ACSM's Health-Related Physical Fitness Assessment Manual SECOND EDITION

FUNCTIONAL CLINICAL O,COST BICYCLE CLASS STATUS mL -kg- 1·min- 1 METS ERGOMETER BRUCE KATTUS BALKE·WARE ~ 1 WATT = 3MIN I GRADE AT ~ STAGES 3.3 MPH 6 KPMIMIN 0 « MPH IGR l·MIN STAGES 5.5 120 ui 56.0 16 FOR 70 KG 5.0 I 18 2. (9 52.5 25 NORMAL 49.0 15 BODY WEIGHT MPH IGR AND I a« 45.5 KPM/MIN 2' !z 42.0 14 4 I 22 23 II 38.5 1500 III W 35.0 13 4.2\\ 16 I.22 IV 31.5 0z 28.0 12 1350 4 I 18 21 24.5 20 W 21.0 11 1200 4 I 14 11. 17.5 18 W 14.0 I10 17 10.5 18 r~~~1; ­ 9 15 7.0 1050 3.4 14 4 I 10 14 3.5 13 8 900 12 II I00 I750 Wf­ •10 f-« 7 2.51 12 3 10 8 I6 600 7 8 5 450 1.7 I 10 2 10 5• Lt!i ~::; 4 300 1.71 5 3 3 ::::i~ 2 1::1;. 150 I 2 1.71 0 -1;; 1 FIGURE 9-1. Common exercise protocols. Stage I of the conventional Bruce \"modified\" Bruce protocol may start at 1.7 mph. 0% grade. or at 1.7 mph.

TREADMILL METS ti PROTOCOLS l> ·SLOW' n ELLESTAD USAFSAM USAFSAM McHENRY STANFORD en 3/213 MIN II STAGES GRADE GRADE s: S AT3 AT2 en' MPH MPH I MPH IGR MPH IGR MPH IGR f­ m 3.3 21 l> 6 I 15 3.3 I 25 ~ ~ !:< 5 I 15 3.3 I 20 14 7' 5 I 10 3.3 I 15 MPH IGR 3.3 18 22.5 : 13 :D 4 I 10 3.3 I 10 3.3 15 20.0 12 3 I 10 2 I 25 ~ 3.3 I 5 2 I 20 33 I 12 ~ f- 1.7 I 10 33 I 0 2 I 15 3.3 I 9 11 mo 2.0 I 0 2 I 10 3.3 I 6 ~ 2I 5 I--­ 'U 2.0 I 3 12.5 :I: 2I0 10.0 ~ 7.5 ~ en-<n 5.0 8 ~ 2.5 0.0 17.5 7 \"T'I 14 6 =< 10.5 5 ~ eenn 74 eel>nn meenn 3.5 3 ;:: ~ m Z 1 -i e treadmill protocol starts at 1.7 mph. 10% grade. The s: . 5% grade, as shown here. l> .cZ ~ I Ql (\") 'c~\" tel

CHAPTER 9 Maximal Exercise Testing 129 TABLE 9-1 THE BRUCE TREADMILL PROTOCOC . Stage Minutes Speed (mph) Grade (%) I 1-3 1.7 10 II 4-6 25 12 III 7-9 34 14 IV 10-12 4.2 16 V 13-15 5.0 18 VI 16-18 5,5 20 • Use a standardized protocol like the famous Bruce treadmill protocoL The Bruce pro­ tocol is popular for graded exercise testing; however, it may not be well suited for testing young healthy individuals or dinical populations like heart patients because it may be too easy or hard for that respective population, It is, however, the most popu­ lar GXT protocol in use today. • Use an individualized protocol designed or customized for the client. From the infor­ mation attained during the interview with the client, it may be possible to develop an individualized GXT protocol. Several standardized protocols are presented in Figure 9-1. Bruce Treadmill Protocol Dr. Robert Bruce, a cardiologist, developed the Bruce protocol in the 1960s. The test con­ sists of several 3-minute stages, where the speed and grade are changed each stage, using the treadmill as a mode, Thus, this protocol uses a continuous, progressive approach. There is approximately a 3 MET increase per stage. The protocol starts out at 1.7 mph and 10% grade. As previously mentioned, the protocol tends to be well suited for most middle-aged adults, Generally, heart rate (HR) is measured each minute. Blood pressure (BP) is mea­ sured once per stage, usually between the second and third minutes. Rating of perceived exertion (RPE) may also be measured around this time, There is a vast amount of experi­ ence and data built up from the use of the Bruce protocol, allowing for easy comparison between subjects, laboratories, and studies. Cardiorespiratory fitness (CRF) can be esti­ mated using several different approaches from a client's performance on the Bruce proto­ col; this is also discussed in this chapter (Table 9-1). One Modification of Bruce Treadmill Protocol For older or less fit individuals and individuals with CAD, the Bruce protocol has been modified to ease the client's approach into the protocol; however, if you examine the pro­ tocol carefully, you will realize that the modification to the protocol is less than complete as it only modifies the first stage of the protocol (Table 9-2). TABLE 9-2 . .. .... .. Stage Minutes Speed (mphl Grade (%j o 1-3 1.7 0% 1.7 5% .5 4-6 .. then proceed into regular Bruce Protocol

130 ACSM's HEALTH-RELATED PHYSICAL FITNESS ASSESSMENT MANUAL· WWw.acsm.org TABLE 9-3 THE BALKE-WARE'if ·'-.1, Balke-Ware summary: l-minute stages at a constant speed of 3.3 mph and a 1% grade increase every minute. Minute Speed (mphl Grade (%) 1 3.3 1 2 3.3 2 3 33 3 4 3.3 4 5 3.3 5 . follow the pattern of a 1% grade increase each minute. Balke-Ware Treadmill Protocol Another 'popular' treadmill GXT protocol is the Balke-Ware protocol developed by Dr. Bruno Balke and colleagues. The Balke-Ware protocol has the distinction of being 'modified' by many and in numerous ways. The original Balke-Ware protocol is shown in Table 9-3. Ramp Protocols A fairly new procedure with treadmill GXTs is to use a ramp protocol instead of the tradi­ tional incremental step protocols (Bruce protocol changes speed and grade every 3 min­ utes in stages). Ramp protocols attempt to more gradually increase the workload by usu­ ally shortening the stage time and decreasing the speed and grade increments. Following is an example of a ramp protocol that mimjcs the Bruce protocol. In this protocol, referred to as the BSUlBruce ramp protocol, speed and grade change every 20 seconds. Modem equipment (treadmill controllers and electrocardiograph [ECG] machines) is typically needed to conduct ramp protocols (Table 9-4). Individualized Protocols Using an individualized protocol, the general idea is to arrive at a comfOitable walking or jogging speed on the treadmill for the client. This then will be the speed used throughout the entire duration of the test. One way to do this: I. As an orientation to the treadmill, start the treadmill at a walking speed of around 2.0 mph. 2. When your client appears to be comfOitable, increase the speed to approach their nor­ mal workout speed, if they use the treadmill to exercise. Allow time for your client to adjust to each new treadmill speed. Closely observe your client to ensure that the speed is appropriate. People will often say they walk/jog faster than they really do. If your client reports to exercise outside by walking or running, then convert the exer­ cise routine into a speed (i.e., they walk about 2.5 miles in 50 minutes; that equals 3 mph), then set the speed of the treadmill slower than this speed. Once again, the key is your client's comfort and appearance. 3. For a walking test, use a modified Balke protocol. Stage I will start at 0% grade and each stage will increase 2.5% every 2 minutes. How to determine the starting speed and grade for the walking protocol depends on your client's HR. The test should start with an HR of around 100 bpm (Table 9-5). 4. For a running test, minutes 1-4 will be at 0% grade. Minutes 5-6 will be increased to 4% grade, contirming at the same running/walking speed. Minutes 7-8 will be at 6% grade, minutes 9-10 at 8% grade, minutes 11-12 at 10% grade, and so on (Table 9-5).

CHAPTER 9 Maximal Exercise Testing 131 TABLE 9-4 .. Stage Time Speed Grade Stage Time Speed Grade 1 000 1.7 0.0 33 10:40 4.0 152 2 0:20 1.7 1.3 34 11:00 4.1 15.4 3 040 1.7 2.5 35 11 :20 4.2 15.6 4 1:00 1.7 3.7 36 11:40 4.2 16.0 5 120 1.7 5.0 37 12:00 4.3 16.2 6 1:40 1.7 62 38 12:20 4.4 16.4 7 2:00 1.7 7.5 39 12:40 4.5 166 8 220 1.7 87 40 13:00 4:6 16.8 9 2:40 1.7 10.0 41 13:20 4.7 17.0 10 300 18 10.2 42 13:40 4.8 17.2 11 3:20 19 102 43 14:00 4.9 17.4 12 340 2.0 10.5 44 14:20 5.0 17.6 13 4:00 2.1 10.7 45 14:40 5.0 18.0 14 4:20 2.2 10.9 46 15:00 51 18.0 185 15 4:40 23 11.2 47 1520 5.1 16 500 2.4 11.2 48 15:40 52 185 17 5:20 2.5 11.6 49 16:00 5.2 190 18 540 2.5 120 50 16:20 5.3 19.0 19 6:00 2.6 12.2 51 16:40 53 19.5 20 620 2.7 12.4 52 17:00 5.4 195 21 6:40 2.8 12.7 53 1720 5.4 20.0 22 7:00 2.9 12.9 54 1740 55 20.0 23 7:20 30 13.1 55 18:00 56 20.0 24 7:40 3.1 13.4 56 1820 5.6 20.5 25 8:00 3.2 13.6 57 18:40 5.7 20.5 26 820 33 138 58 1900 5.7 21.0 27 8:40 3.4 140 59 19:20 58 21.0 28 900 35 14.2 60 1940 5.8 21.5 29 9:20 3.6 14.4 61 2000 5.9 21.5 30 940 3.7 14.6 62 2020 5.9 220 31 10:00 3.8 14.8 63 20:40 6.0 220 32 10;20 39 15.0 From Kaminsky LA. Whaley MH. Evaluation of a new standardized ramp protocol: the BSU/Bruce Ramp Protocol. J Cardiopulm Rehabll 1998; 18:438-444. For this protocol CRF can be estimated by the following equation: \\101_ (mL·kg·Lmin-') = 39 (test time) - 7.0 TABLE 9-5 EXAMPLE OF AN INDIVIDUALIZED;'\"tR.Ef.'DMilllWALKIN t' ••• • Walking Grade (%) Min Speed Grade (%) Min Seed o 0- 2 walking: 0 0-4 running: constant constant 4 3-4 2.5 5-6 6 5-6 5 7-8 8 7-8 7.5 9-10 10 9-10 10 11-12 etc etc.

132 ACSM's HEALTH-RELATED PHYSICAL FITNESS ASSESSMENT MANUAL· www.acsm.org This discussion serves only as a guideline for these protocols. Modifications will be need­ ed based on the client's appearance, performance, BP, and HR responses throughout the test. Generalized Procedures There are several generalized procedures that should be conducted during a graded exer­ cise test. A list of the generalized procedures may be found in Box 9-1. There are several roles or tasks that need to be performed (and, therefore, several tech­ nicians needed) during the administration of a maximal GXT. These roles and tasks are listed in this manual as an example of how an exercise test laboratory might coordinate the tasks that need to be performed. These job descriptions may not be consistent from lab to lab. The following roles are possibly needed: • Test operator • ECG technician • BP technician Role of the Test Operator As the test operator, you are 'in charge' of the GXT. I. Check emergency equipment in the laboratory before the testing session starts, e.g., defibrillator, emergency drug box, oxygen, suction, airway. (ACSM's GETP Appendix B has detailed information on emergency preparation and procedures.) BOX 9·1 Sequence of Measures for HR, BP, RPE, and Electrocardiogram (ECG) During Exercise Testing Pre-Test 1. 12-lead ECG in supine and exercise postures 2. Blood pressure measurements in the supine position and exercise posture Exercise * 1. 12-lead ECG recorded during last 15 seconds of every stage and at peak exer­ cise (3-lead ECG observed/recorded every minute on monitor) 2. Blood pressure measurements should be obtained during the last minute of each stage-;­ 3. Rating scales: RPE at the end of each stage, other scales if applicable Post-Test 1. 12-lead ECG immediately after exercise, then every 1 to 2 minutes for at least 5 minutes to allow any exercise-induced changes to return to baseline 2. Blood pressure measurements should be obtained immediately after exercise, then every I to 2 minutes until stabilized near baseline level 3. Symptomatic ratings should be obtained using appropriate scales as long as symptoms persist after exercise \"In addition, these referenced variables should be assessed and recorded whenever adverse symptoms or abnormal ECG changes occur. 'Note: An unchanged or decreasing systolic blood pressure with increasing workloads should be retaken (i.e., verified immediately).