Exercise testing protocol
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Transcript of Exercise testing protocol
KSUKSU
Exercise Testing Exercise Testing ProtocolProtocol
HazzaaHazzaa M. AlM. Al--HazzaaHazzaa,, PhPh D, FACSMD, FACSMProfessor & DirectorProfessor & Director
Exercise Physiology LaboratoryExercise Physiology LaboratoryKing Saud UniversityKing Saud UniversityTel (office): Tel (office): 46784114678411
Lab: Lab: 46784064678406http://faculty.ksu.edu.sa/hazzaahttp://faculty.ksu.edu.sa/hazzaa
514 RHS 514 RHS -- Fall 2010Fall 2010
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Clinical Exercise TestingClinical Exercise Testing
Routine Treadmill /Bike Routine Treadmill /Bike ((ECG & BP onlyECG & BP only//Gas ExchangeGas Exchange))..
Exercise EchocardiographyExercise Echocardiography
Exercise Nuclear StressExercise Nuclear Stress
DobutamineDobutamine EchocardiographyEchocardiography
DobutamineDobutamine Nuclear StressNuclear Stress
Adenosine Nuclear Stress Adenosine Nuclear Stress
PersantinePersantine Nuclear StressNuclear Stress
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Exercise Testing ProtocolExercise Testing Protocol
Exercise ModeExercise Mode-- Treadmill versus Bicycle.Treadmill versus Bicycle.
Continuous versus discontinuous exercise test Continuous versus discontinuous exercise test protocol.protocol.
Some exercise protocols are designed for Some exercise protocols are designed for clinical exercise testing and others for functional clinical exercise testing and others for functional capacity or capacity or cardiorespiratorycardiorespiratory fitness.fitness.
Maximal versus Maximal versus submaximalsubmaximal exercise.exercise.
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Common Graded Common Graded Exercise Testing Exercise Testing
ProtocolProtocol
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O2
Upt
ake
(ml/k
g.m
in)
Bruce Protocol
0
10
20
30
40
50
60
70
80
3 6 9 12 15 18 21
1122
33
44
55
6677
5577
10101313
16.516.52020
2222
StagesStages
Time (min)
9.68.886.85.542.7Speed(km/h)
22201816141210Grade (%)7654321Stage
METMET
Common Graded Exercise Protocols
StageMinSpeedKm/h
Grade%
MinSpeedKm/h
Grade%
MinSpeedKm/h
Grade%
124.8031.6032.710224.82.532.4024.810324.8533.2026.410424.87.533.23.53810524.81033.27624.812.534.85724.81534.87.5824.817.534.810924.82034.812.51024.822.534.815
Balke Protocol 2Naughton ProtocolEllestad Protocol
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ناتن)Naughton(
بلكي)Bulke(
بروس المعدل)Modified Bruce(
بروس)Bruce(
المرحلة)Stage(
1.83.62.34.613.54.53.57.024.55.04.610.235.45.57.012.146.45.910.214.957.46.412.117.068.36.914.919.37
Heyward V, Advanced Fitness Assessment & Exercise Prescription, 2002
MET Values during Common Exercise Protocols
Bicycle Ergometer Protocol
Approximately 10 -12 minutes of duration
Pedaling frequency of 60 rpm
1-3 minutes resting data
1-3 minutes unloaded pedaling
Interval period of 2-3 minutes (for each stage)
Increase by 5-30 W/minute
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Exercise Testing Protocol
Time (min)
Wor
k L
oad
(wat
t)
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Incremental Incremental versusversus Ramp Ramp
ProtocolProtocol
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Incremental Protocol
0
30
60
90
120
150
180
3 6 9 12 15 18 21Time (min)
Wor
k L
oad
(wat
t)
Incremental increases in load
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Wor
k L
oad
(wat
t)
0
30
60
90
120
150
180
3 6 9 12 15 18 21
Time (min)
Ramp Protocol
Load increases in a constant and continuous manner
Why Ramp Protocol?
With ramp protocol, there is linear increase in heart rate.
Improved prediction of METs
It is an Individualized test using prior test, history or questionnaire.
Test duration is nine-minute for most patients.
Terminating the Exercise Test
All treadmill stress tests should be completed to a symptom-limited endpoint, if possible.
85% of maximal predicted heart rate is required to identify a test as adequate.
Chronotropic Incompetencev Peak heart rate less than 120 BPM.
v Failure to achieve 85% of age-predicted maximum.
Safety of Exercise Stress Testing
The risk of death during or immediately after an exercise test is less than or equal to 0.01%.
The risk of an acute MI during or immediately after an exercise test is less than or equal to 0.04%.
The risk of a complication requiring hospitalization is less than or equal to 0.2%.
ACSM, 2000Gordon & Khol, JCR, 1993
+
Na+ / K+ Na+ / K+ Ions Ions
ImbalanceImbalance
CatecholaminesCatecholamines
In Case of CAD
During ExerciseRight after Exercise
Increased Increased Sympathetic ActSympathetic Act
Reduced Reduced VagusVagus ToneTone
IncresedIncresed HRHRIncreased BPIncreased BP
Increased Myocardial Increased Myocardial OO22 DemandsDemands
Cardiac IschemiaCardiac IschemiaChanges in the Changes in the Conduction of Conduction of
the Heartthe HeartVentricular Ventricular EctopiesEctopies
Changes in Changes in DepoDepo//RepolarizationRepolarization
of Cardiac Cellsof Cardiac Cells
Myocardial Myocardial ExcitationExcitation
Stop of muscle Stop of muscle contractioncontraction
Venous Venous DilationDilation
Reduced Reduced Venous ReturnVenous Return
Reduced BPReduced BP
Reduced COReduced CO
Reduced Heart Reduced Heart PerfusionPerfusion
Anaerobic Anaerobic ThresholdThreshold
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Definition of Anaerobic Threshold Definition of Anaerobic Threshold (AT)(AT)
The exercise VOThe exercise VO22 (& work rate) above which (& work rate) above which anaerobic energy production starts to progressively anaerobic energy production starts to progressively increase, with consequential increase in increase, with consequential increase in lactate/lactate/pyruvatepyruvate ratio, and a net increase in lactate ratio, and a net increase in lactate production at the site of production at the site of anaerobiosisanaerobiosis..
Wasserman et al., Wasserman et al., 19991999
Gas exchange is also affected by increases in Gas exchange is also affected by increases in COCO22 output & minute ventilation as a result of output & minute ventilation as a result of HCOHCO33-- buffering of lactic acid.buffering of lactic acid.
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VOVO22 & HR responses during steady state treadmill & HR responses during steady state treadmill test for a young athlete (test for a young athlete (21 21 yearyear--old) old)
Al-Hazzaa, 1993
0
10
20
30
40
50
60
0 1 2 3 4 5 6 7 8 9 10
10 12 14 16
Time (min)
Speed (km/h)
160
142130117
VO2 max = 69 ml/kg.min (18 Kcalori/min)
b/min189= HR max
HR
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Aerobic MetabolismAerobic Metabolism (Cellular Respiration)(Cellular Respiration)
AdiposeTissues
MuscleGlycogen
Glucose
Skeletal Muscle
Liver
Mitochondria
Glycogen
Glycerol
FFA
ATP
GlycolysisGlycolysisتحلل الجلیكوجین والجلوكوزتحلل الجلیكوجین والجلوكوز
حمض البیروفیك
حمض اللبنیك
الجلوكوزالجلیكوجین
فوسفات - 6جلوكوز
عملیات األكسدة
Aerobicھوائي
Anaerobicھوائي ال
حمض البیروفیك
حمض LDHاللبنیك
H + + HCO3 - H2 CO3 CO2 + H2O
Ventilatory Thresholdعتبة التھویة الرئویة
H+
VE
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Anaerobic Threshold Determination by Anaerobic Threshold Determination by the Vthe V--Slope MethodSlope Method
VO2
VC
O2 AT
SS11
SS22
S1 = < 1S2 = > 1
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Maximal Graded Ergometer Test for a Healthy Saudi MaleMaximal Graded Ergometer Test for a Healthy Saudi MaleAge = Age = 23 23 yrs; Wt = yrs; Wt = 7171..3 3 kg; Ht = kg; Ht = 171 171 cm cm
0
0.5
1
1.5
2
2.5
3
3.5
Rest 2 4 6 8 10
VO2 VCO2
Time Time (min)(min)
Data from: Exercise Physiology Laboratory, KSUData from: Exercise Physiology Laboratory, KSU
L/m
inL
/min
BikeBike
RER >RER >11
AT determined by An Increase in AT determined by An Increase in VentilatoryVentilatory Equivalent Equivalent of Oof O22 (VEVO(VEVO2 2 without an increase in VECOwithout an increase in VECO22
AT determined by An Increase in AT determined by An Increase in VentilatoryVentilatory Equivalent Equivalent of Oof O22 (VEVO(VEVO2 2 without an increase in VECOwithout an increase in VECO22
VOVO22 & VCO& VCO22 ResponsesResponsesAbove & Below ATAbove & Below AT COCO22
3030
60609090
120120
150150
180180
210210
PowerPower((WW))
Casaburi, et al, JAP, Casaburi, et al, JAP, 19891989
COCO22
Mean and lower Confidence Limits for PredictedMean and lower Confidence Limits for PredictedAT/Predicted Peak VOAT/Predicted Peak VO2 2 in adults (%)in adults (%)
Lower 95% CLAnaerobic Threshold (%)
Age (years)
424253532043435454304444555540454556565046465757604747585870
Wasserman, et al.,1999, p.154
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AT Determination is problematic in:AT Determination is problematic in:
Chronic hyperventilation syndrome. Chronic hyperventilation syndrome.
Progressive exerciseProgressive exercise--induced hypoxemia.induced hypoxemia.
Impaired peripheral chemosensitivity with Impaired peripheral chemosensitivity with an associated high airway resistance.an associated high airway resistance.
Wasserman et al., Wasserman et al., 19991999
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Factors affecting Anaerobic Threshold
Physical TrainingNutrition
Muscle Fiber TypesUsed Protocol
Health Status:• Affecting blood carrying capacity.• Blood flow to the muscles.
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What are the reasons for AT Improvement after What are the reasons for AT Improvement after TrainingTraining
Increased blood flow in the muscles after training. Increased blood flow in the muscles after training.
Increased muscle’s ability to oxidized Increased muscle’s ability to oxidized pyruvatepyruvateand FFA.and FFA.
Delay of the fast twitch muscle fibers recruitment.Delay of the fast twitch muscle fibers recruitment.
Wasserman et al., Wasserman et al., 19991999
All these factors are related to muscle metabolism(Local/peripheral factors)
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Oxygen Uptake: Oxygen Uptake: from Rest to Maximal Exercisefrom Rest to Maximal Exercise
VOVO22 increases from increases from 250 250 ml/min at rest to ml/min at rest to 22..55--3 3 l/min l/min at maximal exercise (at maximal exercise (1010--12 12 fold increase). fold increase).
CO increases from about CO increases from about 5 5 l/min at rest to l/min at rest to 2020--25 25 l/min l/min at max exercise (at max exercise (44--5 5 fold increase) .fold increase) .
Explain how is this happening?Explain how is this happening?
What accounts for the differences?.What accounts for the differences?.