituation and learning are slight, and (b) the subject's
arms are relatively immobile, thus permitting such procedures as blood
pressure measurement and catheterization of the arm vessels to be carried
out. The mechanical efficiency of effort can also be more precisely deter-
mined than for other types of effort. On the other hand, careful calibration
is essential in order to measure the work performed, and a good quality
bicycle ergometer is relatively expensive. The ECG may be distorted by
muscle noise, and it is not always easy for a subject encumbered by leads to
dismount in an emergency.
A 23-cm step is familiar to most subjects, but some anxiety may arise
from tripping at rapid rates of ascent. The apparatus is cheap and portable,
and requires no maintenance, calibration or electricity supply. The
intensity of exercise is readily altered by a simple adjustment of the metro-
nome setting. Anaerobic work is minimal. The mechanical efficiency of
effort is a little more variable than on the bicycle ergometer, but if care is
taken to ensure complete ascent and descent, the work performed can be
estimated from the step height and body weight with reasonable accuracy.
The main disadvantage of the step test is that it involves a continuous
movement of the arms and head, and this creates difficulties in the making
of certain physiological measurements.
It is difficult to propose a single test that is suited to the needs of every
experimental situation. In the field situation, there is much to commend a
simple stepping procedure, but a bicycle ergometer should be employed if it is
necessary to measure blood pressure or to carry out vascular catheterization.
 Annex 6

SPECIALIZED TERMS AND UNITS USED IN EXERCISE TESTING*

Symbol Dimension Definition

RESPIRATION

a Arterial (subscript)
A Alveolar (subscript)
C %; ml/litre Gas concentration
Ca ,02 -CV,02 ml/lOO ml or ml/litre Arteriovenous oxygen difference
CV,02 ml/lOO ml Mean concentration of oxygen in
mixed venous blood
D ml/min/mm Hg;a Diffusing capacity
litres/min
DL ml/min/mm Hg;a Lung diffusing capacity
litres/min
DL,02 ml/min/mm Hg;a Lung diffusing capacity for oxygen
litres/min
D L,C0 2 ml/min/mm Hg;a Lung diffusing capacity for carbon
litres/min dioxide
Dm ml/min/mm Hg;a Diffusing capacity of alveolar cap-
litres/min illary membrane
D 02 ml/min/mm Hg;a Diffusing capacity for oxygen
litres/min
Dt ml/min/mm Hg;a Tissue diffusing capacity
litres/min
E Expired (subscript)
fR breaths/min Respiratory rate (breathing
frequency)
FE % Fraction of expired gas
FJ % Fraction of inspired gas

• A dot over a symbol indicates that it refers to a time derivative.

a The traditional units of the physiologist are mlJminJmm Hg. However, in order to be dimensionally
equivalent to alveolar ventilation and cardiac output, diffusion should be expressed as mlJmin per mlJlitre
concentration gradient (Le., litres/min).

-124-
 125
ANNEX 6

Dimension Definition
Symbol
RESPIRATION (continued)
Forced expiratory volume in one
FEV 1.o litres
second
Functional residual capacity
FRC litres
litres Forced vital capacity
FVC Inspired (subscript)
I Pulmonary mid-capacity
MC litres
Maximum minute ventilation
MMV litres
Maximum voluntary ventilation
MVV litres/min
Maximum voluntary ventilation at
MVV loo litres/min
100 breaths/min
Tension (partial pressure) of gas
P mmHg
Arterial carbon dioxide pressure
Pa,COz
mmHg
mmHg Arterial oxygen pressure
Pa,Oz Alveolar carbon dioxide pressure
mmHg
PA,COz Tension of expired carbon dioxide
PE,COz
mmHg
litres/min Peak expiratory flow
PEF Tension of inspired oxygen
mmHg
Pl,Oz Gas exchange ratio (respiratory
R quotient)
Respiratory (ventilatory) equivalent
for oxygen
Oxygen saturation of arterial blood
%
litres Total lung capacity
litres Total lung volume
Transfer coefficient for oxygen
litres/min
uptake
Venous (subscript)
Pulmonary ventilation
litres/min
litres/min Alveolar ventilation
Volume of blood III alveolar
ml
capillaries
litres Vital capacity
Volume of expired air
litres
Expiratory minute volume
litres/min
Pulmonary ventilation during
litres/min
exhaustive muscular effort
litres/min Oxygen uptake
VOz Maximum oxygen uptake
litres/min
(VOz)max Oxygen uptake at heart rate 170
(VOz)170 litres/min
Oxygen uptake at specified work-
(Vozhoo litres/min
load (e. g., 900 kpm/min)
 126
FUNDAMENTALS OF EXERCISE TESTING

Symbol Dimension Definition

RESPIRATION (continued)

ml Tidal volume
Air/blood partition coefficient

CIRCULATION

BP mmHg
CI Blood pressure
litres/min/m 2 Cardiac index
.D
Diastolic (subscript)
fh beats/min Heart rate
f h ,900 beats/min
Heart rate at specified work-load
(e.g., 900 kpm/min)
beats/min
Heart rate at specified oxygen
LPI uptake (e.g., 2.10 litres/min)
mljbeat; kpm/beat Leistungspu!sindex (oxygen pulse)
P mmHg Mean pressure
Pc mmHg
PD,a Mean capillary pressure
mmHg Diastolic pressure, arterial
PD,ao mmHg Diastolic pressure, aortic
PD,p mmHg
PS,a Diastolic.pressure, pulmonary
mmHg Systolic pressure, arterial
PS,ao mmHg Systolic pressure, aortic
~S,p mmHg
Systolic pressure, pulmonary
Q litres/min Cardiac output
Qc mljmin Pulmonary capillary flow
Qs ml Stroke volume
R dynes sec/cm s ; Vascular resistance
mm Hg/mljmin
Systolic (subscript)
mljstroke/m 2 Systolic index
ml Heart volume

WORK

kgm*
kpm* kilogram-metre
W* kilopond-metre
W watt (also symbol for "Work")
kpm/min; watts Work rate

* The relationship between the various units of power and work is explained in Chapter 8.
 ANNEX 6 127

Dimension Definition
Symbol

WORK (continued)

kpm/min; watts Work rate at a specified oxygen

uptake (e.g., 2.10 litres/min)
kpm/min; watts Work rate at a heart rate of 170
W170 Work of the heart
Wh mm Hg x beats/min
kpm/min; watts Maximum work rate
Wmax Work of left ventricle
Wi kpm/min; watts
kpm Total work performed in time "t"
Wt
OTHER TERMS AND UNITS

Ambient temperature and pressure,

ATPS saturated with vapour
Body temperature and pressure,
BTPS
saturated with vapour
m2 Body surface area
BSA
litres Blood volume
BV
kg Body weight
BW
litres Central blood volume
CBV
Electrocardiogram
ECG
cm Height
H
Haemoglobin
Hb
% Haematocrit
Hc
kg Lean body mass
LBM Ratio of MR to basal metabolic rate
Met
kcal/min Metabolic rate
MR
Metabolic units
MU Non-obesity tissue
NOT kg
litres Plasma volume
PV
ml Red cell volume
RCV Standard temperature and pressure,
STPD
dry gas
Temperature
T Rectal temperature
Tr Skin temperature
Ts Rectal-skin temperature gradient
Tr - s Total blood volume
TBV
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 130 FUNDAMENTALS OF EXERCISE TESTING

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