Assessing Cardiorespiratory

Endurance
A Fitness Indicator
Determination of Fitness Level
Everyone possesses some degree of
cardiorespiratory endurance (CRE)
CRE=a health associated component
that relates to the ability of circulatory
and respiratory systems to supply fuel
during sustained physical activity and to
eliminate fatigue products after
supplying fuel.
VO
2
max
VO
2
max is the most commonly used
index to assess CRE
Definition - The largest amount of
oxygen that an individual can utilize
during strenuous exercise to complete
exhaustion
Has become the accepted measure of
CRE
AEROBIC GLYCOLYSIS AND THE
ELECTRON TRANSPORT CHAIN
KREBS
CYCLE
METABOLISM OF FAT
OXIDATIVE PHOSPHORYLATION
VO
2
max

Units
liters/minute or ml/minute (absolute)
ml/kg/min (relative to body weight)
ml/kg of FFM/min (relative to FFM)
Range 15 (sedentary with disease) to
75 (young endurance runner) ml/kg/min
Women about 10-20% lower than men
Methods of Determining VO
2
max
Submaximally
Maximally

GXT
Graded Exercise Testing - GXT
(incremental increases in workload)
General Guidelines
measure the subjects HR and BP and
RPE at regular intervals (near the end of
each stage [HR, BP, RPE] or every minute
[HR])
if HR does not reach steady state during
the stage extend stage 1 minute
GXT
General Guidelines
All testing begins with a 2-3 min warm-up
Cool- down at a low intensity for at least 4
minutes - continue measuring HR, BP and
RPE
increase intensity in .5-2 MET increments
closely observe subject for
contraindications
Submaximal Assumptions
1. A steady-state HR is obtained for
each exercise work rate
2. A maximal HR for a given age is
uniform (220-age)
Assumptions
3. Mechanical efficiency (ie. VO
2
at a
given work rate) is the same for
everyone.
This may not be true and it has been
suggested that submaximal exercise
testing underestimates VO
2max
in the
untrained and overestimates in the trained
Submaximal Assumptions
4. There is a linear relationship
between HR and Workload
5. HR will vary depending on fitness
level between subjects at any given
workload

Age vs. HR
HR vs. Age
90
140
190
240
10 20 30 40 50 60 70 80
Age (years)
H
R

(
b
e
a
t
s
/
m
i
n
)
HR - max
Submaximal Protocols
Oxygen consumption for any given WL
does not vary between subjects
The slope of the line is about the same
for any two given subjects
The rate of increase in O2 consumption
with increasing WL does not vary
between subjects
EXERCISE INTENSITY AND OXYGEN
UPTAKE
Submax Protocols
HR does vary between subjects
rate of increase in HR depends on
fitness level
The more fit you are the lower your HR
at any given WL
An untrained person will reach their HR
max at a lower WL vs. a trained person
of the same age.
HEART RATE AND INTENSITY
HEART RATE AND TRAINING

HR vs. Workload
90
110
130
150
170
190
3
0
0
6
0
0
9
0
0
1
2
0
0
1
5
0
0
1
8
0
0
2
1
0
0
Workload (kgm/min
H
R

(
b
p
m
)
untrn
trn
HEART RATE, VO
2
, AND INCREASING
WORK
.
HR vs. WL and VO
2

0
50
100
150
200
250
150
0.6
600
1.5
1050
2.4
1500
3.5
1950
4.6
VO
2
(l/min) and Workoad
(kgm/min)
H
R

(
b
p
m
)
Hr
Submaximal Protocols
1. YMCA - bike
2. Astrand Rhyming bike
3. ACSM - bike
4. Bruce Protocol - treadmill
5. McCardles Step Test
YMCA
Multi-stage protocol
3-4 consecutive 3 minute stages
HR between 110-150 bpm (the HR
range at which the relationship between
VO
2
and WL is most linear)
YMCA Procedures
1. Adjust seat height (legs nearly
straight when extended - 5 bend)
2. Measure pre-exercise BP and HR
with subject seated on bike
3. Pedal at 50 rpm (if using a
metronome - 100x/minute)
4. Warm-up, zero resistance for 2-3
minute
YMCA Protocol
5. Stage 1
.5 kp for 3 minutes
at every stage measure BP at 2.0 min
(more often if hypertensive)
at every stage measure HR during last half
of minutes 2 and 3
if HR at 2 and 3 minutes differ by more
than 6 bpm extend the stage for 1 min
YMCA Protocol
6. Stage 2
Workload in this stage and successive
stages depends on HR during stage 1 (p
75 guidelines)
7. Continue test until HR recorded at
two successive WL are between 110
and 150 bpm (for many this occurs
during 2nd and 3rd WL)
YMCA Protocol
8. Note that if HR is greater than 110 at
end of 1st stage then only one more
stage is necessary
9. At completion of test reduce
resistance to .5kp and allow subject to
pedal for at least 4 minutes or until HR
falls below 100 bpm and BP stabilizes.
YMCA Protocol
10. The HR measured during the last
minute of each stage is plotted against
workload.
11. The line generated from the plotted
points is extrapolated to the age-
predicted HR max
12. A perpendicular line is dropped to
the x-axis to estimate the work rate this
person would achieve if taken to max.
0
50
100
150
200
150
0.6
450
1.2
750
1.8
1050
2.4
1350
3.2
1650
3.8
VO
2
(l/min) and Workload
(kgm/min)
H
R
Hr
ACSM Bike Test
1. 2-3 minute warm-up
2. Take HR twice during each stage (3
minute stages) and RPE/BP once
(similar to YMCA)
3. If HRs are greater than 110, steady
state should be reached (HRs within
6bpm) before increasing the workload

ACSM

Protocol A B C (kgm/min)
Stage 1 150 150 300
Stage 2 300 300 600
Stage 3 450 600 900
Stage 4 600 900 1200
ACSM
Protocol Selection
BW Very Active
(kg) No Yes
<73 A A
74-90 A B
>91 B C
*very active is defined as aerobic exercise
20 minutes, 3 days/week
ACSM
5. Terminate test when HR reaches
85% of age-predicted max HR or 70%
of HR reserve
6. Recovery at workload equal to the 1
st

stage or less for at least 4 minutes with
HR, BP, and RPE monitored.
ACSM
Plot HRs from last two stages to
determine VO2max much like YMCA.
Astrand Rhyming
Single-stage test (VO2 max is
determined using 1 submaximal data
point-HR)
Duration of test is 6 minutes
Astrand Rhyming
1. Adjust seat height (legs nearly
straight when extended - 5 bend)
2. Measure pre-exercise BP and HR
with subject seated on bike
3. Pedal at 50 rpm (if using a
metronome - 100x/minute)
4. Warm-up, zero resistance for 2-3
minute
Astrand Rhyming
5. Pedal rate is 50 rpm
6. Determine Workload
unconditioned males - 300 or 600 kgm/min
conditioned males - 600 or 900 kgm/min
unconditioned females - 300-450 kgm/min
conditioned females - 450 or 600 kgm/min
7. 6 minute test

Astrand Rhyming
8. At end of 2nd minute of pedaling
take HR (BP at 1.25-1.5 min)
want the HR to be between 125-170bpm
if less than 125 increase resistance by 1 kp
for men and 1/2 kp for women
if greater than 170 bpm decrease
resistance by 1 kp
continue to monitor HR every minute until
HR exceeds 125
Astrand Rhyming
9. At the end of the 5th and 6th minute
take HR and average the two values
(make sure values are within +6bpm to
assure a steady state HR was obtained)
10. BP at 4:30 and 5:30
11. Reduce resistance and cool-down
for 4 minutes.
Astrand Rhyming
10. Determine VO
2
from nomogram (p.
73 guidelines, p.69 Heyward)
11. Age-correction factor (p. 74
guidelines, p.72 heyward)
12. Convert to relative value

Treadmill Tests
Bruce Protocol
Balke
Ellestad
Others.
Treadmill Protocols
Bruce and Ellestad
larger increments
use on younger and/or more physically
active
Balke-Ware
smaller increments (1MET/stage or lower)
use on older, deconditioned, and/or
diseased subjects
Treadmill Protocol
Single-stage (using one data point)
even though we may have more than
one stage
May need to have a long
accustomization period and explanation
of procedures before beginning
Bruce Treadmill Protocol
1. Measure resting BP and HR while
standing on the belt of the treadmill
2. Ask subject to straddle the belt while
starting treadmill at 1.7 mph and 0% grade
3. Ask subject to begin walking and when
comfortable release handrails
4. This is a warm-up and should continue
until subject is comfortable
Bruce Treadmill Protocol
5. Stage 1
Increase grade to 10%
3 minutes long
Measure HR at end of each minute and BP
at end of each stage
Bruce Treadmill Protocol
6. The objective is to reach a steady
state HR between 115 and 155 bpm
(usually occurs during the first 6
minutes of exercise or by the end of the
2nd stage) Page 98 guidelines
7. Once subject reaches proper HR
terminate the test at the end of that
stage
Bruce Treadmill Protocol
8. Reduce treadmill speed to 1.7mph
and 5% grade and cool-down for 4
minutes.
9. VO2 is estimated from the last
minute of a fully completed stage

Treadmill Protocol
10. Calculate VO
2
from the gender specific
equations
Males
VO
2
=SM
VO2
[(HR
max
-61)/(HR
SM
-61)]
Females
VO
2
=SM
VO2
[(HR
max
-72)/(HR
SM
-72)]
SM
VO2
= submaximal VO
2
from table or ACSM
equations
HR
SM
= submax HR from test
Modified Bruce Protocol
Start at 1.7 mph, 0% grade or at 1.7
mph and 5% grade (used on diseased
and elderly populations)
Treadmill Protocol
Protocols should be individualized
Test time should ideally be 8-12min
Increments of 10-15 W/min or 1-3%/min
grade can be used for the elderly
McCardles Step Test
Bench ht. = 41.25 cm
Step Rate = 24 step/min (metronome =
96) for men and 22 step/min
(metronome=88) for women
3 minutes of stepping
Record HR from the first 15seconds
after the stepping has stopped
McCardle
Men
VO
2
= 111.33 - (0.42 x HRrec)
Women
VO
2
= 65.81 - (0.1847 x HRrec)

value is ml/kg/min
Maximal Testing
Assumption: The subject was highly
motivated and gave a maximal effort.
Max Testing
Laboratory Tests
1. Open Circuit Indirect Calorimetry
2. Cycle
3. Treadmill (Bruce)

Maximal Protocols
Field Tests
4. 12 minute run
5. 1.5 mile run
6. Rockport Walking Test

Measuring Energy Costs of
Exercise
Direct calorimetrymeasures the
body's heat production to calculate
energy expenditure.
Indirect calorimetrycalculates
energy expenditure from the respiratory
exchange ratio (RER) of CO
2
and O
2
.
A CALORIMETRIC CHAMBER
Open Circuit Indirect
Calorimetry (Gas Analysis)
% O
2
in the Air=20.93% V
I
=Volume of Air
(for simplicity 21%) Inhaled by the subject
For example 100L/min

Gas
Analysis

V
E
-Volume of Air
Expired by Subject
VO
2E
=Volume of O
2
expired=16L/min (lets assume for
simplicity = V
I
=100L/min)
VO
2max
= 21L/min 16 L/min
= 5L/min
Respiratory Exchange Ratio

The ratio between CO
2
released (VCO
2
)
and oxygen consumed (VO
2
)
RER = VCO
2
/VO
2
The RER value at rest is usually 0.78 to
0.80
RER
Value ranges from .7-1.0
0.7 mainly uses fats as an energy
source
1.0 mainly uses carbohydrates as an
energy source
Can exceed 1.0 during heavy non-
steady state, maximal exercise, or when
nervous due to hyperventilation
(increased CO2)
KCALS
(RER + 4) x (Liters of O
2
consumed per
minute) = kcal/minute
For example:
RER determined from gas analysis = .75
4 + .75 = 4.75
L of O
2
per minute = 3 liters
4.75 x 3 = 14.25 kcal/min
If exercised for 30 minutes = 427.5 kcals
Cycle to Max
15 W/min protocol
VO
2males
=10.51 (power in W) + 6.35
(BW in kg) - 10.49 (age in y) + 519.3
VO
2females
=9.39 (power in W) + 7.7 (BW
in kg) - 5.88 (age in y) + 136.7
values are in ml/min - divide by BW in
kg

Treadmill to Max (Bruce)
VO
2
= 14.8 - 1.379 (time in min) + 0.451
(time
2
) - 0.012 (time
3
)

While holding handrail
VO
2
= 2.282 (time in min) + 8.545
Population-specific Equations
P. 61 Heyward
Active vs. Sedentary, Gender specific,
Cardiac patients
12 minute run
VO2
0
20
40
60
80
1
.
1
1
.
3
1
.
5
1
.
7
1
.
9
Distance
V
O
2
VO2
12 minute run

The further you can run in 12 minutes
the higher your VO
2max

1.5 mile run/Rockport Walking
0
20
40
60
80
6 8 10 12 14 16 18
time
V
O
2
VO2
1.5 Mile Run/1 Mile Walk
The faster you can run 1.5 miles or walk
1 mile the higher your VO
2max

Field Tests
12 min run
VO
2
= 3.126 (meters in 12 min) - 11.3
1.5 mile run
VO
2
= 3.5 + 483/(time in minutes)
Rockport Walking Test (1 mile walk)
VO
2
= 132.853 - 0.1692 (BW in kg) -
0.3877 (age in y) + 6.315 (gender) - 3.2649
(time in min) - 0.1565 (HR)
0 for female; 1 for male; HR at end of walk
Normal Responses to GXT
1. Systolic BP increases in direct
proportion to increasing WL
2. HR increases linearly with WL
3. Diastolic BP changes very little
4. Shortened QT Interval
5. Reduced R-wave amplitude
6. Positive upslope of ST segment
Abnormal responses to GXT
1. ST segment depression
2. Increased R-wave amplitude
3. V-tach
4. Multiform PVCs
5. Failure of HR to rise with WL
6. Failure of systolic to rise
7. Systolic and diastolic greater than 250 or
120
Test Termination
1. Have reached a pre-determined
endpoint
Absolute
1. Suspicion of myocardial infarction
2. Moderate to severe angina
3. Drop in Systolic BP with increasing
Workload (>20)
Absolute
4. Arrhythmias
5. Pale or cold and clammy skin
6. Severe shortness of breath
7. Dizzy, blurred vision, or confusion
8. Patient requests stop
9. V-tach or multiform PVCs
10. ST segment depression
Absolute

11. Excessive rise in BP (systolic >250;
diastolic >120)
12. Failure of HR to increase
Relative
1. ECG changes from baseline
2. Chest pain that is increasing
3. Wheezing
4. Leg cramps
5. High Systolic/Diastolic
6. Less serious arrhythmias
7. Less severe shortness of breath
Advantages of Submaximal
Testing
1. Safer
2. Controlled pace (motivation not a
factor)
3. Not population specific (no pacing
advantage)
4. Quick assessment
5. Cost effective
Advantages of Submaximal
Testing
6. Dont need highly trained personnel
7. Can do mass testing
8. No physician supervision required (if
symptom and disease free)
Disadvantages of Submaximal
Testing
1. VO
2
max is not directly measured
(error rate of 10-20%)
2. Dont get a measure of true maximal
HR
estimates of max HR using 220-age can
vary by +15 bpm for individuals of the
same age
Advantages and Disadvantages of
a Maximal Test
Advantages
1. More accurate
Disadvantages
1. Motivation is a factor
2. More risk involved
3. Time
4. Cost of equipment (if using metabolic
cart)
Walking/Running vs.
Cycling/Stepping
Walking/Running are the most natural
forms of locomotion (most Americans
are unaccustomed to cycling
In general, subjects reach higher
VO2max values during treadmill tests
Treadmill are more expensive than
cycles
Treadmill is less portable
Walking/Running vs.
Cycling/Stepping
Body weight has a much smaller effect
on cycle ergometry versus treadmills
Treadmill more dangerous (greater risk
of a fall
Measurement of HR is more difficult on
a treadmill and while stepping