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Gemma Bridge

HHP 655

05/02/15

Chapter 5: Clinical Exercise Testing
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In regards to testing to return to work, what should you discuss with the patient?
What should you measure during an exercise test?
Describe the subjective rating scales used during exercise testing
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Responses are monitored during the test to look for signs or manifestations of
CV issues such as myocardial ischemia
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Indications and Purposes
GXT are used for diagnostic, prognostic and therapeutic purposes
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The purpose of the GXT can mean that the recommendations for conducting
the tests are different due to the different data that is needed to be gathered
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This is because of the impact that exercise has on posttest probability of disease
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In patients with chronic conditions such as CHF, exercise testing can prove to
be valuable in guiding treatment decisions
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Sub-maximal exercise tests are recommended to be conducted
before hospital discharge at 4-6 days after MI
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This is useful information for physical activity
counseling, Ex Rx, disability assessment and to help with estimates of prognosis
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Functional capacity can either be evaluated based on a patient’s percentile ranking, which is based on healthy
men and women, or by comparing the patients percentage of MET’s for age using a nomogram with 100%
considered normal
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Gemma Bridge
HHP 655
05/02/15
Exercise Test Modalities
The treadmill is the most common exercise testing mode in the USA
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In addition,
the treadmills that are used in exercise laboratories should have handrails in order to give the patient support
and stability if they need it (but the patient should be told not to hold the handrail during testing due to the
affect it can have on the accuracy of test results)
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Cycle ergometers are the most common exercise testing mode in Europe
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Cycle ergometers must have handlebars and an adjustable
seat which allows for the subject to bend their knees adequately
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Arm ergometry can be used for patients who are unable to move their legs
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Exercise Protocols
The purpose of the evaluation, the specific outcomes desired, and the characteristics of the individual being
tested should all be considered before conducting an exercise test
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However it has been suggested that this form of protocol is probably best
suited to younger and more physically active individuals, whereas protocols with smaller increments such as
the Balke- Ware tests are preferable for older or de-conditioned individuals
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This can be due to concerns over health,
employer stereotypes, economic conditions, or worker attitudes
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Patients can undergo work assessment and counseling to help
them to make decisions about returning to work
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GXT provides information regarding a patient’s ability to safely return to work
because responses can help assess prognosis and estimated MET capacity can be compared to the estimated
aerobic demands of the job to assess expected relative work energy demands
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Measurements during Exercise Testing
 HR and BP
o Should be measured before, during and after the GXT
o Standardized procedure should be adopted
 ECG
o Areas for electrode placement should be prepped appropriately i
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shaved if needed
o Should be measured before, during and after the GXT (can be monitored continuously)
 Signs and symptoms
o Degree of chest pain, burning, discomfort

Gemma Bridge
HHP 655
05/02/15
o Assessed throughout the test
 RPE
o Ratings of perceived exhaustion
o Can provide a number verbally (i
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rating scale of 1-10)
o Patient should be given clear and concise instructions before exercise testing begins
 Gas exchange
o Assess VE, RER and VCO2
o Analysis of ventilator expired gas overcomes inaccuracies associated with estimating VO2 from
work rate
o Direct measurement of VO2 remains the most accurate measurement of functional capacity
Subjective Rating Scales
There are a number of alternative rating scales that can be used during the GXT
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The
Angina scale, the Claudication scale and the Dyspnea scale can be used to assess the patient’s level of angina,
claudication and dyspnea
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During testing the staff members can ask the patient how they are feeling
and the patient is able to easily say a number that describes their pain
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Pharmacologic Stress Tests
Patients who are unable to undergo GXT for whatever reason (e
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severe deconditioning) can be evaluated by
pharmacologic stress testing
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Some protocols include light
exercise in conjunction with pharmacologic infusion
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 Adenosine is a vasodialator
o Assess coronary perfusion in conjunction with a nuclear imaging agent
o Cause maximal coronary vasodilatation in normal epicardial arteries but not in stenoic
segments
o Use nuclear perfusion imaging and compare it to imaging at rest
 Not recommended in patients with asthma
 Caffeine can block vasodilatation effects- so should be avoided for 24 hrs before testing
Supervision of Exercise Testing
Individuals who supervise exercise tests must have the necessary cognitive (e
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knowledge of end points of
testing, and competence in CPR and exercise protocols) and technical skills to safely administer the exercise
test as clinical events and complications can occur during or post exercise
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Physicians should be on call if the patient
has a particularly high risk of having a cardiac event

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