䢇

Perspective

Submaximal Exercise Testing:

Clinical Application and
Interpretation

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Compared with maximal exercise testing, submaximal exercise testing

appears to have greater applicability to physical therapists in their role
as clinical exercise specialists. This review contrasts maximal and
submaximal exercise testing. Two major categories of submaximal tests
(ie, predictive and performance tests) and their relative merits are
described. Predictive tests are submaximal tests that are used to predict
maximal aerobic capacity. Performance tests involve measuring the
responses to standardized physical activities that are typically encoun-
tered in everyday life. To maximize the validity and reliability of data
obtained from submaximal tests, physical therapists are cautioned to
apply the tests selectively based on their indications; to adhere to
methods, including the requisite number of practice sessions; and to
use measurements such as heart rate, blood pressure, exertion, and
pain to evaluate test performance and to safely monitor patients.
[Noonan V, Dean E. Submaximal exercise testing: clinical application
and interpretation. Phys Ther. 2000;80:782– 807.]

Key Words: Functional limitation, Maximal exercise test, Outcome measures, Oxygen transport,
Performance, Prediction, Rehabilitation, Submaximal exercise test.
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў

Vanessa Noonan

Elizabeth Dean

782 Physical Therapy . Volume 80 . Number 8 . August 2000

 ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў
Submaximal

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exercise testing

A
lthough maximal exercise testing is consid- have served as a stan-
ered the gold standard for assessing maximal dard against which to
aerobic capacity, the role of such testing is overcomes many of compare other mea-
limited in people whose performance may be sures.8 Maximum oxy-
the limitations of
limited because of pain or fatigue rather than exertion gen consumption is
and in cases where maximal exercise testing is contrain- maximal exercise dependent on the abil-
dicated. Submaximal exercise testing overcomes many of ity of the oxygen trans-
the limitations of maximal exercise testing, and it is the testing. port system to deliver
method of choice for the majority of individuals seen by blood and the ability of
physical therapists in that these individuals are likely to cells to take up and uti-
be limited physically by pain and fatigue or have abnor- lize oxygen in energy production.9 Theoretically, a max-
mal gait or impaired balance. This article contrasts imal test is defined by the plateau of V̇o2 with further
maximal and submaximal exercise testing and describes increases in workload.10,11 Other indexes used to assess
the clinical application of submaximal testing. The maximal effort include obtaining HRmax within 15
strengths and limitations of both predictive and perfor- beats per minute (bpm) of age-predicted HRmax
mance submaximal tests and the means of maximizing (ie, 220⫺age) and a respiratory exchange ratio ⬎1.10
validity and reliability of data are presented. Predictive (ratio of metabolic gas exchange calculated by carbon
tests are submaximal tests that are used to predict dioxide production divided by V̇o2).12 Maximum oxygen
maximal aerobic capacity. Typically, heart rate (HR) or consumption is typically expressed relative to body
oxygen consumption (V̇o2) at 2 or more workloads is weight (ie, mL䡠kg⫺1䡠min⫺1),13 which enables individuals
measured.1,2 A predicted V̇o2 value is obtained by extrap- of different body masses to be compared. When a
olating the relationship between HR and V̇o2 to age- maximal test is performed but the criteria for V̇o2max
predicted maximal heart rate (HRmax). Performance are not met, the maximal V̇o2 achieved is termed a
tests involve measuring the responses to standardized “V̇o2peak.”14 Few individuals reach a true V̇o2max, and
physical activities that are typically encountered in every- V̇o2peak values are often incorrectly reported as maxi-
day life. Finally, we discuss the use of submaximal mal values.14 The intraindividual day-to-day variation in
exercise testing in clinical decision making and the measuring V̇o2max is between 4% to 6% in individuals
implications for professional education and research. with no known cardiopulmonary pathology or impair-
ment.15,16 In people with various diagnoses, such as those
Maximal Versus Submaximal Exercise Tests with chronic obstructive pulmonary disease (COPD),
Maximal exercise tests either measure or predict maxi- this variation is between 6% and 10%.17
mum oxygen consumption (V̇o2max) and have been
accepted as the basis for determining fitness.3–7 They

V Noonan, PT, MSc, is Research Coordinator, Orthopaedic Spine Program, Vancouver Hospital, Vancouver, British Columbia, Canada.

E Dean, PT, PhD, is Professor, School of Rehabilitation Sciences, University of British Columbia, T325-2211 Wesbrook Mall, Vancouver, British
Columbia, Canada V6T 1Z3 (elizdean@rehab.ubc.ca). Address all correspondence to Dr Dean.

Both authors provided concept/idea, writing, literature collection and analysis, project management, and consultation (including review of
manuscript before submission). Dr Dean also provided clerical support.

Physical Therapy . Volume 80 . Number 8 . August 2000 Noonan and Dean . 783
There are several limitations to assessing maximal per- Indications
formance with a V̇o2max test. Unless an individual is Maximal exercise testing has a role in the assessment of
able to attain a V̇o2max without fatiguing first or being maximal aerobic capacity or functional work capacity.
limited by musculoskeletal impairments or other prob- Because people are frequently limited by cardiopulmo-
lems, the results of the test are invalid. In addition, nary, musculoskeletal, and neuromuscular impairments
higher levels of motivation are required by the individ- and complaints such as exertion, dyspnea, fatigue, weak-
ual, and maximal tests require additional monitoring ness, and pain during their activities of daily living,
equipment (eg, electrocardiograph machine) and maximal testing is often contraindicated or of limited
trained staff and are labor intensive.1,13,18 value. In people without cardiopulmonary or musculo-
skeletal impairments, the reserve capacity of the cardio-
In comparison with maximal tests, submaximal exercise pulmonary and musculoskeletal systems is thought to be
tests and their applications have been less well devel- barely tapped during daily activities.22 In people with
oped, which we find surprising given the large number pathology, this reserve can be greatly reduced, and a
of patient types and individuals who should be able to greater than usual proportion of a person’s maximal

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benefit from nonmaximal exercise tests. For the purpose capacity may be needed to perform routine activities.23
of this review, submaximal tests are classified as either
predictive tests or performance tests. Exercise constitutes a major physiological stress that can
lead to untoward responses in patients as well as in
Clinical Application of Submaximal Exercise individuals without known pathology. In addition, such
Testing testing is resource intensive and thus should be applied
and performed judiciously. The purposes of maximal
Safety tests include determination of V̇o2max and use as diag-
Exercise constitutes a physiologic stress that may pose a nostic or treatment outcome tools. Submaximal exercise
greater risk to people with various diagnoses than to tests can be used to predict V̇o2max, to make diagnoses
people without pathology or impairment. The space for and assess functional limitations, to assess the outcome
testing must be sufficient to minimize injury should the of interventions such as exercise programs, to measure
patient fall or have an arrest. All physical therapists the effects of pharmacological agents, and to examine
should have current certification in cardiopulmonary the effect of recovery strategies on exercise
resuscitation. Emergency procedures and basic equip- performance.13,19,23–25
ment need to be in place to ensure that the individual
has immediate care until paramedical or medical assis- Guidelines for Test Selection
tance arrives. There are other critical needs for exercise There are numerous submaximal tests from which to
testing. Basic emergency supplies, including a sugar choose. These tests have been developed to meet the
source for people with diabetes, should be on hand. A needs of people with various functional limitations and
portable oxygen source and suction device should be disabilities and the needs of older adults. In our opinion,
accessible. People who are stable and who have a history however, inappropriate selection may lead to either
of angina should have their antianginal medication, and understressing or overstressing the individual. Such
the physical therapist should have access to this medica- understressing or overstressing of the person, in our
tion. Monitoring equipment should be maintained and view, can lead to invalid conclusions because of ceiling
regularly calibrated. or floor effects, and the testing may be hazardous. The
goal of testing should be to produce a sufficient level of
Indications for testing and any contraindications for exercise stress without physiologic or biomechanical
testing should be determined before testing.19 In the strain. Factors that we believe should be considered in
presence of relative contraindications, the person may selecting the appropriate test include the person’s pri-
require additional monitoring (eg, 12-lead electrocardi- mary and secondary pathologies and how these pathol-
ography) or be cleared for such testing by an appropri- ogies physically affect the person’s daily life. Other
ate medical practitioner. A high proportion of people factors include cognitive status, age, weight, nutritional
over the age of 65 years without known cardiac disease status, mobility, use of walking aids or orthotic or
have a high incidence of cardiac dysrhythmias,20,21 which prosthetic devices, independence, work situation, home
may necessitate greater attention to monitoring cardiac situation, and the person’s needs and wants. People who
status during exercise. Individuals requiring additional may be medically unstable and at risk for an arrest may
monitoring or considered to be at hemodynamic risk need to be tested in the presence of a cardiologist or
should be tested in a setting with medical personnel pulmonary specialist or by a physical therapist in a
present. specialized setting where emergency services are on
hand. The population for which a given test was devel-
oped, the degree of validity and reliability of measure-

784 . Noonan and Dean Physical Therapy . Volume 80 . Number 8 . August 2000
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ments obtained with each test, and test sensitivity also perform such testing. Premature ventricular contrac-
should be considered (Appendix). Reports in the liter- tions can be detected reliably only with electrocardio-
ature on the common submaximal tests described in this grams and not by palpation or verbal report. A detailed
article vary with respect to the adequacy of establishing anginal history, including what triggers episodes of
validity, reliability, and sensitivity; thus, test interpreta- angina and the frequency of self-medication with anti-
tion may be limited. These limitations should be consid- anginal medication and its effect, should be recorded.
ered in the selection of each test. Physical therapists Any history of chest discomfort or pain from any cause
should determine what information will be added by should be noted by the tester. We also believe that any
performing an exercise test and how that information medication should be checked for its expiration date
will alter clinical decision making. and should be available in the event it is needed during
or after the test. A person with a history of angina and for
Pretest Workup whom antianginal medication is prescribed, in our opin-
A detailed medical and surgical history is needed to ion, should be considered at risk even if the medication
identify the indications for an exercise test and to alert has not been required for a prolonged period. We advise

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the physical therapist about any underlying conditions that a risk assessment should be conducted for every
(eg, cardiovascular, pulmonary, musculoskeletal, or neu- individual, regardless of whether a maximal exercise test
rological dysfunction or the presence of diabetes, hyper- or a submaximal exercise test is being performed. This
tension or heart block requiring a pacemaker, anemia, assessment will help to determine which test is appropri-
thyroid dysfunction, obesity, deformity, vertigo, or ate, predict an adverse response to testing, identify the
impaired cognitive function). The therapist should be level of monitoring needed, and whether there are any
aware of medications (indications, response, and side contraindications to submaximal exercise testing.
effects) that can influence the test procedures and the
response to the exercise. Laboratory tests and investiga- Standardization of Procedures
tions that may be relevant include electrocardiograms, A primary concern about submaximal exercise testing is
echocardiograms, pulmonary function tests, investiga- the lack of standardization of the procedures. We believe
tions of peripheral vascular function, blood chemistry that general procedures should include informing the
tests, bone density measures, radiographs, scans, thyroid person about the type and purpose of the test and
function tests, glucose tolerance tests, autonomic ner- instructing the person to avoid any strenuous activity for
vous system function tests, sleep studies, nutritional 24 hours prior to testing and to avoid a heavy meal,
assessment, and tests for level of hydration. caffeine, or nicotine within 2 to 3 hours of testing.19
Medications taken prior to testing should be noted by
The effect of each medication on exercise response and the examiner, and, if appropriate, their use should be
the medication’s side effects should be known to the consistent from one test to the next. The individual
person administering the test. Beta blockers, for exam- should become familiar with the equipment and test
ple, attenuate normal HR and blood pressure (BP) procedures to minimize anxiety. Many tests require one
responses to exercise and contribute to fatigue in some or more practice sessions. If time and resources do not
people. The purpose of the test must be clear so that the permit these practice sessions, we argue that the test
person can be appropriately premedicated (eg, with should not be performed because the results, in our
antidysrhythmic drugs, inotropic drugs, anticoagulants, view, will not be valid. Appropriate rest periods, in our
antithrombolytics, bronchodilators, vasodilators, diuret- opinion, need to be scheduled between practices and
ics, and analgesics). For example, medications such as between the last practice and the actual test. We have
bronchodilators and analgesics have peak effect times; previously shown that performance of a submaximal
thus, it is important to ensure that these medications are treadmill walking test requires at least one practice
at peak effect during the test and that this effect is session, even in young subjects without functional
replicated on subsequent tests. impairments, in order for the measurements to be
valid.26 For some individuals, more practice sessions are
People with a history of angina should be screened justified. The number of practice sessions required to
carefully. The objective of submaximal testing is to test make the results valid, in our opinion, is dependent on
the individual below the work rate that induces angina. the test and on the experience and functional capacity of
The person’s anginal history will divulge the range of the person being tested. Verbal encouragement in sub-
activities and the activities that are not associated with maximal testing should be standardized to ensure that
symptoms. Labile angina, angina at rest, and frequent this does not affect the person’s performance.27 Failure
premature ventricular contractions (PVCs) at rest are, in to calibrate both exercise devices and monitoring equip-
our opinion, absolute contraindications to exercise test- ment can lead to erroneous results.
ing in the absence of a cardiologist unless in a special-
ized setting where physical therapists are qualified to

Physical Therapy . Volume 80 . Number 8 . August 2000 Noonan and Dean . 785
Measurements Table 1.
Modified Bruce Treadmill Test: Protocola
Basic measures of exercise responses include HR, BP,
respiratory rate (RR), rating of perceived exertion
(RPE), and breathlessness. Depending on the person’s Stage Speed (mph) Grade (%) Duration (min)
history and other variables, the examiner may find other 0 1.7 0 3
measures to be useful (eg, a 3-lead electrocardiogram, 0.5 1.7 5 3
arterial saturation assessed using a pulse oximeter, 1 1.7 10 3
cadence, ratings of fatigue and discomfort or pain). 2 2.5 12 3
3 3.4 14 3
Because tests are performed over a wide area or circuit, 4 4.2 16 3
monitoring equipment should be portable. Repeated 5 5.0 18 3
measurements of each variable of interest, in our opin- 6 5.5 20 3
ion, should be taken prior to the exercise test to ensure 7 6.0 22 3
a stable baseline, at various points during the test a
Adapted from Bruce RA. Exercise testing of patients with coronary artery
(depending on the type of test), and during the cool- disease: principles and normal standards for evaluation. Ann Clin Res. 1971;3:

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down period, if applicable, and these measurements 323–332 and Bruce RA, Kusumi F, Hosmer D. Maximal oxygen intake and
nomographic assessment of functional aerobic impairment in cardiovascular
should be repeated during recovery to ensure that the disease. Am Heart J. 1973;85:564 –562. The standard Bruce protocol begins at
measures have returned to baseline levels. As a precau- stage 1; stages 0 and 0.5 are used for individuals with reduced exercise
tion, we recommend that the person should not leave capacity.

the testing area until all measures have returned to

within 10% of resting values.19 Based on the history of
the person being tested, additional monitoring may be consistent with deconditioning or pathology, or both.
indicated to maximize the safety of the test. Comparison of the responses with pretest and posttest
measurements is particularly useful for assessing the
Because the measurement of BP is an important part of effect of an intervention such as an exercise program. In
exercise testing, the validity of these measurements this case, a reduction in submaximal exercise responses
should be maximized with an appropriately sized cuff, its such as HR, RR, and BP can be consistent with improved
position on the midshaft of the humerus, its tightness, aerobic conditioning or movement economy, or both.
the cuff deflation rate, and the position of the stetho- Movement economy refers to the efficient use of energy
scope over the brachial artery as it courses over the during movement (ie, not excessive V̇o2 for a given
antecubital fossa.28 Skill in recording BP is essential, activity or work rate).
given that many people have undiagnosed or poorly
controlled hypertension. Predictive Submaximal Exercise Tests

Measures of exertion, breathlessness, fatigue, discomfort Modified Bruce Treadmill Test

or pain, and well being in response to physical activity or
exercise are important exercise responses reported by Description. The Bruce Treadmill Test5 is a maximal
the person being examined. Many people, particularly test that was designed to diagnose coronary heart dis-
older people, more readily and reliably monitor and act ease. Some preliminary stages have been added to the
on their complaints, rather than using measures such as original test, which has given rise to the use of the
HR to guide their activities or exercise intensity. Modified Bruce Treadmill Test in people with other
conditions.29,30 Compared with the original test, which
Interpretation starts at 1.7 mph at a grade of 10%, the modified test has
The interpretation of the submaximal exercise test a zero stage (1.7 mph at 0% grade) and a one-half-stage
results is based primarily on the type of test conducted, (1.7 mph at 5% grade) (Tab. 1). Predictive equations for
its indications (eg, assessment, diagnostic, exercise pre- estimating V̇o2max have been developed and can be
scription), specified outcomes, and, in some instances, used with the original and modified tests. Bruce et al5
norms (Appendix). Submaximal exercise tests can be developed the first predictive equations, which are
used to predict aerobic capacity or to assess the ability to population-specific for active and sedentary adults with
perform a standardized exercise or task. In addition, and without cardiac conditions. Individuals must be
measurements taken before, during (where applicable), correctly classified to determine which equation is
and after the test can yield valuable information regard- appropriate. Foster et al30 later developed a regression
ing the person’s exercise response. These values can be equation applicable to all men based on a sample of 230
compared across subsequent tests. They can alert the men of various ages with a variety of clinical conditions
physical therapist to undue pretest arousal (a measure of (symptomatic angina, n⫽14; postmyocardial revascular-
the adequacy of the pretest standardization), exagger- ization surgery, n⫽36; outpatient cardiac rehabilitation
ated exercise responses, and delayed recovery, which are surgery, n⫽63; preventative medicine program, n⫽90,
and athletes, n⫽27) and activity levels. The details of the

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Modified Bruce Treadmill Test are provided in the Strengths and weaknesses. This test is suitable for test-
Appendix. ing people with various diagnoses in clinical and
research settings. It consists of only a warm-up session
Reliability and validity. Bruce et al5 reported Pearson and a single stage on the treadmill. This test, in our view,
product moment correlation coefficients (r) between is useful for assessing people who are prone to fatigue.
predicted V̇o2max and measured V̇o2max of .94 for
without cardiac conditions (n⫽292), .93 for women Further research is needed to validate this test in people
without cardiac conditions (n⫽509), and .87 for men with various diagnoses, in individuals over 60 years of
with cardiac disease (n⫽153). Foster et al30 compared age, and in both unfit and highly trained individuals.
predicted V̇o2max and measured V̇o2max for the gen- Further studies are needed to establish its sensitivity to
eral equation and the population-specific equations detect change. Finally, because this test is based on HR,
introduced by Bruce et al.5 The average predicted error factors that affect HR must be controlled; otherwise, the
was ⫺0.6 mL䡠kg⫺1䡠min⫺1 for the general equation versus test results will be invalidated.
⫺2.0 mL䡠kg⫺1䡠min⫺1 for the population-specific equa-

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tions. The correlation between measured V̇o2max and Astrand and Ryhming Cycle Ergometer Test
predicted V̇o2max for the general equation was high
(r ⫽.96), with a multiple correlation coefficient (R) Description. The Astrand and Ryhming (A-R) Cycle
of .98 and a standard error of the estimate (SEE) of Ergometer Test, which is used to predict V̇o2max by use
3.5 mL䡠kg⫺1䡠min⫺1.30 of a cycle ergometer, is based on the linear relationship
between V̇o2 and HR.31 Astrand and Ryhming31 noted
Strengths and weaknesses. The Bruce Treadmill Test that, in subjects aged 18 to 30 years, the men had an
and the Modified Bruce Treadmill Test are widely used, average HR of 128 bpm at 50% of V̇o2max and an
especially for the diagnosis of coronary heart disease, average HR of 154 bpm at 70% of V̇o2max, and the
and, as a result, normative data are available. Compared women had an average HR of 138 bpm at 50% of
with the original protocol, which starts with a large V̇o2max and an average HR of 164 bpm at 70% of
workload, the modified protocol has a more gradual V̇o2max. A nomogram was developed by Astrand and
initial workload. Thus, we contend that the modified Ryhming31 to estimate V̇o2max (Fig. 1), and later an
protocol is more applicable for individuals with low age-correction factor was incorporated to account for
functional capacity. The large increases in workload in the decrease in HRmax with age (Tab. 2).32 Modification
the original protocol, however, allowed the test to be of the A-R nomogram were proposed by Legge and
completed within 6 to 9 minutes.23 Banister33 and by Hartung and colleagues9,34 to improve
the accuracy of the equation. A revision to the A-R
Single-Stage Submaximal Treadmill Walking Test nomogram was also proposed by Siconolfi et al.35 The
details of the A-R Cycle Ergometer Test are presented in
Description. Ebbeling et al12 developed the Single- the Appendix.
Stage Submaximal Treadmill Walking Test (SSTWT),
which can be used by individuals of various ages and Reliability and validity. Astrand32 reported a correlation
fitness levels. The test was developed on a sample of 139 (r) of .71 between the measured V̇o2max and the
volunteers with no health problems (67 men and 72 estimated V̇o2max in the original A-R Cycle Ergometer
women) aged 20 to 59 years. The subjects were randomly Test and a correlation (r) of .78 between the measured
assigned to either an estimation group (n⫽117) or a V̇o2max and the A-R Cycle Ergometer Test using the
cross-validation group (n⫽22). Subjects walked on a age-correction factor. Teraslinna et al36 reported a cor-
treadmill at a constant speed, ranging from 2.0 to 4.5 relation (r) of .69 between the original A-R Cycle Ergome-
mph at grades of 0%, 5%, and 10%, with each stage ter Test and the measured V̇o2max and a correlation (r) of
lasting 4 minutes. A maximal test was then performed. .92 using the age-correction factor in a sample of 31
The regression equation used to estimate V̇o2max was sedentary men. Kasch37 reported that the A-R Cycle
based on data obtained from the estimation group from Ergometer Test predicted a V̇o2max that was too low (by
the 4-minute stage at a grade of 5%. The details of the 21%) in 83 men aged 30 to 66 years. Other research-
SSTWT are given in the Appendix. ers38,39 have reported similar findings. Hartung et al,34 in
a study of women aged 19 to 70 years, found that the A-R
Reliability and validity. The SSTWT was validated by method overestimated V̇o2max by 3% to 21%. In addi-
correlating the estimated V̇o2max and the measured tion, an overestimation of V̇o2max by the A-R method
V̇o2max in the cross-validation group. A correlation (r) has been documented in women who were pregnant.40
of .96 was obtained, with a multiple correlation (R) of
.86 (SEE⫽4.85 mL䡠kg⫺1䡠min⫺1). Legge and Banister33 reported a correlation (r) between
their revised nomogram and the measured V̇o2max of

Physical Therapy . Volume 80 . Number 8 . August 2000 Noonan and Dean . 787
 .98. Hartung and colleagues9,34 reported a correlation
(r) of .95 between the measured V̇o2max and the
estimated V̇o2max using their revised nomogram. How-
ever, the revised nomogram still predicted a V̇o2max
that was too low (by 8.1 mL䡠kg⫺1䡠min⫺1) in a sample of
sedentary and trained men.9 In a sample of women
(n⫽38) aged 19 to 47 years, the revised nomogram
overestimated V̇o2max by 18.5%.34

Strength and weaknesses. The A-R Cycle Ergometer

Test is one of the most frequently used submaximal cycle
ergometer tests.41,42 This test has been a standard used
by fitness facilities as part of fitness evaluations and to
develop a training plan and evaluate the results.43 The

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protocol uses HR, which is easy to measure. Limitations
of the test include the margin of error in the predicted
V̇o2max values. The protocol can elicit lower-extremity
discomfort in some people, which may invalidate the
results.

Canadian Aerobic Fitness Test

Description. The Canadian Aerobic Fitness Test

(CAFT), formerly known as the Canadian Home Fitness
Test, is unique in that it was designed to promote fitness
testing at home. The CAFT was developed on a sample
of 1,544 individuals (699 men and 845 women) aged 15
to 69 years.44 The CAFT is a measure of fitness and is
based on the duration of the step test and a 10-second
recovery of HR (Tabs. 3 and 4). Norms for the recovery
HR in men and women have been reported,44 and a
“Physical Fitness Evaluation Chart” for various age
groups is available (Tab. 5). In addition, Jette et al45
developed a regression equation for the CAFT to predict
V̇o2max. A sample of 59 individuals, aged 15 to 74 years,
completed the CAFT and then underwent a progressive
treadmill test to evaluate V̇o2max.

The CAFT was modified (mCAFT)46,47 following reports

that it predicted a V̇o2max that was too low in women
aged 20 to 30 years and in heavy, older, and well-trained
individuals.48 –50 Use of too few stages can produce a
ceiling effect, and, if the target HR is not attained, the
Figure 1.
The Astrand and Ryhming nomogram. Estimated maximum oxygen
V̇o2max prediction may be too low.46 The modification
consumption (V̇O2max) can be determined by reading horizontally from allows an individual to complete the number of stages
the body weight scale (step test) or workload scale (cycle test) to the necessary to reach a target HR within 85% of the
oxygen uptake (V̇O2) scale. The predicted V̇O2max value is obtained by age-predicted maximum. Weller et al46 developed 2
connecting the point on the V̇O2 scale (V̇O2 , liters per minute) with the additional stages for the original CAFT for individuals
corresponding point on the pulse rate scale (in beats per minute). The
horizontal line extends from the workload and V̇O2 scales to the pulse
who exceed stage 6. A new regression equation was also
rate scale. Where the line intersects the max V̇O2 scale (liters per minute) developed.51 The details of the CAFT52 are shown in the
is the estimate of the individual’s V̇O2max. Reprinted with permission Appendix.
from Astrand I. Aerobic capacity in men and women with special
reference to age. Acta Physiol Scand. 1960;49(suppl 169):2–92. Reliability and validity. The reliability of measurements
of recovery time for HR for the CAFT was determined
using a sample of 102 individuals (r ⫽.79).44 In terms of
validity, the regression equation developed by Jette

788 . Noonan and Dean Physical Therapy . Volume 80 . Number 8 . August 2000
 ўўўўўўўўўўўўўўўўўўўўўўўўўўў
Table 2. Table 3.
Astrand and Ryhming Cycle Ergometer Test: Correction Factor for Canadian Aerobic Fitness Test: Starting Tempo of the Stepping
Age-Predicted Maximal Heart Ratea Exercise Based on Age and Sexa

Maximal Heart Starting Exerciseb

Age (y) Factor Rate (bpm) Factor
Age (y) Males Females
15 1.10 210 1.12
60 and over 1 (66) 1 (66)
25 1.00 200 1.00
50 –59 2 (84) 1 (66)
35 0.87 190 0.93
40 – 49 3 (102) 2 (84)
40 0.83 180 0.83
30 –39 4 (114) 3 (102)
45 0.78 170 0.75
20 –29 5 (132) 3 (102)
50 0.75 160 0.69
15–19 5 (132) 4 (114)
55 0.71 150 0.64
60 0.68 a
Reprinted with permission from Operations Manual: Canadian Home Fitness
65 0.65 Test, 2nd ed, Health Canada. © Minister of Public Works and Government

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Services Canada, 2000.
a
Use the correction factor if the individual is over 30 to 35 years of age or if b
Stepping tempo (in parentheses) in steps per minute.
the maximal heart rate is known. The actual factor should be multiplied by
the value in Table 2. Note: one correction factor is multiplied by age, and the
other correction factor is multiplied by maximal heart rate. Reprinted with Table 4.
permission from Astrand PO, Rodahl K. Textbook of Work Physiology. 2nd ed. Canadian Aerobic Fitness Test: Ceiling Postexercise Heart Ratesa
New York, NY: McGraw-Hill Book Co; 1977:279.

Heart Rate
10 s After 10 s After
et al45 had a multiple correlation (R) of .905 Age (y) 1st Stage 2nd Stage
(SEmeas⫽4.08 mL䡠kg⫺1䡠min⫺1). The regression equation
60 and over 24 23
for the mCAFT demonstrated the same strength
50 –59 25 23
between the predicted V̇o2max and the measured 40 – 49 26 24
V̇o2max as the original equation for the CAFT (mCAFT, 30 –39 28 25
r ⫽.88; CAFT, r ⫽.99), but there was a lower mean 20 –29 29 26
square error (mCAFT⫽37.0 and CAFT⫽63.3). 15–19 30 27
a
Reprinted with permission from Operations Manual: Canadian Home Fitness
Strengths and weaknesses. The CAFT is a step test and, Test, 2nd ed, Health Canada. © Minister of Public Works and Government
Services Canada, 2000.
therefore, is inexpensive to administer and requires no
electricity or calibration. A person’s power output can be
calculated within 6% to 7% if the individual steps in time was developed. The details of the 12-MRT are shown in
with the beat, stands erect on the top step, and places the Appendix.
both feet flat on the ground at the end of each stepping
cycle.11 Reliability and validity. Test-retest reliability (r) of mea-
surements obtained with the 12-MRT was reported by
This test may not be suitable for people whose ability to Cooper53 to be .90. In terms of validity, Cooper53
balance is diminished because no handrail is used. It is reported a correlation (r) of .90 between the 12-MRT
also difficult to monitor individuals while they are step- distance and V̇o2max. Jessup et al55 reported a lower
ping. Because we believe there is a ceiling effect, we correlation (r) of only .13 between the 12-MRT and
contend that the original protocol appears to be more V̇o2max in a sample of male subjects with no health
suited for assessing individuals who are unfit. Further problems aged 18 to 23 years. Safrit et al56 reported
research is needed to validate both the CAFT and the findings similar to those of Jessup et al.55
mCAFT with people with various diagnoses.
Strengths and weaknesses. The 12-MRT requires no
12-Minute Run Test specialized equipment and allows more than one indi-
vidual to be tested at a time. We suggest that this test is
Description. The 12-Minute Run Test (12-MRT) was appropriate for assessing the cardiopulmonary fitness of
developed by Cooper53 in 1968. This test is based on the individuals with high levels of function. The 12-MRT has
work of Balke,54 which indicated that various run-walk been modified as a 12-Minute Walk Test (12-MWT),
tests could relate V̇o2 to either the distance covered in a which we believe is more appropriate for the rehabilita-
given period of time or the time taken to cover a given tion setting.
distance. A sample of 115 men with no health problems
aged 17 to 52 years completed two 12-MRTs and a This test was developed using a male population. No
V̇o2max test on a treadmill, and a regression equation cross-validation group was used to validate the equation.
The 12-MRT requires a constant level of motivation, and

Physical Therapy . Volume 80 . Number 8 . August 2000 Noonan and Dean . 789
Table 5.
Canadian Aerobic Fitness Test: Physical Fitness Evaluation Charta

Start at Stepping
Exercise No.
Age
Group Males Females Your pulse rate after first exercise

60s 1 1 Stop if 24 or more If 24 or more, you have an Go only if 23 or less Everybody stop
undesirable (below average)
personal fitness level
50s 2 1 Stop if 25 or more If 25 or more, you have an Go only if 24 or less Stop if 23 or more
undesirable personal fitness
level
40s 3 2 Stop if 26 or more If 26 or more, you have an Go only if 25 or less Stop if 24 or more
undesirable personal fitness

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level
30s 4 3 Stop if 28 or more If 28 or more, you have an Go only if 27 or less Stop if 25 or more
undesirable personal fitness
level
20s 5 3 Stop if 29 or more If 29 or more, you have an Go only if 28 or less Stop if 26 or more
undesirable personal fitness
level
15–19 5 4 Stop if 30 or more If 30 or more, you have an Go only if 29 or less Stop if 27 or more
undesirable personal fitness
level

Your pulse rate after second exercise Your pulse rate after third exercise
* Caution: The advanced version of the Canadian Home Fitness Test is
intended for use only by those individuals who have attained the
recommended fitness level.
If 23 or more, you have If 22 or less, you have Advanced ONLY
the minimum personal the recommended
fitness level personal fitness
level
If 23 or more, you have Go only if 22 or less Everybody If 23 or more, you have If 21–22, you have If 20 or less, you have
the minimum personal stop the recommended the recommended the recommended
fitness level personal fitness level personal fitness personal fitness
GOOD level level
VERY GOOD EXCELLENT
If 24 or more, you have Go only if 23 or less Everybody If 24 or more, you have If 22–23, you have If 21 or less, you have
the minimum personal stop the recommended the recommended the recommended
fitness level personal fitness level personal fitness personal fitness
GOOD level level
VERY GOOD EXCELLENT
If 25 or more, you have Go only if 24 or less Everybody If 25 or more, you have If 23–24, you have If 22 or less, you have
the minimum personal stop the recommended to recommended the recommended
fitness level personal fitness level personal fitness personal fitness
GOOD level level
VERY GOOD EXCELLENT
If 26 or more, you have Go only if 25 or less Everybody If 26 or more, you have If 24 –25, you have If 23 or less, you have
the minimum personal stop the recommended the recommended the recommended
fitness level personal fitness level personal fitness personal fitness
GOOD level level
VERY GOOD EXCELLENT
If 27 or more, you have Go only if 26 or less Everybody If 27 or more, you have If 25–26, you have If 24 or less, you have
the minimum personal stop the recommended the recommended the recommended
fitness level personal fitness level personal fitness personal fitness
GOOD level level
VERY GOOD EXCELLENT
a
Reprinted with permission from Operations Manual: Canadian Home Fitness Test, 2nd ed, Health Canada. © Minister of Public Works and Government Services
Canada, 2000.

790 . Noonan and Dean Physical Therapy . Volume 80 . Number 8 . August 2000
 ўўўўўўўўўўўўўўўўўўўўўўўўўўў
Reliability and validity. In terms of reliability, the test-
retest correlation (r) for the 20-MST was reported to be
.89 for children (n⫽139) aged 8 to 19 years and .95 for
adults (n⫽81) aged 20 to 45 years.58 Leger et al58
reported a correlation (r) of .71 (SEE⫽5.9
mL䡠kg⫺1䡠min⫺1) between the 20-MST and measured
V̇o2max in children and a correlation of .90 in adults.
Paliczka et al61 confirmed the validity of measurements
obtained with the 20-MST by demonstrating a high
correlation between 20-MST and V̇o2max (r ⫽.93), as
well as with a 10-km race time (r ⫽⫺.93). The test has
been further validated on active women.62 The 20-MST
was reported to yield valid and sufficiently sensitive
measurements such that the intensity of exercise could

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be modified for children with asthma.63
Figure 2.
The setup and protocol for the 20-Meter Shuttle Test. Reprinted with Strength and weaknesses. The 20-MST is based on an
permission from Leger LA, Mercier D, Gadoury C, Lambert J. The individual’s MAS. This test has multiple stages, enabling
multistage 20-meter shuttle run test for aerobic fitness. J Sports Sci. a wide range of fitness levels to be tested. It requires little
1988;6:93–101. equipment, and more than one individual can be tested
at a time. The 20-MST is unique because it paces the
individual with the use of sound signals on a pre-
the individual must pace herself or himself. The wording recorded cassette tape.
of the instructions makes this a potentially maximal
exercise test, so well-defined testing criteria are needed Due to the frequent stopping and starting of this test, we
to ensure that it is a submaximal exercise test. Finally, believe that it is important to screen the individual prior
this test fails to account for age or body weight, which to testing to ensure that she or he is suitable. The test
can influence exercise responses.18 may not be suitable for some individuals due to the
progressive increments of speed each minute and the
20-Meter Shuttle Test requirement to pivot when they run between 2 lines. For
example, this test may not be suitable for elderly people
Description. The 20-Meter Shuttle Test (20-MST)57,58 or those with musculoskeletal impairments. Some indi-
assesses maximal aerobic power. This test was designed viduals may find it difficult to pace themselves with the
for children, adults attending fitness classes, and athletes signals. Finally, testing criteria are needed to ensure that
participating in sports requiring constant stopping and the test is submaximal.
starting. The test requires subjects to run between 2 lines
spaced 20 m apart at a pace set by signals on a pre- 1-Mile Track Walk Test (Rockport Fitness Test)
recorded cassette tape (Fig. 2). Starting speed is
8.5 km䡠h⫺1, and the frequency of the signals is increased Description. The 1-Mile Track Walk Test (1-MTW), also
0.5 km䡠h⫺1 each minute. When the subject can no known as the Rockport Fitness Test, estimates V̇o2max
longer maintain the set pace, the last completed speed across a range of age groups and fitness levels. The
(ie, stage) is used to predict V̇o2max. Leger and Lam- prediction equations were developed based on a sample
bert59 found that maximal speed, subsequently termed of 390 volunteers with no health problems (183 men and
“maximal aerobic speed” (MAS), for 2-minute stages in 207 women, aged 30 to 69 years).64 Each individual
the 20-MST, could predict V̇o2max, with a correlation (r) performed a minimum of two 1-MWTs on separate days.
of .84 (SEE⫽10.5%). A regression equation was devel- The walk times in the 2 tests had to be within 30 seconds.
oped on a sample of 188 boys and girls aged 8 to All individuals also performed a V̇o2max test on a
19 years.58 Another regression equation was developed treadmill. This test has also been validated on individuals
for adults based on a sample of 77 adults (53 men and with mental retardation.65,66 Variations in the distance
24 women) aged 18 to 50 years, in which age is held used with this test have been reported (eg, 1-mile
constant at 18 years.58 Norms have been established for run/walk,67,68 1.5-mile run,68 2-mile run69). The details
children aged 6 to 17 years.57 Berthoin et al60 modified of the 1-MWT are given in the Appendix.
the 20-MST by incorporating 1-minute stages rather than
2-minute stages because they reported that faster speeds Reliability and validity. Kline et al64 reported the reli-
could be achieved when the work stages were shorter. ability (r) of measurements obtained for the last quarter-
The details of the 20-MST are presented in the Appen- mile HRs to be .93 (SEE⫽7.6 bpm) and the reliability (r)
dix.

Physical Therapy . Volume 80 . Number 8 . August 2000 Noonan and Dean . 791
of measurements obtained for the total time for the 2 Table 6.
Modified Shuttle Walking Test: Protocola
trials of the track walk to be .93 (SEE⫽0.26 minute). The
validity of the regression equation was established by
having a validation group (n⫽174) and a cross- Speed Speed No. of
Level (m/s) (mph) Shuttles
validation group (n⫽169). The sample of 390 volunteers
were assigned to the validation and cross-validation 1 0.50 1.12 3
groups based on alternate case assignment (ie, odd-even 2 0.67 1.50 4
case selection). Descriptive statistics revealed no differ- 3 0.84 1.88 5
4 1.01 2.26 6
ence between the 2 groups. The correlation (r) between 5 1.18 2.64 7
the predicted V̇o2max and the actual V̇o2max was .93 6 1.35 3.02 8
(SEE⫽0.325 L䡠min⫺1) for the validation group and .92 7 1.52 3.40 9
(SEE⫽0.355 L䡠min⫺1) for the cross-validation group. 8 1.69 3.78 10
9 1.86 4.16 11
10 2.03 4.54 12
Strengths and weaknesses. This test, in our view, is

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11 2.20 4.92 13
applicable to a wide range of individuals. It requires little 12 2.37 5.30 14
specialized equipment and uses the familiar activity of a
Reprinted with permission of the BMJ Publishing Group from Payne GE,
fast walking. Thus, we contend that it is suitable for use Skehan JD. Shuttle walking test: a new approach for evaluating patients with
in the rehabilitation setting. The test was cross-validated, pacemakers. Heart. 1996;75:414 – 418.
which confirms the accuracy of prediction.

The test and regression equations need to be validated no difference was found between the 2 tests on separate
in patient groups. Finally, research is needed to deter- days. In terms of validity, the assessments (ie, standard-
mine whether a practice test improves the prediction. ized HR from the SPWT and a progressive cycle test)
were correlated (r ⫽.79).70
Performance Submaximal Tests
Strengths and weaknesses. The SPWT assesses cardio-
Self-Paced Walking Test pulmonary fitness as well as walking efficiency, both of
which are beneficial in daily activities.70 This test is
Description. The Self-Paced Walking Test (SPWT)70 is suitable for individuals requiring mobility devices or
an exercise test developed for elderly and frail individu- when a treadmill or cycle ergometer is not indicated.
als. It consists of free walking at 3 speeds down an indoor This test may also be suitable for monitoring an older
corridor (ie, 250 m). Various exercise responses can be person’s mobility status over time, including the effects
assessed such as speed, time, stride frequency, stride of aging and the effect of using mobility aids and
length, HR, and predicted V̇o2max. The test was devel- devices.70 The information obtained from this test can
oped on 24 individuals aged 64 to 66 years. Ten active provide safety guidelines (eg, for crossing an intersec-
students aged 19 to 21 years served as a comparison tion safely requires a speed of 3.5 ft/s).24 Individuals who
group. Each subject performed the SPWT and a progres- are at risk for injury while crossing an intersection may
sive cycle ergometer test. Only 17 elderly individuals be identified. Individuals who are not able to walk at this
could complete the cycle ergometery test, whereas all of speed should be identified as being not safe, and alter-
them completed the SPWT. native means of mobility or mobility aids need to be
recommended.
Performance of the SPWT is correlated with V̇o2max and
is independent of age.71 Following an exercise program, This test is limited because it does not provide a measure
the speed of walking was reported to increase, whereas of endurance and may not be sufficiently sensitive to test
HR remained unchanged.72 A predicted V̇o2max can be individuals with higher levels of function. For some
obtained from estimating V̇o2 from an aerobic demand individuals with diminished function, it may be too
curve and then extrapolating a predicted V̇o2max from difficult to complete the 3 selected walks with only 5
V̇o2 and HR. To date, this test has been used primarily minutes of rest.
with older individuals.71–73 The details of the SPWT are
presented in the Appendix. Modified Shuttle Walking Test

Reliability and validity. The test-retest reliability for Description. The Modified Shuttle Walking Test
measurements obtained with the SPWT when it was (MSWT) was modified from the 20-MST to provide a
repeated a few days later for the older group was ⫾5.2%, standardized progressive test for obtaining a symptom-
⫾4.7%, and ⫾11% for the fast, normal, and slow paces, limited maximum performance in individuals with
respectively.70 The younger group varied by ⫾7%, but chronic airway obstruction (CAO).74,75 The individual
walks up and down a 10-m course at incremental speeds

792 . Noonan and Dean Physical Therapy . Volume 80 . Number 8 . August 2000
 ўўўўўўўўўўўўўўўўўўўўўўўўўўў
of 0.17 m/s each minute dictated by a prerecorded minutes to complete. A sample of 61 women aged 48 to
audio signal on a cassette deck74 (Tab. 6), whereas the 93 years was recruited from the community and a
original 20-MST required the individual to run a 20-m residential home. Fifty-six subjects completed the test.
distance at a starting speed of 8.5 km/h with increments The maximal weight they could carry up and down the
of 0.5 km/h each minute.58 stairs ranged between 3 and 26 kg. The test developers
concluded that this test was easy to administer and
A sample of 35 individuals with CAO aged 45 to 74 years suitable for testing individuals with higher levels of
was used to develop the test.74 This test has been further function. The details of the BCT are presented in the
validated on individuals with pacemakers.76 Singh and Appendix.
colleagues74,75 have recommended the MSWT for use as
an assessment tool for individuals with a wide range of Reliability and validity. The test-retest reliability of mea-
cardiac and respiratory disabilities. The details of the surements obtained with the BCT was established by
MSWT are shown in the Appendix. administering the BCT 3 days later (r ⫽.89). Maximal
HR was 90%⫾10% of the HR achieved during the

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Reliability and validity. The measurements obtained V̇o2peak test on a cycle ergometer. The BCT correlated
with this test were replicable in a sample of 10 individu- with force of the quadriceps femoris muscle (r ⫽.43),
als after one practice trial.74 The mean difference hamstring muscle (r ⫽.54), gastrocnemius muscle
between trials 2 and 3 was ⫺2.0 m (95% confidence (r ⫽.52), and soleus muscle (r ⫽.62).77
interval of ⫺21.9 to 17.9 m). The validity of measure-
ments obtained with the test, which was established by Strength and weaknesses. The BCT is designed to inte-
comparing the distance completed during the MSWT grate endurance, muscle force, and balance capability
with the distance completed during the 6-Minute Walk and is based on an everyday activity. This test, in our
Test (6-MWT), was moderate (rho⫽.68).74 The HRs, view, is easy to administer and can be used in research
however, were higher on the MSWT, indicating a greater and clinical settings. However, it may be difficult to
cardiovascular response. A strong relationship (r ⫽.81 replicate the test with 4 steps. A platform or landing
and r ⫽.88) was observed on comparing the V̇o2max should be at the top of the stairs to allow the individual
recorded in 2 tests using treadmill walking with the to turn around safely.
V̇o2max recorded during the MSWT.75
The guidelines for administering this test are not well
Strengths and weaknesses. The MSWT requires little described in the literature. There are no specifications
equipment and is easy to administer. The audio signal regarding the height of the steps, whether the individual
standardizes the increments in walking speed and moti- is allowed to use a handrail for support, or whether a
vates the individual. We believe that the initial speed is practice trial is required. In the absence of criteria for
sufficiently slow to be used with most types of patients. administering the test, this test could become a maximal
No individual in the studies attained the highest level test if the individual is not properly monitored during
(ie, level 12).74,75 This test can be used to prescribe an the test. We argue that this test has the potential to be a
appropriate walking speed for an exercise program by very useful submaximal exercise test if the individual is
evaluating the individual’s HR and RPE responses at the timed as opposed to being scored by only the weight he
various stages.74 or she carried. The number of circuits completed in a
specified time could be measured, or the time to com-
This test, however, requires a near-maximal effort by plete the circuit while carrying a specified weight and
having the speeds continue to increase. We believe, walking at a safe and comfortable pace could be scored.
therefore, that it is essential to monitor the individual
during the test to ensure that she or he is responding Timed Up & Go Test
appropriately. Familiarizing the individual with the pac-
ing required for the test may require some time. Description. The Timed Up & Go Test (TUGT)78 was
modified from the Get-up & Go Test.79 Both tests are
Bag and Carry Test based on a functional task of rising from a standard
armchair, walking 3 m, turning, and returning to the
Description. The Bag and Carry Test (BCT)77 is used to chair. Podsiadlo and Richardson,78 however, changed
assess a task that evaluates both endurance and muscle the scoring system from an observer rating of 1 to 5 to a
force. The BCT involves walking a circuit carrying a timed version. The test was modified using a sample of
0.9-kg package for 7.5 m, up and down a 4-step flight of 60 frail, community-dwelling, elderly individuals (23
stairs, and back 7.5 m. On the completion of each men and 37 women, aged 60 to 90 years) and 10
circuit, 0.9 kg is added to the package until the individ- volunteers with no health problems (6 men and 4
ual can no longer complete the circuit. It requires 10 women, aged 70 to 84 years). Medical diagnoses of the
study population included cerebrovascular accident

Physical Therapy . Volume 80 . Number 8 . August 2000 Noonan and Dean . 793
(n⫽23), Parkinson disease (n⫽10), rheumatoid arthritis used with individuals with end-stage lung disease,95 peo-
or osteoarthritis (n⫽9), and miscellaneous conditions ple with chronic heart failure,96,97 people with COPD,98 –100
(eg, postsurgical hip fractures, general deconditioning) children who are severely ill,101 people with chronic
(n⫽8).78 The TUGT has been used as a test of mobility renal failure,102 and older adults between the ages of 65
to assess change following an exercise program for and 89 years.103 Two practice tests appear to be required
elderly individuals aged 79 to 86 years80 and aged 75 to to obtain reproducible results,93,94 the walking circuit
96 years.81 No improvement in mobility based on this test needs to be identical,92 and encouragement needs to be
following an exercise programs was reported.80,81 The standardized.27 Walk tests with durations of 4 minutes104
details of the TUGT are given in the Appendix. and 2 minutes93 have also been reported. The details of
the 6-MWT and the 12-MWT are presented in the
Reliability and validity. The interrater reliability for Appendix.
times obtained on the same day and the intrarater
reliability tested 3 days to 5 weeks apart were good Reliability and validity. Reliability has been assessed for
(intraclass correlation coefficient⫽.99 for both).78 Valid- measurements obtained with the 12-MWT. Mungall and

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ity was assessed by correlating the time (in seconds) on Hainsworth89 reported a coefficient of variation of
the TUGT with the log-transformed scores on the Berg ⫾8.2% over 6 tests. This statistic, however, is not a
Balance Scale (r ⫽⫺.72), gait speed (r ⫽⫺.55), and probabilistic measure, which is normally used to assess
Barthel Index of Activities of Daily Living (r ⫽⫺.51). The reliability. If the results of the first 2 tests were elimi-
correlations were negative, indicating that those individ- nated, however, the coefficient of variation was reduced
uals who took longer with the TUGT had lower scores on to ⫾4.2%. Guyatt et al94 also reported that 2 practice
the Berg Balance Scale, with gait speed, and on the tests are required. Other researchers95,96 have reported
Barthel Index. intraclass correlation coefficients of .96 to .99 between
the second and third administrations of the 6-MWT,
Strengths and weaknesses. The TUGT is easy to admin- suggesting that only one practice test is required.
ister, and no training is required. This test is easy to
perform in research and clinical settings. The results The concurrent validity of measurements obtained with
from this test provide information related to mobility. the 6-MWT and the 12-MWT based on measurements of
Based on the time taken to complete the test, the level of V̇o2max or V̇o2peak is not clear. Some investigators have
assistance required in mobility tasks can be reported a correlation between the distance covered in
determined.78 the 6-MWT and V̇o2peak (r ⫽.6496 and r ⫽.70101) as well
as between the distance covered in the 12-MWT and
A limitation of this test is that it may not detect a change V̇o2max (r ⫽.4985 and r ⫽.5282). Other researchers have
following an exercise program because of the lack of reported no correlation between V̇o2max and either the
sensitivity of the measure.81 Further studies are war- distance covered in the 6-MWT94 or the distance covered
ranted to examine its sensitivity, using a larger sample, in the 12-MWT.82 The physiologic demand of the walk
and to investigate its predictive capacity. Sensitivity could test appears to be distinct from that of cycle ergometer
possibly be improved by increasing the distance walked tests and, therefore, may be a better indicator of func-
or having subjects sit down and get up again at each end tion in normal daily activities.102,105 The correlation
of the 3-m walkway, but research is needed to determine between lung function and the distance covered in the
whether this is true. 6-MWT and the 12-MWT has also shown conflicting
results.85,99,100
12- and 6-Minute Walk Tests
Strengths and weaknesses. The 6-MWT and the
Description. The 12-MWT was introduced by McGavin 12-MWT are simple tests that are inexpensive to admin-
and colleagues82,83 to assess the distance covered in 12 ister. Walking for a given time seems, in our opinion, to
minutes in individuals with chronic bronchitis. The total correspond to functional activities used in daily activities.
distance covered in 12 minutes is recorded, and the These tests, therefore, can be administered to individu-
individual is allowed to stop and rest. This test was als without health problems and to patients with a variety
modified from the 12-MRT described by Cooper53 for of diagnoses. The use of a standard time rather than a
individuals without health problems. The 12-MWT has predetermined distance provides a better test of endur-
been used primarily for people with COPD,82–91 but it ance.82 The tests allow the individual to set her or his
has also been used with college-aged students.92 own pace and stop if necessary. The 12-MWT can be
used to detect a change following an exercise program.86
Butland et al93 reported that similar results could be
obtained in 6 minutes. Guyatt et al94 applied the 6-MWT In the literature in which these tests are described, the
in individuals with heart failure. The 6-MWT has been number of practice trials varies. Often only one practice

794 . Noonan and Dean Physical Therapy . Volume 80 . Number 8 . August 2000
 ўўўўўўўўўўўўўўўўўўўўўўўўўўў
test was given,99 –102 and there was considerable variation Chronologic age is not thought to be a primary factor in
in the rest periods between tests. Some investiga- determining gait speed.113
tors95,96,100,102 reported having the subjects perform the
test on the same day as the practice, whereas other Researchers have assessed a maximum walking speed for
investigators94,99,105 reported having the test and practice a given distance (eg, 30 m). In a sample of 70-year-old
on separate days. In addition, different versions of the subjects (n⫽602), the maximum walking speed was the
instructions have been used for both the 6-MWT and the most reliable predictor of dependence in activities of
12-MWT. Some investigators101 stated in their instruc- daily living.112 The critical levels for the threshold of
tions that the individual was allowed to stop if necessary, being dependent in activities of daily living was found to
whereas other investigators85 instructed the individual to be a maximum walking speed of 1.7 m䡠s⫺1 in men and
pace herself or himself so that she or he would not have 1.5 m䡠s⫺1 in women. It is not entirely clear whether a
to stop. The scoring of the test has also varied. Most decline in cardiopulmonary fitness affects walking
investigators83,94,105 used the final distance (ie, that of speeds for short distances; it is more likely to be a
the last test trial), whereas some investigators99 reported contributing rather than a primary factor.112

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the longest distance of all test trials. We believe that
other limitations of the timed walk tests include lack of Other performance tests cited in the literature include a
monitoring of physiological variables while the individ- step test. This test requires 3 boxes combined to form
ual is completing the test and the lack of specific steps of 10, 20, 30, 40, and 50 cm in height and a
performance criteria to ensure that a maximal effort is handrail on the wall.112 The highest possible step height
not performed. that the individual is able to climb up and down with
either leg and without a rail is recorded. There are also
Other Performance Tests variations of this step test.115,116 Correlations have been
Performance tests are frequently incorporated as a mea- reported between the maximum step height up and
sure of mobility in global physical assessments used for down with a comfortable walking speed in 70-year-old
elderly people. The most common performance test is a men (r ⫽.39) and women (r ⫽.37).112
measure of walking speed, which is similar to the 3
An obstacle course described by Imms and Edholm113 is
walking speeds (ie, slow, normal, and fast) used with the
used in a test that is similar to the BCT. In this test, the
SPWT. Typically, a 10-ft walk106 –108 is used for assessing
individual rises from a chair, walks across the room,
individuals who are confined indoors and a 50-ft
climbs 3 stairs (rails on either side), turns around,
walk107,109 –111 is used for all others. A 30-m walk has also
descends the stairs, and returns to the chair. The indi-
been used, as this is the usual distance for pedestrian
vidual is allowed to go at her or his own speed and to use
crossings.112 The instructions are for the individual to
a mobility aid. Two practice trials are given, and the time
walk from a standing start at his or her regular pace and
(in seconds) taken to complete the course is recorded.
to use any mobility devices that he or she normally uses.106
In a sample of 71 subjects (28 men and 43 women) aged
The individual is timed, and the walking speed (in meters
60 to 99 years, the time to complete the course was not
per second or feet per second) is calculated. Reports of
correlated with age but was correlated with walking
average walking speed range from 0.74⫾0.29 m䡠s⫺1 for
speed (r ⫽⫺.80).113
individuals aged 60 to 99 years113 to 1.1 and 1.2 m䡠s⫺1 for
70-year-old women and men with no health problems,
Examples of Test Selection
respectively.112
1. The patient is a 65-year-old man with severe chronic
The assessment of walking speed is very important for airflow limitation and right atrial enlargement. He has
assessing independent mobility in the community. no history of angina but does have hypertension, which
Pedestrian intersection crossing times are calculated is controlled with medication. He is 18.1 kg (40 lb)
based on a walking speed of 1.22 m䡠s⫺1.114 A walking overweight and is unaccustomed to physical activity. His
speed of 11.5 m䡠min⫺1 is a threshold value for predicting activity is normally terminated by shortness of breath.
nursing home status,107 with a normal walking speed
being 70 m䡠min⫺1.107 Two factors, quadriceps femoris Indications: to establish an exercise profile to ensure that
muscle weakness and joint impairment, are thought to he is safe to undertake an exercise program and to
be critical variables in determining walking speed, define the parameters for such a program.
which, in turn, determines some aspect of dependency
in elderly people. Variations in walking speed are due to Test: 6-MWT or SPWT.
a change in stride length rather than an alteration in
Clinical Decision-Making Process: The 6-MWT and the
frequency or cadence.113 The onset of pathology short-
SPWT are both suited for older patients with chronic
ens the stride length and influences speed of walking.113
lung disease. This patient is deconditioned, overweight,
and hypertensive. These tests enable him to perform an

Physical Therapy . Volume 80 . Number 8 . August 2000 Noonan and Dean . 795
activity (ie, walking) that is useful to him on a daily basis. We believe that there is a need for standardized submaxi-
In addition, with portable equipment, including HR mal ergometer tests for people with musculoskeletal
monitor, BP measurement apparatus, and pulse oxime- limitations, people who have impaired balance, people
ter, he can be readily monitored. Furthermore, the scale who are overweight, people who are unable to walk on a
of breathlessness can be used to assess his symptoms. treadmill for other reasons, and for people who require
The physical therapist can correlate the rating of breath- close monitoring during exercise. There is also, in our
lessness and physiologic parameters to prescribe the opinion, a need for the development of upper-extremity
parameters of an exercise program, including type of submaximal exercise tests for people with lower-
exercise, intensity, frequency, duration, continuous ver- extremity paresis or severe deformity.
sus discontinuous program, and its course. These tests
can be repeated at various intervals to evaluate the We contend that stringent monitoring of exercise
outcome of the training program. responses is essential both for test validity and for safety.
When testing people with a wide range of conditions,
2. The patient is a 52-year-old man who had bypass including cardiovascular and cardiopulmonary condi-

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surgery 10 years ago. He had one recurrence of angina. tions that can be life threatening, even people without
He has intermittent claudication in the left calf at a known health problems can exhibit unexpected
moderate walking speed. responses. People without known health problems, for
example, can have cardiac dysrhythmias; and this inci-
Indications: to establish safe exercise intensity (no angi- dence increases with advancing age.20 Safety and mini-
nal symptoms) and a training program for his peripheral mizing undue strain, in our view, are essential in plan-
vascular disease as well as heart disease. ning and implementing submaximal exercise testing.

Test: Modified Bruce Treadmill Test, SPWT, or 6-MWT. Research is also needed for the development and re-
finement of scales used to assess exercise response
Clinical Decision-Making Process: This patient is showing (eg, exertion, breathlessness, fatigue, discomfort or
signs and symptoms of reocclusion of his coronary pain, and even well being associated with physical activ-
arteries and stenosis of a lower-extremity artery, which ity). Given that people are limited by their symptoms
results in claudication. He could be a candidate for that correlate to physiologic measures, assessment of
maximal exercise testing; however, if he stops because of their symptoms can provide critical information about
leg pain, the test results will be limited. Alternatively, he their exercise responses as well as a basis for setting the
could undergo submaximal exercise testing (eg, Modi- intensity of tolerable physical activity or an exercise
fied Bruce Treadmill Test, SPWT, 6-MWT). Because of program.
his cardiac history, precautions must be taken. Having a
cardiologist present is recommended, and the treadmill References
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103 Harada ND, Chiu V, Stewart AL. Mobility-related function in older aged 75 and older. J Am Geriatr Soc. 1995;43:1081–1087.
adults: assessment with a 6-minute walk test. Arch Phys Med Rehabil.
116 Winograd CH, Lemsky CM, Nevitt MC, et al. Development of a
1999;80:837– 841.
physical performance and mobility examination. J Am Geriatr Soc.
104 Flavell HA, Carrafa GP, Thomas CH, Disler PB. Managing low back 1994;42:743–749.
pain: impact of an interdisciplinary team approach. Med J Aust.
1966;165:253–255.
105 Guyatt GH, Thompson PJ, Berman LB, et al. How should we
measure lung function in patients with chronic heart and lung disease?
J Chronic Dis. 1985;38:517–524.

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 Appendix.
Predictive and Performance Submaximal Exercise Testsa

Predictive Submaximal Exercise Tests

Set-up and
Test Supplies Practice Protocol Outcome Regression Equations Population Studied

Modified Bruce Clinic/laboratory Familiarize the ● The individual uses 1 to 2 A predicted V̇O2max 1. Bruce and colleagues5,30; ● Men and women in good

800 . Noonan and Dean

Treadmill individual with fingers for handrail support value (mL䡠kg⫺1䡠min⫺1) Ward et al18 health
Test5,29,30 ● Motor-driven treadmill ● Follow the Modified Bruce is obtained using the (a) Active men, estimated ● Patients with cardiac disease
treadmill walking Treadmill Test protocol appropriate regression V̇O2max (mL䡠kg⫺1䡠min⫺1)⫽ ● Endurance athletes
● HR monitor (Tab. 1) and the individual equation 3.778⫻time (min)⫹0.19 ● Sedentary individuals (see
● Stopwatch continues until he or she (b) Sedentary men, estimated Bruce et al5)
● Electrocardiogram develops predetermined V̇O2max⫽3.298⫻time (min)
(optional) signs or symptoms30 ⫹4.07
● Reduce the grade to 0%, (c) Patients with cardiac disease,
reduce speed, and continue estimated V̇O2max⫽2.327⫻
walking slowly to cool down time (min)⫹9.48
(d) Adults in good health,
estimated V̇O2max⫽
6.70⫺2.82⫻sex (1⫽men
and 2⫽women)⫹0.056⫻
time (s)

2. Foster et al30
V̇O2max (mL䡠kg⫺1䡠min⫺1)⫽
14.76⫺1.38⫻time (min)
⫹0.451⫻time (min)2
⫺0.012⫻time (min)3
Single-Stage Clinic/laboratory Familiarize the ● Establish a safe, but A predicted V̇O2max Estimated V̇O2max ● Men and women in good
Submaximal individual with comfortable, walking speed value (mL䡠kg⫺1䡠min⫺1) (mL䡠kg⫺1䡠min⫺1)⫽ health aged 20 –59 y
Treadmill ● Motor-driven treadmill between 2.0 and 4.5 mph, is obtained using the 15.1⫹21.8⫻speed (mph)
Walking Test treadmill walking at a 0% grade for 4 min; an regression equation ⫺0.327⫻HR (bpm)
(SSTWT)12 ● HR monitor HR between 50% and 70% ⫺0.263⫻speed⫻age (y)
● Stopwatch of age-predicted HRmax ⫹0.00504⫻HR⫻age⫹5.98
● Rating of should be obtained ⫻sex (0⫽women, 1⫽men)
perceived exertion ● Increase the grade to 5%
(RPE) scale and walk at the established
speed for 4 min
● Record the HR and RPE at
the end of the warm-up
session and the first stage
● Reduce the grade to 0%
and continue walking slowly
to cool down

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 Astrand and Clinic/laboratory Familiarize the ● Adjust the seat height The mean value for the ● Men and women in good
Ryhming (A-R) individual with ● Select a workload of 450 HRs of the last 2 min health aged 18 –30 y31
Cycle ● Mechanically or pedaling on a kg䡠m䡠min⫺1 (75 W), 600 and the final workload ● Men in good health aged
Ergometer electrically braked cycle kg䡠m䡠min⫺1 (100 W), or (kg䡠m䡠min⫺1) are 19.9⫾2.39 y; modified
⫺1
Test31,32 cycle ergometer ergometer 900 kg䡠m䡠min (150 W), required for the protocol41
● HR monitor depending on level of nomogram (Fig. 1); ● Men in good health aged
● Stopwatch training and sex; a suitable multiply the derived 19.7⫾2.2 y42
● Metronome workload is 450 or 600 V̇O2max value ● Pregnant women aged
kg䡠m䡠min⫺1 for women and (L䡠min⫺1) by the age- 30.9⫾0.7 y (SE) at time of
600 or 900 kg䡠m䡠min⫺1 for correction factor delivery40
men; for an older individual (Tab. 2) ● Men in good health aged
or an untrained individual, 18 –24 y (conditioned and
a workload of 300 sedentary)39
kg䡠m䡠min⫺1 may be ● Men in good health aged
appropriate 17–33 y38
● The pedal speed is set at 50 ● Men in good health aged
rpm, and the first workload 47.7⫾7.3 y37
is maintained for 6 min; ● Men and women in good

Physical Therapy . Volume 80 . Number 8 . August 2000

measurements of HR are health 20 –70 y35
taken for the last 15 to 20 s ● Men in good health
of every minute 23– 49 y36
● If the individual has an HR ● Men in good health (trained
between 130 and 170 bpm and untrained) aged
and the difference between 20 –29 y33
the HR values of minutes 5
and 6 is less than 5 bpm,
the test is finished
● If the difference between the
HR values of minutes 5 and
6 is greater than 5 bpm, the
individual continues pedaling
for 1 min or longer; if the
individual’s HR is less than
130 bpm, the workload is
increased by 300 to 600
kg䡠m䡠min⫺1 and is
maintained for another 6
min; the test is continued
until the HR values for
minutes 5 and 6 are within
5 bpm
● On completion of the test,
the individual should
continue to pedal with no
resistance to cool down ўўўўўўўўўўўўўўўўўўўўўўўўўўў

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 Appendix.
Continued

Predictive Submaximal Exercise tests

Set-up and
Test Supplies Practice Protocol Outcome Regression Equations Population Studied

Canadian Aerobic At home or clinic/ Demonstrate the ● CAFT44,52 Consult the “Physical 1. CAFT (Jette et al45) ● Men and women in good

802 . Noonan and Dean

Fitness Test laboratory stepping cycle ● Measures of resting BP and HR Fitness Evaluation estimated V̇O2max health aged 15– 69 y44,45
(CAFT)44,45,52 and allow the are optional Chart” (see Tab. 5) to (mL䡠kg⫺1䡠min⫺1)⫽ ● Men and women in good
and modified ● A double 8-in individual to ● Following a warning signal on determine level of 42.5⫹16.6⫻V̇O2 health aged 15–74 y,
CAFT (20.3-cm) step practice an audiotape, the individual is fitness based on the (L䡠min⫺1)*⫺0.12⫻body modified protocol47
(mCAFT)46,47,51 ● HR monitor instructed to climb a double final exercise HR weight (kg)⫺0.12⫻HR ● Men and women in good
● Prerecorded 8-in step for a 3-min “warm- reading52; a following last stage health aged 15– 69 y46,47
audiotape up” at a stepping tempo based predicted V̇O2max (bpm)⫺0.24⫻age (y) ● Men and women in good
● Cassette recorder on his or her age (see value (mL䡠kg⫺1䡠min⫺1) health aged 15– 69 y51
● Sphygmomanometer Tab. 3)52; the Standardized Test is obtained using the *V̇O2 is the average oxygen
● Stethoscope of Fitness package52 contains regression equation cost of the last completed
● Stopwatch the cassettes with the various stage (L䡠min⫺1); obtain value
tempos; following the first stage, from the table “Energy
the instructions on the cassette Requirements for the Various
indicate when to obtain a 10-s Stages of the CAFT”45
measurement of HR
● Consult the table “Ceiling 2. mCAFT (Weller et al51)
Postexercise Heart Rates” (see estimated V̇O2max
Tab. 4)52 to determine whether (mL䡠kg⫺1䡠min⫺1)⫽
the individual continues for a 32.0⫹16.0⫻V̇O2 for final
second stage or whether the test stage (L䡠min⫺1)⫺0.17⫻body
is terminated weight (kg)⫺0.24⫻age (y)
● If the individual has an HR
below the ceiling HR indicated
in the table, he or she proceeds
to the second stage; HR is
measured again following the
second stage to determine
whether he or she proceeds to
the third and final stage; a
measure of HR is taken for 10 s
following the third stage
● In the postexercise period,
measurements of BP can be
taken in the first 2 min and
measurements of resting HR can
be taken in the third minute
● Following the test, the individual
should continue stepping or
walking slowly to cool down
● For the protocol of the CAFT,
see Weller and colleagues46,47

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 12-Minute Run Measured track Familiarize the ● The individual is instructed A predicted V̇O2max value 1. Cooper53 walk/run ● Men in good health aged
Test (12-MRT)53 individual with to “cover the longest (mL䡠kg⫺1䡠min⫺1) is distance⫽0.3138⫹0.0278 17–52 y53
● Stopwatch the track and possible distance in 12 min, obtained using the ⫻V̇O2 (mL䡠kg⫺1䡠min⫺1) ● Men in good health aged
● Tape measure the concept of running preferably but regression equations 18 –2355
pacing walking whenever necessary 2. Ward et al18 estimated
to prevent becoming V̇O2max (mL䡠kg⫺1䡠min⫺1)⫽
excessively exhausted” 53 35.97⫻distance (mile)
● Record the distance in miles ⫺11.29
completed in 12 min
● On completion of the test,
the individual should
continue walking to cool
down
20-Meter Shuttle Measured corridor Familiarize the ● The individual runs between A predicted V̇O2max value 1. General equation (Leger ● Men and women in good
Test individual with 2 lines 20 m apart; when (mL䡠kg⫺1䡠min⫺1) is et al58) estimated V̇O2max health aged 20 – 45 y58
(20-MST)57–59 ● HR monitor the course the individual hears a short obtained using the (mL䡠kg⫺1䡠min⫺1)⫽31.025 ● Boys and girls in good health
● Prerecorded sound, he or she has to be regression equations ⫹3.238⫻speed (km䡠h⫺1) aged 6 –19 y58,62
audiotape on 1 of these 2 lines, and ⫺3.248⫻age (y) ● Boys and girls in good health

Physical Therapy . Volume 80 . Number 8 . August 2000

● Cassette recorder when a long sound is heard, ⫹0.1536⫻(age⫻speed) aged 8 –19 y58
● Pylons it indicates a change in ● Active men in good health
● Tape measure stage 2. Adults (Leger et al58) aged 18 – 42 y (modified
● The first stage is 8.5 km䡠h⫺1 estimated V̇O2max protocol)60
for women and 10 km䡠h⫺1 (mL䡠kg⫺1䡠min⫺1)⫽ ● Men and women with asthma
for men; the speed is ⫺24.4⫹6.0⫻speed (km䡠h⫺1) aged 12–17 y63
increased by 0.5 km䡠h⫺1
per 1-min stages (see Fig. 2)
● The individual continues until
she or he is unable to
maintain the rhythm of
running
● The speed at the last
completed running stage is
termed the “maximal
aerobic speed” (MAS)
● On completion of the test,
the individual should
continue walking to cool
down

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 Appendix.
Continued

Predictive Submaximal Exercise tests

Set-up and
Test Supplies Practice Protocol Outcome Regression Equations Population Studied

1-Mile Track Measured track ● A minimum of ● The individual is instructed “to The HR at the end of the Kline et al64 estimated V̇O2max ● Men and women in good

804 . Noonan and Dean

Walk Test 2 tests are walk as fast as possible fourth quarter of the (L䡠min⫺1)⫽6.9652⫹0.0091 health aged 30 – 69 y64
(Rockport ● Stopwatch required; the around the course”64 test is used for the ⫻body weight (lb) ● Men and women with
Fitness Test) ● HR monitor times of both ● Record HR at the end of every regression equation; ⫺0.0257⫻age (y) mental retardation aged
(1-MTW)64 ● Tape measure tests should be quarter mile a predicted V̇O2max ⫹0.5955⫻sex (men⫽1, 26 – 40 y65
within 30 s of ● Record the time to complete value (L䡠min⫺1) is women⫽0)⫺0.2240⫻T1
each other; the test (in minutes) obtained using the (track walk time)
otherwise, ● On completion of the test, the regression equation ⫺0.0115⫻HR1– 4 (fourth
subsequent individual should continue quarter HR for track walk)
tests are walking to cool down
performed until
this is achieved

Performance Submaximal Exercise Tests

Set-up and
Test Supplies Practice Protocol Outcome Population Studied

Self-Paced Measured corridor Familiarize the ● The individual is instructed to walk a For each walking trial, the speed, time to ● Men in good health aged
Walking Test individual measured distance (ie, 250 m) at 3 complete the distance, and stride 64 – 66 y
(SPWT)70 ● HR monitor with the different speeds, with a 5-min rest frequency are calculated; in addition, ● Active men in good health
● Stopwatch course between trials: (a) rather slowly average HR, stride length, and a aged 19 –21 y70
● Tape measure (ie, slow pace), (b) at a normal predicted V̇O2max value can be ● Men in good health
● Pylons pace, neither fast nor slow, and (c) determined aged 19 – 66 y71,72
rather fast, but without overexerting
yourself (ie, fast pace)
● Record the time in seconds for each
of the 3 trials
● Following the 3 trials, the individual
should continue walking slowly to
cool down

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 Modified Shuttle Measured corridor One practice ● The test starts with a triple beep; Total number of shuttles at each level; ● Men and women with chronic
Walking Test 10 m in length trial is after that, a single beep indicates report total distance (in meters) airway obstruction aged
(MSWT)74,75 with 2 pylons required when the individual should be 45–74 y74,75
placed 0.5 m walking around the cone; a triple ● Men and women with
from each end beep also signifies a change in pacemakers aged 27–74 y76
stage
● HR monitor ● The individual is instructed: “Walk
● Prerecorded at a steady pace, aiming to turn
audiotape around when you hear the signal,
● Cassette you should continue to walk until
recorder you feel that you are unable to
● Pylons maintain the required speed without
● Tape measure becoming unduly breathless”74
● RPE scale ● The MSWT starts at 0.50 m䡠s⫺1
(1.12 mph) for level 1; each level
lasts 1 min, and the speed is
increased by 0.17 m䡠s⫺1 for 12
min; the final speed is 2.37 m䡠s⫺1
(see Tab. 6)
● The individual continues until: (a) he

Physical Therapy . Volume 80 . Number 8 . August 2000

or she is too breathless to maintain
the required speed, (b) he or she is
more than 0.5 m away from the
cone when the beep is sounded, or
(c) attainment of 85% of age-
predicted HRmax
● The total number of completed
shuttles (10-m lengths) at each level
is recorded (in meters)
● On completion of the test, the
individual should continue walking
slowly to cool down

Bag and Carry Measured course ● The individual is instructed to walk The heaviest weight (in kilograms) ● Women aged 48 –93 y
Test (BCT)77 7.5 m in length, the circuit carrying a package carried by the individual
in addition to a weighing 0.9 kg, with both arms,
4-step flight of 7.5 m, up and down a 4-step flight
stairs of stairs, and back 7.5 m
● On completion of each circuit, 0.9
● HR monitor kg of weight is added to the
● Package to package, the individual continues
carry weights until he or she is no longer able to
● Weights of 0.9 complete the circuit carrying the
kg each package, record the heaviest weight
● Stopwatch the individual carried
● Tape measure

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 Appendix.
Continued

Performance Submaximal Exercise Tests

Set-up and
Test Supplies Practice Protocol Outcome Population Studied

Time Up & Go Clinic/corridor One practice ● The individual starts with his or her Report the time (in seconds) ● Older inpatients and

806 . Noonan and Dean

Test (TUGT)78 that has at least trial is back against the chair, arms resting outpatients; male and female
a 3-m floor required on the armrests, and mobility aid in geriatric patients aged
space hand, if needed; no physical 52–74 y79
assistance is given ● Elderly men and women in
● Armchair (seat ● Instructions are “On the word ‘Go,’ good health aged 70 – 84 y
height of 46 cm) you are to get up and walk at a ● Men and women, aged
● Stopwatch comfortable and safe pace to a line 60 –90 y, with Parkinson
● Tape on the floor 3 meters away, turn, syndrome, stroke, rheumatoid
● Tape measure return to the chair, and sit down arthritis and osteoarthritis,
again”74; record the time (in postsurgical hip fractures,
seconds) general deconditioning78
● Elderly men and women with
limited mobility aged 75–96 y81
12-Minute Walk Measured Two practice ● The individual walks a measured Report the total distance covered (in ● 12-MWT; men with chronic
Test corridor, trials are distance (eg, 33 m) meters) bronchitis aged 40 –70 y82
(12-MWT)82,83 approximately required ● For the 12-MWT, the individual is ● 12-MWT; men and women
33 m in length instructed “to cover as much ground with chronic bronchitis aged
6-Minute Walk as possible on foot in 12 minutes 22–75 y83
Test ● HR monitor and to keep going continuously if ● 6-MWT; patients with chronic
(6-MWT)27,94 ● Stopwatch possible but not to be concerned if heart failure (respiratory and
● Tape measure you have to slow down or rest”82,83; cardiac conditions) aged
at the end of the test, subjects 64.7⫾8.3 y27,94
should feel they could not have ● 6-MWT; men and women with
covered more ground in the time COPD aged 40 – 84 y92
● For the 6-MWT, the individual is ● 12-MWT, modified protocol;
instructed “to walk from end to end, men with COPD aged 67⫾4 y85
covering as much ground as ● 12-MWT; men and women with
possible in 6 minutes”94; at the end COPD aged 31–75 y87
of the 6 or 12 min, the individual is ● 12-MWT; men and women with
instructed to stop; the total distance COPD aged 68.4⫾9.6 y88
is recorded ● 6-MWT; men and women with
● If encouragement is given, COPD aged 48 – 85 y98
predetermined phrases should be ● 4-MWT; men and women with
delivered every 30 s while facing low back pain (no age range
the individual reported)104
● On completion of the test, the ● 12-MWT; men with chronic
individual should continue walking respiratory disability aged
to cool down 61.2⫾5.0 y86
● 6-MWT; men and women with
advanced heart failure aged
49⫾8 y96

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 ● 6-MWT; men and women with
chronic renal failure aged
22– 67 y102
● 6-MWT; men and women with
end-stage lung disease aged
43.5⫾11 y95
● 6-MWT; men and women with
chronic lung disease and
asthma aged 57.4⫾12.9 y
and 62.3⫾9.1 y100
● 6-MWT; boys and girls with
cystic fibrosis, pulmonary
hypertension, and obstructive
lung disease aged 9 –19 y101
● 12-MWT; men and women
with chronic airway obstruction
aged 38 –75 y84
● 12-MWT; men and women
with chronic obstructive lung
disease aged 49 –73 y90

Physical Therapy . Volume 80 . Number 8 . August 2000

● 6-MWT; men and women with
COPD aged 58⫾10 y99
● 6-MWT; elderly people and
men and women with chronic
heart failure aged 70 –90 y97
● 12-MWT; men with chronic
obstructive airway disease
aged 47– 64 y89
a
HR⫽heart rate, V̇o2max⫽maximum oxygen consumption, HRmax⫽maximal heart rate, COPD⫽chronic obstructive pulmonary disease, BP⫽blood pressure, V̇o2⫽oxygen consumption.

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