Hindawi

BioMed Research International

Volume 2018, Article ID 4863454, 7 pages
https://doi.org/10.1155/2018/4863454

Research Article
The Reliability and Validity of a Modified Squat Test to
Predict Cardiopulmonary Fitness in Healthy Older Men

Chiu-Ping Yeh,1,2 Hsien-Cheng Huang,3 Yaju Chang ,4

Ming-De Chen ,5 and Miaoju Hsu 6,7
1
Department of Physical Education, National Taiwan Normal University, Taipei, Taiwan
2
Physical Educational Office, National Kaohsiung University of Applied Sciences, Kaohsiung, Taiwan
3
Section of Cardiology, Department of Internal Medicine, Taipei City Hospital, Yangming Branch, Taipei, Taiwan
4
Department of Physical Therapy and Graduate Institute of Rehabilitation Science, Chang Gung University, Taoyuan, Taiwan
5
Department of Occupational Therapy, College of Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan
6
Department of Physical Therapy, College of Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan
7
Department of Rehabilitation, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Correspondence should be addressed to Miaoju Hsu; mjhsu@kmu.edu.tw

Received 31 August 2017; Accepted 16 November 2017; Published 2 January 2018

Academic Editor: Leonardo dos Santos

Copyright © 2018 Chiu-Ping Yeh et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Shortcomings are noted in currently available cardiopulmonary field tests for the older adult and thus relevant research
is still ongoing. Purpose. The purpose of this study was to investigate the reliability and validity of a modified squat test and to
establish a regression model for predicting aerobic fitness in the older adult. Methods. Twenty-five healthy men aged 60 to 75 years
completed this study. Each subject performed two modified squat tests with a prototype testing equipment and a maximal exercise
test to determine maximal oxygen consumption. Recovery heart rates (HR) (0∼30, 60∼90, and 120∼150 seconds) were measured
following the modified squat tests. The fitness indexes included the sum of recovery HR, recovery HR index, age-adjusted recovery
HR index, and immediate HR. Results. The results revealed that the age-adjusted recovery HR index fitness had the highest intraclass
correlation coefficients (ICC) of 0.9 and Pearson’s correlation coefficients of 0.71, which suggested the modified squat test can
reasonably assess cardiopulmonary fitness for the older adult. The regression equation for estimating aerobic power was VO ̇ 2 max
= 16.781 + 16.732 × (age-adjusted recovery HR index) + 0.02467 × (physical activity level). Conclusion. The modified squat test is a
valid and reliable field test and thus can be an option to assess the cardiopulmonary fitness level of healthy older men in clinics or
communities.

1. Introduction immediately or during recovery after the stepping test are

recorded and calculated. Different stepping frequency, bench
Cardiopulmonary fitness, which is most accurately presented height, test duration, the number of stages, and the scoring
by maximal oxygen uptake (VO ̇ 2 max), is related to mortality method have been developed for particular populations. For
in older adults. Laboratory maximal exercise tests with a example, Petrella et al. [3] established a self-paced step test for
treadmill or an ergometer can precisely evaluate VO ̇ 2 max, the community-dwelling older adult, which is implemented
which is not always accessible due to expensive equipment at 40 cm height and requires stepping 20 times at different
and trained personnel being required [1, 2]. For practical paces. A high correlation coefficient of 0.75∼0.94 is found
purposes, field tests are developed and used to measure between the observed and the predicted maximal oxygen
cardiopulmonary fitness. Based on the characteristics of the consumption (VO ̇ 2 max). Though the self-paced step test
older adult, the common test modes of field tests are stepping appears to accurately estimate cardiopulmonary fitness in
and walking tests. older adults, it is argued that stepping movements might
A three-minute stepping test is widely used to predict cause orthopedics problems in knees as well as increase the
cardiopulmonary fitness in that heart rate (HR) responses fall risk to mobility-limited older adults [4]. Rikli et al. [5, 6]
2 BioMed Research International

developed a two-minute self-paced test involving stepping Table 1: Cornell-Modified Bruce Protocol.
in place, which is safer for the older adult. However, the Stage Min Speed (mph) Grade (%)
relationship between this two-minute step-in-place test and
0.0 2 1.7 0
maximal oxygen consumption is not established.
The walking test employs functional movements in nature 0.5 4 1.7 5
and is easy to conduct. Particularly, the walking test is much 1.0 6 1.7 10
safer than the stepping test and thus is more commonly 1.5 8 2.1 11
used in senior people. Six-minute walking test and Rockport 2.0 10 2.5 12
fitness walking test can reasonably predict cardiopulmonary 2.5 12 3.0 13
fitness in the elderly [7, 8] while shortcomings are noted. 3.0 14 3.4 14
Numerical studies have demonstrated that the 6 min walking 3.5 16 3.8 15
test is not appropriate to evaluate changes in cardiorespira- 4.0 18 4.2 16
tory fitness in healthy older men who received endurance 4.5 20 4.6 17
training for 24 weeks [9–12]. Moreover, a spacious walk-
5.0 22 5.0 18
way is needed. Therefore, research on developing new field
tests of cardiopulmonary fitness for the older adult is still
ongoing. 2.3. Maximal Exercise Test. Aerobic capacity was measured
Inoue and Nakao developed a cardiopulmonary fitness by performing a treadmill exercise test using the Cornell-
test, a squat test, that is simple to administer in a confined modified Bruce treadmill exercise protocol (Table 1). The
space with minimum apparatus [13]. Participants should protocol, which was used to determine the cardiopulmonary
repeat squatting 30 times per min by bending of the legs fitness of the elderly, consists of 2-min stages, beginning
until the hips meet with the heels. A significant correlation with 0 stage at 1.7 mph and 0% grade, gradually increasing
(𝑟 = 0.92 for women, 𝑟 = 0.82 for men, 𝑝 < .001) intensity to stage 5 of the Bruce protocol [14, 15]. The 12–lead
between VO ̇ 2 max and the fitness index of the squat test has EKG was monitored during the test as well as the recovery
been found in young adults. Considering difficulties to fully stage. Heart rate was recorded every minute, and blood
squat down in the older adult and the heavy loading of the pressure and Borg’s rating of perceived exertion (RPE) on a
knee joint during the squatting activity due to the nature scale of 6–20 were assessed every 2 minutes. Respiratory
of the movement, we modified the original squat test from gas samples were analyzed breath-by-breath using a portable
full squatting to half-squatting in order to minimize possible metabolic system (K4b2 , COSMED, Rome, Italy). The test was
injuries to knee joints. The purpose of this study was to terminated based on American College of Sports Medicine
evaluate the reliability and validity of the modified squat test (ACSM) guidelines for conducting a maximal exercise test
and to construct a model for the estimation of aerobic fitness [16, 17], with the age-predicted maximum heart rate calcu-
based on the modified squat test performance. lated as (208 − 0.7 × age) [18] and respiratory exchange
ratio (RER) adjusted for 1.00 [19]. Aerobic power (VO ̇ 2 max),
HRmax , maximal blood pressure, rating of perceived exertion
2. Method (RPE) based on a 6–20 points’ Borg Scale, and the time of the
2.1. Participants. Thirty-three healthy older subjects between exercise test were obtained.
the ages of 60 and 75 years participated in this study.
2.4. Modified Squat Test. A custom-made lightweight equip-
Exclusion criteria included cardiovascular disease, metabolic
ment platform (Figure 1(a)) was developed to conduct the
disease, pulmonary disease, mental problems, and severe
modified squat test. The vertical part of the testing equipment
orthopedic diseases of the lower extremity. Informed consent
(Figure 1(b)) could be detached from the horizontal part so
was obtained from all participants. To assess potential risks of
that the equipment could be easily carried. When performing
performing a maximal exercise test, the Physical Activity
the modified squat test, the subject started at a standing
Readiness Questionnaire (PAR-Q) was administered and
position with his elbows 90∘ flexed at the sides of the waist
the resting 12-lead EKG was conducted and screened by a
(Figure 2(a)), followed by squatting down to 45∘ knee flexion
cardiologist. Before testing, body weight, height, body fat
with both arms pushed out at the same time (Figure 2(b)), and
(TANITA, Taiwan), and Physical Activity Scale for the Elderly
then returned to the starting position (Figure 2(a)). The sub-
(PASE) score were recorded.
ject repeated the above-mentioned sequences at a rate of 104
cycles/min for 3 minutes, using a metronome. Recovery heart
2.2. Experimental Protocol. All participants had to complete rates (HR) (0∼30, 60∼90, and 120∼150 seconds) were counted
a maximal exercise test and two modified squat tests. The sub- following the modified squat test with using a stethoscope.
ject performed the first modified squat test, followed by the Blood pressure and RPE were recorded at the end of the
second modified squat test with oxygen consumption mea- test. To compare with previous studies, we calculated several
sured and then a maximal exercise test. An adequate rest was fitness indexes including immediate HR, the sum of recovery
provided between the tests in order to allow heart rate and HR, and recovery HR index (18000/((HR0∼30 + HR60∼90 +
blood pressure to be returned to the level of baseline, which HR120∼150 ) × 2)). In addition, we developed a new index
was defined as within 5 beats/minutes for heart rate and calculated as (recovery HR index/age). The indexes obtained
5 mmHg for blood pressure. from the modified squat test were determined as follows.
BioMed Research International 3

(a) (b)

Figure 1: Custom-made lightweight equipment. (a) Assembled testing device. (b) A diagram from a lateral view showing the upright part of
the device can be detached from the horizontal part.

(a) (b)

Figure 2: Movements of the modified squat test. (a) Starting position. (b) Ending position.

2.4.1. Immediate HR. After the termination of the modified 2.4.4. Age-Adjusted Recovery Heart Rate. The fitness index
squat test, heart rate measured from Polar was recorded was calculated according to the following equation:
immediately.
Age-adjusted recovery heart rate

2.4.2. The Sum of Recovery HR. When the modified squat test recovery HR index (2)
= .
was finished, cumulative heart beats were counted during age
0∼30, 60∼90, and 120∼150 seconds. The total number of
recovery pulse counts was calculated as the sum of recovery 2.5. Statistical Analysis. Test-retest reliability for the modified
HR. squat test was established by determining the intraclass corre-
lation coefficient (ICC). The ICC values greater than 0.75 were
2.4.3. Recovery HR Index. The fitness index was revised from considered as good reliability, those between 0.5 and 0.75 as
the equation of Harvard step test [20]: moderate reliability, and those below 0.5 as poor reliability
[21]. Pearson correlation analysis was used to evaluate the cor-
Recovery HR index relation between the fitness indexes of the modified squat test
and the maximal exercise test performance. Correlation coef-
test duration of modified squat test (second) × 100 (1) ficients (𝑟) higher than 0.6 were defined as high correlations,
= .
(the sum of recovery HR) × 2 those between 0.3 and 0.6 as moderate correlations, and those
4 BioMed Research International

Table 2: Physical characteristics and baseline physiological param- 3.4. Reliability of Squat Test. All the modified squat test
eters for the subject (𝑁 = 25). fitness indexes showed high test-retest reliabilities, with ICC
values ranging from 0.77 to 0.90. As shown in Table 5, age-
Mean SD
adjusted recovery HR index had the highest ICC value (0.90)
Age (years) 65.16 4.90 among the four squat test indexes.
Weight (kg) 66.11 8.58
Height (cm) 166.52 5.21 3.5. Validity of the Modified Squat Test. As shown in Table 6,
BMI (kg/m2 ) 23.81 2.59 a significant negative correlation was seen between the sum
Body fat (%) 20.57 5.73 of recovery HR and VO ̇ 2 max, whereas significant positive
Heart rate rest (beats/min) 73.80 11.69 correlations between the recovery HR index and age-adjusted
recovery index and VO ̇ 2 max were found. Age-adjusted recov-
Systolic blood pressure (mmHg) 128 14.59
ery HR index had the highest correlation with VO ̇ 2 max.
Diastolic blood pressure (mmHg) 81.28 9.34
Physical Activity Scale for the Elderly 137.07 64.81
3.6. Prediction of 𝑉𝑂̇ 2 𝑚𝑎𝑥 Equation. Table 7 presents the
SD: standard deviation. result of the stepwise multiple regression analysis for pre-
diction of VȮ 2 max. Age-adjusted recovery HR index and
Table 3: Physiological responses to maximal exercise test (𝑁 = 25). ̇ 2 max
physical activity level were strongly correlated with VO
Mean SD and accounted for 63% of the variance. The prediction
̇ 2 max (ml/kg/min)
VO 35.82 4.44 equation for VȮ 2 max from the modified squat test was
RER 1.05 0.11 ̇ 2 max = 16.781 + 16.732
VO
Time to exhaustion (min) 12.80 2.00
HRmax (beats/min) 165.12 8.25 × (Age-adjusted recovery HR index) (3)
Systolic blood pressure (mmHg) 196.75 18.88
+ 0.02467 × (physical activity level) .
Diastolic blood pressure (mmHg) 88.00 10.49
RPE 17.28 1.24
SD: standard deviation.
4. Discussion
Cardiopulmonary fitness is associated with risks of car-
̇ 2 max from diovascular diseases [22–24]. With aging, maximal oxygen
under 0.3 as poor correlations [21]. To predict VO
consumption declines at the rate of 1% per year [25]. Regular
the best fitness index, a stepwise multiple regression analysis
exercise has been considered to be a safe and effective strategy
was performed with physical activity level and physiological
to delay the aging process. Evaluation of cardiopulmonary
and anthropometric data (age, resting HR, height, weight,
fitness is essential to assure that a safe exercise prescription
BMI, and percent of body fat) as independent variables.
is implemented for older people [26]. Considering the nature
of physical characteristics of older individuals, we modified
3. Results a squat test, which was originally designed for young healthy
3.1. Participant Characteristics. Thirty-three male partici- adults.
pants aged 60 to 75 years were recruited. Eight of these
4.1. Reliability. The ICC analyses on the fitness indexes (the
participants did not complete the maximal exercise test due
immediate HR, sum of recovery HR, recovery HR index, and
to cardiac and/or balance problems and were excluded for
age-adjusted recovery HR index) of the modified squat test
data analysis. The baseline characteristics of the remaining 25
revealed that the ICCs ranged from 0.77 to 0.90, suggesting
participants analyzed are presented in Table 2.
high reliabilities according to the definition of reliability level
proposed by Portney and Watkins [21]. Age-adjusted recov-
3.2. Maximal Graded Exercise Test. Physiological responses ery HR index had the highest ICC among the four modified
of the participant to the maximal exercise test are shown in squat test fitness indexes, showing the best reliability. On the
Table 3. Twenty-five subjects completed the maximal exercise contrary, the immediate HR yielded the lowest ICC value
test without any abnormal ECGs or complications. The VO ̇ 2 (0.77). The older adult has greater variations in physiological
and RER at baseline were 4.86 ± 1.03 (ml/kg/min) and responses to an exercise and slower adaptations to an exercise,
̇ 2 and RER at maximal efforts
0.76 ± 0.10, respectively. The VO which contributes to the lower ICC seen in the immediate HR
reached 35.82±4.44 (ml/kg/min) and 1.05±0.11, respectively. fitness index.
The time to volitional exhaustion was within an optimal Petrella et al. investigated the validity of the self-paced
exercise time of 8 to 12 minutes as suggested by ACSM. step test in older adults while the reliability was not conducted
[3]. Kervio et al. assessed the reliability of the 6-minute walk
3.3. The Modified Squat Test. Table 4 presents the result of the test in 12 healthy old individuals [27]. In their study, six trials
two modified squat tests. As shown in Table 4, the intensity of the 6-minute walk test were performed. However, only the
for the modified squat test was 20.72 ± 3.60 ml/kg/min, coefficient of variation (CV) instead of ICCs was reported.
corresponding to 58.22 ± 10.00% of VO ̇ 2 max and 80.98 ± Fenstermaker et al. investigated the test-retest ICC reliability
10.92% of age-predicted maximal HR. of the Rockport walking test on the fitness indexes of walking
BioMed Research International 5

Table 4: Parameters of the modified squat test (𝑁 = 25).

S1 S2
Immediate HR (beats/min) 131.40 ± 17.85 134.04 ± 18.63
Recovery HR 0–30 s (beats) 51.16 ± 9.59 58.36 ± 9.63
Recovery HR 60–90 s (beats) 47.80 ± 8.27 48.60 ± 9.57
Recovery HR 120–150 s (beats) 44.84 ± 8.01 45.96 ± 9.17
Sum of recovery HR (beats) 149.80 ± 24.79 152.92 ± 27.45
Recovery HR index 61.92 ± 11.81 60.70 ± 10.85
Age-adjusted recovery HR index 0.96 ± 0.21 0.94 ± 0.18
̇ 2 (ml/kg/min)
VO — 20.72 ± 3.60
̇ 2 max (%)
Percentage of VO — 58.22 ± 10.00
Percentage of age-predicted HRmax (%) 80.93 ± 10.88 82.53 ± 11.05
SBP (mmHg) 167.11 ± 17.27 164.27 ± 22.48
DBP (mmHg) 95.78 ± 8.21 88.18 ± 11.43
RPE 12.20 ± 1.44 12.48 ± 1.81
S1: the first modified squat test; S2: the second modified squat test with oxygen consumption measurement; —: not available.

Table 5: Test-retest reliability of the modified squat test (𝑁 = 25).

Index Immediate HR (beats) Sum of recovery HR (beats) Recovery HR index Age-adjusted recovery HR index
ICC 0.77 0.88 0.87 0.90

̇ 2 max (𝑛 = 25).
Table 6: Correlations between the squat test indexes and VO

S1 S2
Immediate HR (beats/min) −0.52∗∗ −0.51∗
Sum of recovery HR (beats) −0.64∗∗ −0.60∗∗
Recovery HR index 0.68∗∗ 0.64∗∗
Age-adjusted recovery HR index 0.70∗∗ 0.71∗∗
∗∗ 𝑝
< .001; ∗ 𝑝 < .05; S1: the first modified squat test; S2: the second modified squat test with oxygen consumption measurement.

̇ 2 max.
Table 7: The regression model for the modified squat test to predict VO

Regression coefficient (𝐵) SE Standardized regression coefficients (𝛽) 𝑝 value

Age-adjusted recovery HR index 16.732 3.149 0.497 .000
Physical activity level 0.02467 0.009 0.130 .000
Constant 16.781 3.203 .011
𝑅2 0.63
Adjusted 𝑅2 0.59
SE: standard error; 𝑅2 : coefficient of determination.

time, HR, and estimated VO ̇ 2 max [9]. The ICC values of The self-paced step test used a step with 40 cm height, which
Rockport walking fitness indexes ranged from 0.67 to 0.71. In may predispose older individuals to increased risk of falls
our study, a high ICC of 0.90 for age-adjusted recovery HR during testing. In our study, moderate to high correlations
index suggests that the reliability of the modified squat test is between fitness indexes and VO ̇ 2 max, with the highest
comparable or superior to the above-mentioned fitness tests. correlation of 0.7 seen in age-adjusted recovery HR index,
suggested the modified squat test is a valid fitness test in the
4.2. Validity. Previous studies have developed several aerobic older individual and comparable to or even superior to other
fitness tests for old individuals. Rikli and Jones investigated fitness field tests reported in previous studies. The modified
the validity of the 6 min walk test in older individuals by squat test is convenient, has low cost, is safe to administer,
correlating the treadmill performance time reaching 85% of and requires limited space and thus may be another option
Though those commonly seen aerobic fitness tests have for assessing aerobic fitness for old healthy individuals.
acceptable validity, there are some shortcomings. For exam- Recovery HR after exercise has been found to be corre-
ple, the 6 min walk test needs a spacious testing environment. lated with the fitness level and mortality in old individuals
6 BioMed Research International

[28, 29]. The immediate HR fitness index had the worst maximal HR, corresponding to a moderate exercise work-
validity among the fitness indexes. One contributory factor load. No discomfort or injuries during the testing were
might be due to the aged autonomic nervous system. Imme- reported. The modified squat test is submaximal while
diate HR recovery is primarily a function of reactivation of appearing to be able to elicit substantiate physiological
the parasympathetic nervous system, while later recovery of exercise responses to allow one’s maximal aerobic power to
HR is associated with gradual withdrawal of the sympathetic be assessed safely and accurately. Moreover, it is interesting
nervous system [30, 31]. Aging results in slower adaptations of to note that most of the subjects expressed that they would
the autonomic nervous system to the termination of exercise practice the modified squat test as an exercise afterwards,
[32, 33]. In other words, it takes longer for older adults to suggesting the continuous movement of the modified squat
recover their HR to the baseline. Therefore, fitness indexes test might potentially be developed as an interesting form
using several recovery HRs would be more representative of of exercise. To serve this purpose, the prototype testing
the fitness level of the older individual. device used in this study should be further developed to
provide adjustments of exercise workloads as well as feedback
of exercise intensity. The prototype testing device could
4.3. Prediction of Equation. Kervio et al. reported that pre-
̇ 2 max equation for older individuals from the be manufactured with sensors monitoring HR and with a
dicted VO
device indicating different rates of half-squatting. In addition,
6-minute walk test parameters (distance, heart rate) and
an electronic goniometer could well be integrated into the
anthropometric value (age, weight, and height) accounted for
̇ 2 max, with a small subject number testing system to indicate the appropriate angle of squatting.
94% of the variance in VO
There are several limitations in this study. First, the
of 12 [27]. In the self-paced step test, stepping time, heart
sample size of this study was small. In addition, most of the
rate, age, BMI, and O2 pulse were significantly associated
̇ 2 max and were chosen to establish the predictive subjects tended to be young older adults (aged < 70 years).
with VO
Therefore, a larger sample size with individuals aged 70 years
formula, which can explain 72% to 86% of variance [3]. The
̇ 2 max of the self-paced step and beyond is required in future studies to enhance the
correlation of the predicted VO ̇ 2 max prediction equation determined
̇ application of the VO
test and the measured VO2 max was from 0.88 and 0.90 for
from the modified squat test. Second, the subjects of this
low-fitness men and women and 0.83 and 0.94 for high-
study were all males. Whether the modified squat test is valid
fitness men and women. In our study, the age-adjusted
for healthy older females still needs to be confirmed.
recovery HR fitness index had the highest validity among four
fitness indexes calculated and thus was chosen to develop a
prediction equation for aerobic power of the older individual. 5. Conclusions
Factors which might affect VO ̇ 2 max value such as age, resting
HR, height, weight, body fat, and physical activity were taken The results reveal that the modified squat test is valid and
into account for regression analysis to establish the prediction reliable and can be an option for evaluating the fitness level in
of VȮ 2 max. The predicted VO ̇ 2 max using this model was healthy elderly men in clinics or communities. The best index
highly correlated (𝑟 = 0.79) with measured VO ̇ 2 max from the is age-adjusted recovery heart rate. The predicted equation
for VȮ 2 max is 16.781 + 16.732 × age-adjusted recovery HR
maximal exercise test. The predictive model based on age-
adjusted recovery HR and physical activity explained 63% + 0.02467 × physical activity level (score of PASE question-
of the variances in VȮ 2 max. The variance explained by the naire).
prediction equation in our study appears to be lower than
those in the 6 min walk test and the self-paced step test. Conflicts of Interest
However, only 12 subjects were recruited to develop the
prediction equation from the 6 min walk test in Kervio et al. The authors declare no conflicts of interest.
study. In the prediction model for the self-paced step test,
O2 pulse was used as one of predictive parameters. Petrella Acknowledgments
et al. indicated that O2 pulse from the self-paced step test
was strongly associated with VO ̇ 2 max and improved the The authors would like to thank all of the participants who
percentage variance to be explained in the prediction of volunteered their time to participate in the study.
VȮ 2 max [3]. For clinical practice purposes, we did not
include O2 pulse in our model, which might contribute to the
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