Exercise Evaluations in the Physical Therapy Clinic

The Submaximal Clinical Exercise Tolerance Test (SXTT)

to Establish Safe Exercise Prescription Parameters
for Patients with Chronic Disease and Disability
Eduard Gappmaier, PT, PhD

University of Utah, Department of Physical Therapy, Salt Lake City, UT

ABSTRACT Guidelines for Americans, published by the United States

Purpose: To describe how to perform a Submaximal Clini- Department of Health and Human Services, adults should
cal Exercise Tolerance Test (SXTT) as part of an exercise perform at least 150 minutes a week of moderate-intensity,
evaluation in the physical therapy clinic to determine an or 75 minutes a week of vigorous-intensity aerobic physi-
appropriate exercise prescription and to establish safety cal activity, or an equivalent combination of moderate- and
of exercise for physical therapy clients. Summary of Key vigorous-intensity aerobic activity.1,2(p vii) Moderate-intensity
Points: Physical activity is crucial for general health main- aerobic physical activity has been defined as 40% to 59%
tenance. An exercise evaluation includes a comprehensive of aerobic capacity reserve and vigorous-intensity activity
patient history, physical examination, exercise testing, and as 60% to 84% of reserve.2(p55) Healthy, asymptomatic, pre-
exercise prescription. The SXTT provides important clini- viously inactive adults may begin moderate-intensity activi-
cal data that form the foundation for an effective and safe ty safely without the need to consult a health care provider.
exercise prescription. Observations obtained during the However, individuals with symptoms, chronic conditions,
exercise evaluation will identify at-risk patients who should or disabilities are advised to begin an exercise program af-
undergo further medical evaluation before starting an exer- ter appropriate medical evaluation and with guidance of a
cise program. Two case examples of SXTTs administered to health care provider.1,2,3(pp viii,36,39,43,44)
individuals with multiple sclerosis are presented to demon- The American Physical Therapy Association (APTA) en-
strate the application of these principles. Statement of Rec- thusiastically endorses the national effort to increase physi-
ommendations: Due to their unique qualifications, physical cal activity in all sedentary persons.4 Due to their extensive
therapists shall assume responsibility to design and monitor clinical background, their expertise in exercise physiology
safe and effective physical activity programs for all clients and the movement sciences and the physical therapy pa-
and especially for individuals with chronic disease and dis- tient management model with a focus on client-centered
ability. To ensure safety and efficacy of prescribed exercise care, the physical therapist is uniquely positioned to assist
interventions, physical therapists need to perform an appro- people of all ages and abilities to design and monitor safe
priate exercise evaluation including exercise testing before and effective physical activity programs that help establish
starting their clients on an exercise program. life-long habits of physical activity.5,6
Since persons with symptoms, chronic conditions, or
Key Words: exercise evaluation, clinical exercise testing, disabilities may have limited exercise tolerance and are at
exercise prescription increased risk for adverse events associated with physical
activity, they require a clinical exercise evaluation to screen
INTRODUCTION AND PURPOSE for potentially dangerous signs or symptoms of exercise in-
The health benefits of regular physical activity have tolerance and to establish safe and appropriate parameters
been widely publicized. On the other hand, many clini- for their exercise prescription.
cal observations indicate that negative physical effects oc- A maximal exercise test or clinical “stress test” is con-
cur with inactivity. According to the 2008 Physical Activity sidered the gold standard to determine maximal exercise
capacity as a baseline for exercise prescription and to re-
veal potential signs and symptoms suggesting myocardial
Address correspondence to: Eduard Gappmaier, PT, ischemia due to coronary artery disease or other abnormal
PhD, Department of Physical Therapy, University of physiological responses to exercise. These tests however
Utah, 520 Wakara Way, Salt Lake City, UT 84108 (ed. require advanced expertise and equipment. They are asso-
gappmaier@hsc.utah.edu). ciated with a higher risk for complications due to exercise
to the point of volitional exhaustion or occurrence of signs

Vol 23 v No 2 v June 2012 Cardiopulmonary Physical Therapy Journal 19

or symptoms of cardiovascular compromise and thus may
require medical supervision.
Standard submaximal exercise tests as described in
ACSM’s Guidelines for Exercise Testing and Prescription and
summarized by Noonan et al7,8 to estimate maximal oxygen
uptake are based on several assumptions. One primary as-
sumption is that the maximal heart rate of the individual
undergoing the test is similar to a predicted maximal heart
rate based on a formula such as “220-age.” Such formulae
may be applied with caution to healthy individuals as long
as one is aware of the significant inter-individual variability
(SD=10-12 beats/min) of maximal heart rate.9,10 However,
many studies that measured maximal aerobic capacity of
persons with a variety of medical conditions such as car-
diovascular, metabolic, neurologic or neuromuscular dis-
ease found significantly lower maximal heart rates in these
patient populations.11-20 In addition, patients may be on Figure 1. Components of an Exercise Evaluation
medications that alter heart rate response to exercise.21,22
Another assumption underlying standard submaximal exer-
cise testing is that mechanical efficiency (oxygen consump- amination as well as a careful cardiovascular and pulmo-
tion at a given work rate) is the same for every person un- nary screening examination including assessment of resting
dergoing the test. However, many studies on persons with heart rate and pulse, blood pressure, peripheral vascular
chronic disease and disability, especially if neuromuscular status, auscultation of heart and lung sounds, pulse oxim-
symptoms are present, have found a significant difference etry, and ideally, in patients with increased cardiac risk, a
in oxygen cost for a given work rate as compared to healthy resting ECG. Special tests dependent on the client’s specif-
controls.23-25 Since these assumptions which underlie aer- ic diagnoses, impairments, and functional limitations may
obic capacity predictions based on standard submaximal include functional mobility testing, quantitative strength
exercise tests are frequently not met when testing persons assessment, body composition analysis, pulmonary func-
with clinical conditions, these tests are usually not appro- tion testing, health-related quality of life assessment, and
priate for these populations. The author therefore suggests disease specific assessments such as fatigue assessments for
that a “Submaximal Clinical Exercise Tolerance Test (SXTT)” patients with chronic fatigue syndrome, cancer, or multiple
is most appropriate in the standard physical therapy clinic sclerosis. While many of these tests may be optional, the
to provide baseline data and to determine safe and effective minimum information that must be obtained through the
exercise prescription parameters. The purpose of this paper patient history and physical examination before conducting
is to describe how an exercise evaluation including a SXTT the exercise test includes information to satisfy safety and
is performed and to discuss how the resulting data and ob- test protocol considerations. Based on the cardiac screen-
servations are used to determine an appropriate exercise ing and risk assessment and initial risk stratification follow-
prescription for clients seen in the physical therapy clinic. ing ACSM guidelines,8(p23) the physical therapist determines
if it is safe to proceed with an exercise test or if the patient
THE EXERCISE EVALUATION needs to be referred back to the referring physician for fur-
The objectives of an exercise evaluation include: first, to ther medical evaluation and medical exercise testing. Con-
establish safety for exercise participation, second, to collect traindications to exercise testing are summarized in Table
the necessary information to write an appropriate exercise 1. Based on the activity history, musculoskeletal exam, and
prescription and lastly, to collect baseline data for outcome cardiovascular and pulmonary screening the therapist de-
assessment. The components of an exercise evaluation are termines the optimal exercise test mode and the appropri-
summarized in Figure 1. It is recommended that clients ate test protocol. Finally, as should be standard practice
obtain a referral for an exercise evaluation and prescrip- today for any physical therapy intervention, an informed
tion from their physician. The physician may note valuable consent document is reviewed and discussed with the cli-
special precautions or considerations on the referral or may ent and signed before proceeding with the exercise test.
recommend prior medical evaluation and testing of high
risk patients. The pretest evaluation includes a comprehen- Test Protocol
sive patient history including a complete medical history, When performing exercise evaluations in the physical
medication list, screening for heart disease risk factors, signs therapy clinic, the clinician may face major challenges
and symptoms, and an activity history. This information is when considering the “optimal exercise protocol.” The cli-
best obtained through a comprehensive questionnaire that nician will encounter a dramatic range of maximal exercise
is completed by the patient before the appointment and capacities. We sometimes test patients with a peak exer-
then reviewed and clarified if necessary during the patient cise capacity of as low as 2 METs (ie, person with severe
interview. The physical therapy examination includes a cardiopulmonary disease who barely endures 2 minutes of
standard musculoskeletal and neurological screening ex- walking at 1.5 mph) and occasionally test physically ac-

20 Cardiopulmonary Physical Therapy Journal Vol 23 v No 2 v June 2012

Table 1. Contraindications to Exercise Testing mands. It should be obvious that no single “gold standard”
clinical exercise testing protocol (ie, Bruce Treadmill Proto-
col) will meet the demands of such a heterogeneous patient
Absolute
population. This environment requires a highly individual-
 A recent significant change in the resting ECG suggesting ized approach based on either a large menu of standard-
significant ischemia, recent myocardial infarction (within 2
days) or other acute cardiac event
ized facility protocols or a custom design method driven by
the pretest assessment of the individual client.
 Unstable angina
The first decision for the examiner to make is to choose
 Uncontrolled cardiac dysrhythmias causing symptoms or the most appropriate mode of exercise for the exercise test.
hemodynamic compromise While treadmills and cycle ergometers are most commonly
 Symptomatic sever aortic stenosis used for clinical exercise testing, these standard exercise
 Uncontrolled symptomatic heart failure devices are frequently not optimal for physical therapy cli-
ents if lower extremity impairments or balance problems
 Acute pulmonary embolus or pulmonary infarction
are limiting their lower extremity work capacity. For such
 Acute myocarditis or pericarditis individuals combined arm- and leg ergometry results in
 Suspected or known dissecting aneurysm higher peak work load, heart rate, and oxygen uptake val-
 Acute systemic infection, accompanied by fever, body ues.26,27 Due to testing and training specificity issues, it is
aches, or swollen lymph glands recommended that the client, if possible, is tested on an
exercise device that is consistent with the preferred and
Relative available mode of training for the subsequent exercise pro-
 Left main coronary stenosis gram. The main requirement for an exercise device used
 Moderate stenotic valvular heart disease for a progressive testing protocol is a reliable, repeatable,
stepwise workload adjustment, ideally with the option to
 Electrolyte abnormalities (eg, hyopkalemia, hypomagnesemia)
calibrate the power input to assure accuracy. Based on ex-
 Severe arterial hypertension (i.e. systolic BP of >200 mm perience and clinical judgment, the evaluator then defines
HG and/or a diastolic BP of >110 mmHg) at rest
an individualized work rate progression for the respective
 Tachydysrhythmia or bradydysrhythmia client that will achieve the desired end-point within an op-
 Hypertrophic cardiomyopathy and other forms or outflow timal exercise time of 8 to 12 minutes after a low intensity
tract obstruction warm-up or chooses an appropriate testing protocol from a
 Neuromuscular, musculoskeletal, or rheumatoid disorders series of previously defined facility protocols (see Table 2).
that are exacerbated by exercise When performing a treadmill test on previously inactive,
 High-degree atrioventricular block deconditioned clients, the author customizes the protocol
to the individual as follows: the testing protocol is started
 Ventricular aneurysm
with 2 minutes at a “slow” walking pace to allow accom-
 Uncontrolled metabolic disease (eg, diabetes, modation to the treadmill. The treadmill speed may range
thyrotoxicosis, or myxedema)
from 1.0 mph (in rare cases even slower) to 2.5 mph. Over
 Chronic infectious disease (eg, mononucleosis, hepatitis, the next few 2-minute stages the walking pace is advanced
AIDS)
 Mental or physical impairment leading to inability to
exercise adequately
Table 2. Generic Exercise Testing Protocols (Workload in
Reprinted, with permission from the American College of Sports Medicine. ACSM’s
Watts)
Guidelines for Exercise Testing and Prescription, 8th ed. Baltimore, MD: Lippincott
PROTOCOL I II III IV V
Williams & Wilkins; 2010:54.
min VERY LOW MEDIUM HIGH VERY
LOW HIGH
Workload 5 10 15 20 30
increments
tive chronic disease patients with mild disability who easily
per stage
achieve a peak intensity greater than 10 METs. Further-
more, the clinician encounters a great variability in car- 0-2 20 20 30 40 60
diovascular risk profiles. An otherwise healthy client with 2-4 25 30 45 60 90
chronic disease and disabilities may have no significant 4-6 30 40 60 80 120
cardiovascular risk factors while another client may have
6-8 35 50 75 100 150
serious signs and symptoms of cardiovascular, pulmonary,
or metabolic disease. In addition the clinician may work 8-10 40 60 90 120 180
with people with chronic disease and a wide range of mus- 10-12 45 70 105 140 210
culoskeletal or neuromuscular impairments. Conditions 12-14 50 80 120 160 240
such as degenerative joint disease, chronic low back pain,
14-16 55 90 135 180 270
or other musculoskeletal pain syndromes may “flare up”
when subjected to unaccustomed increased physical de- 16-18 60 100 150 200 300

Vol 23 v No 2 v June 2012 Cardiopulmonary Physical Therapy Journal 21

in 0.5 mph increments to a “brisk but comfortable” walk- automated units are not reliable during exercise, these
ing speed. During subsequent 2-minute stages, intensity is measurements are best obtained through manual ausculta-
increased by raising the treadmill grade in 2% increments tory methods.28
until criteria for test termination are achieved. This occurs At the end of each test stage, RPE is measured with a
in most cases within the recommended time period of 10 to standard Borg8,29,30 or Omni RPE scale31 and dyspnea rat-
20 minutes (including incorporated low-intensity warm-up) ings are obtained with a standardized dyspnea rating
with a well-tolerated, comfortable work load progression. scale32 (see Table 3). Before the test, patients are instructed
When testing on upright or reclined leg cycle ergometers to report any abnormal signs and symptoms they may ex-
or all-extremity ergometers (ie, Schwinn Airdyne™ cycle perience during the test. Throughout the test and the re-
ergometer, NuStep™ recumbent cross trainer) we select covery period, the patient is carefully observed for signs
one of 5 workload progressions based on the pretest assess- and symptoms of cardiovascular compromise such as sub-
ment of the client that usually results in an appropriate test sternal chest pain or other angina symptoms, lightheaded-
duration with a well-tolerated work load progression (see ness, pallor, nausea or sudden, unusual sweating or fatigue.
Table 2). Patients with chronic disease and disability also need to be
monitored for other clinical symptom changes such as ex-
Measurements acerbation of pain in persons with arthritis, symptom modi-
Measurements obtained during each stage of a SXTT fication due to increased core temperature in persons with
always include workload, heart rate, blood pressure, and multiple sclerosis, onset or increases in tremor in persons
ratings of perceived exertion (RPE) and dyspnea. In ad- with neurodegenerative disease, etc.
dition, the client is continuously monitored for abnormal
signs or symptoms. When indicated by the client’s history Table 3. 5-Grade Dyspnea Scale
and diagnoses, oxygen saturation and the electrocardio-
gram (ECG) may also be monitored. 0 no dyspnea
Peak workload obtained with a maximal exercise test 1 mild, noticeable
2 mild, some difficulty
(“stress test”) is the best indicator of fitness and physical 3 moderate difficulty, but can continue
work capacity. When evaluated in relationship to indica- 4 severe difficulty, cannot continue
tors of relative intensity and effort (heart rate, RPE, dys-
pnea), the peak workload obtained during a SXTT may be Reprinted, with permission from American Association of Cardiovascular and Pulmonary Re-
habilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 4th
used effectively to determine an appropriate intensity for ed. Champaign, IL: Human Kinetics; 2004:81.
the exercise prescription and may allow for an estimate of
physical work capacity (see discussion of test endpoints
and exercise prescription below).
Heart rate may be reliably monitored through palpation Test termination criteria
of a radial or carotid pulse or may be obtained through aus- One of the most challenging questions when adminis-
cultation, however, inexpensive telemetric heart rate moni- tering a SXTT is when to stop the test. The test is stopped
tors are very accurate and reliable as long as electric inter- without hesitation if any of the indications for (maximal or
ference is avoided and are much easier to use. Heart rate “symptom-limited”) exercise test termination as defined by
may also be obtained with an ECG. Increasingly affordable the ACSM guidelines are met (see Table 4 and 5). In addi-
ECG systems have the advantage of also monitoring heart tion, any exercise test intended to be classified as a “sub-
rhythm and allow for detection of abnormalities suggestive maximal” exercise test should be stopped when a heart
of myocardial dysfunction, both at rest and during exercise, rate of 85% of age-adjusted maximal heart rate (AAMHR)
which may warrant further medical evaluation. In his well- is achieved as per definition of “submaximal” by ACSM
ness practice, the author has been detecting such rhythm guidelines.8(pg79) However due to their clinical condition
abnormalities during exercise evaluations on average in 1-2 or due to the great inter-individual variation of maximal
clients (out of 50-60 exercise evaluations) each year. All heart rate, the testing subject may reach volitional exhaus-
of these clients have been referred with negative cardiac tion before achieving 85% of AAMHR. This predetermined
history and medical clearance for exercise evaluation and “submaximal exercise test endpoint” is thus, in many cases,
prescription by their physicians. Due to these abnormal not relevant. In most cases the SXTT will be terminated by
findings these patients subsequently have been referred decision of the tester based on predetermined test objec-
back to their referring physicians with the recommendation tives, the tester’s clinical observations and the tester’s clini-
for further cardiac evaluation. Physical therapists can be cal judgment of the individual’s risk of adverse events. In
at times intimidated by this technology, although essential order to determine an appropriate exercise intensity for the
ECG monitoring skills can easily be acquired through a ba- exercise prescription, the tester needs an estimate of the
sic ECG interpretation course offered by many medical fa- subject’s maximal physical work capacity. Based on an in-
cilities, publishers, or online education providers and some tegrated assessment of both physiological and subjective
practice in the clinic. indicators of subject effort (heart rate, dyspnea level, RPE
Blood pressure should be measured at rest in sitting and rating), the experienced tester can usually predict a reliable
in the exercise position followed by measurements during estimate of the subject’s maximal exercise capacity thus
each test stage and during recovery. Since most standard meeting one of the primary objectives of the test. This stage

22 Cardiopulmonary Physical Therapy Journal Vol 23 v No 2 v June 2012

Table 4. General Indications for Stopping an Exercise Test Table 5. Indications for Terminating Exercise Testing
in Low-Risk Adults
Absolute Indications
• Onset of angina or angina like symptoms • Drop in systolic blood pressure of >10 mm Hg from baseline
blood pressure despite an increase in workload when
• Drop in systolic BP of >10 mm HG from baseline BP despite
accompanied by other evidence of ischemia
an increase in workload
• Moderately severe angina (defined as 3 on standard scale)
• Excessive rise in BP: systolic pressure >250 mm Hg or diastolic
pressure >115 mm Hg • Increasing nervous system symptoms (eg, ataxia, dizziness,
or near syncope)
• Shortness of breath, wheezing, leg cramps, or claudication
• Signs of poor perfusion (cyanosis or pallor)
• Signs of poor perfusion: light-headedness, confusion, ataxia,
pallor, cyanosis, nausea, or cold and clammy skin • Technical difficulties monitoring the ECG or systolic blood
pressure
• Failure of heart rate to increase with increased exercise
intensity • Subject’s desire to stop
• Noticeable change in heart rhythm • Sustained ventricular tachycardia
• Subject requests to stop • ST elevation (+1.0 mm) in leads without diagnostic Q-waves
(other than V or a VR)
• Physical or verbal manifestations of severe fatigue
Relative Indications
• Failure of the testing equipment
Reprinted, with permission from the American College of Sports Medicine. ACSM’s • Drop in systolic blood pressure of >10 mm Hg from
Guidelines for Exercise Testing and Prescription. 8th ed. Baltimore, MD: Lippincott Wil-
liams & Wilkins; 2010:83.
baselinea blood pressure despite an increase in workload in
the absence of other evidence of ischemia.
• ST or QRS changes such as excessive ST depression (>2
mm horizontal or downsloping ST-segment depression) or
in the test will usually be 1-2 levels above the subsequently marked axis shift
prescribed, ideal training intensity, so that another objec-
• Arrhythmias other than sustained ventricular tachycardia,
tive of the SXTT is met: to demonstrate appropriate acute including multifocal PVCs, triplets of PVCs, supraventricular
adaptations to exercise to a level beyond the prescribed tachycardia, heart block, or bradyarrhythmias
training intensity suggesting that the subsequently pre-
• Fatigue, shortness of breath, wheezing, leg cramps, or
scribed exercise parameters will be safe for the client. Thus claudication
the SXTT should be terminated, once based on the adminis-
• Development of bundle-branch block or intraventricular
trator’s subjective appraisal the following two objectives are conduction delay that cannot be distinguished from
accomplished: first, an estimate of maximal workload is ventricular tachycardia
perceptible and second, the intensity of exercise has been
• Increasing chest pain
safely progressed beyond apparent moderate to vigorous
exercise prescription parameters. The confidence in mak- • Hypertensive response (systolic blood pressure of >250 mm
Hg and/or a diastolic blood pressure of >115 mm Hg)
ing this somewhat subjective decision increases with tester
experience and the novice test administrator is advised to
perform a number of tests under the supervision of a more ECG, electrocardiogram; PVC, premature ventricular contraction
experienced tester to hone this skill. If this is not possible, a.
Baseline refers to a measurement obtained immediately before
then (s)he should proceed initially cautiously with tests on the test and in the same posture as the test is being performed.
low-risk individuals until confidence in making this deci-
sion appropriately is gained. Reprinted, with permission from the American College of Sports Medicine. ACSM’s
Guidelines for Exercise Testing and Prescription. 8th ed. Baltimore, MD: Lippincott Wil-
liams & Wilkins; 2010:115.
Safety considerations and contraindications
In order to ensure safety during exercise testing the tes-
ter needs to have adequate knowledge of exercise testing
and management principles, and understand and follow ap-
propriate exercise testing guidelines as summarized in the tions may not be ruled out by a review of the patient’s history
ACSMG. Absolute and relative contraindications to exercise and a brief physical exam in the physician’s office. It is not
testing are listed on Table 1. Contraindications to exercise unusual that a careful pretest screening and physical exami-
testing most commonly seen in our clinic are uncontrolled nation by the physical therapist reveals signs and symptoms
hypertension and previously undetected rhythm abnormali- of cardiopulmonary disease that would warrant a cardiology
ties. The author recommends that the physical therapist re- evaluation in a client who presents with an appropriate phy-
quire a physician’s referral with clearance for exercise par- sician’s referral. In this case the patient is sent back to the
ticipation before proceeding with an exercise evaluation. referring physician with a note documenting the findings and
However, it is important to understand that such a document the suggestion that “due to these findings a medically su-
does not assure the absence of undiagnosed cardiovascular pervised exercise test is recommended by ACSM guidelines
disease and risk of adverse events in response to physiologi- before starting an exercise program.” Referring physicians
cal stress in previously sedentary individuals. These condi- usually graciously comply with this proposition.

Vol 23 v No 2 v June 2012 Cardiopulmonary Physical Therapy Journal 23

 To ensure appropriate responses to potential adverse
events during exercise testing, facility emergency pro-
cedures need to be clearly defined and basic emergency
equipment such as an automated external defibrillator
(AED) should be readily available in the testing area.33,34
The tester and support staff should have a minimum of
basic cardiac life support (BCLS) certification. A physical
therapist who may independently evaluate patients in the
high risk category should strongly consider advanced car-
diac life support (ACLS) certification.

EXERCISE PRESCRIPTION AND ACTIVITY RECOMMEN-

DATIONS
The exercise prescription for cardiovascular condition-
ing includes the following exercise parameters: mode,
intensity, duration, and frequency. The exercise prescrip-
tion needs to be individualized to the respective physical Figure 2. Recumbent Cross Trainer with Leg Stabilizers and
therapy client based on the data obtained in the exercise Grip-Assist Device
evaluation and clinical diagnosis, history, current health
status, risk profile, exercise history, and the client’s goals
and preferences. A comprehensive, long-term “rehabilita-
tion and wellness program” should also include resistance
and flexibility exercises and, if indicated, functional mobil-
ity and balance training.3 However, a discussion of these
areas is beyond the scope of this paper and the discussion
in this article will be limited to cardiovascular conditioning
or aerobic training.
Due to the principle of specificity of exercise, the ex-
ercise prescription will be most specific for the mode of
exercise that was used during the exercise test. Howev-
er, exercise parameters may be adapted to other training
modes that are appropriate for the respective client. For
clients without significant physical impairments and func-
tional limitations, a wide variety of training modes and
exercise equipment may be considered. For most of such Figure 3. Custom Pedal with Straps for Combined Arm/Leg
individuals with low to moderate fitness levels, walking can Ergometer
be used for a simple but effective exercise program35-37 or
they may use any aerobic exercise equipment as long as
the prescribed exercise parameters can be achieved and In order to appropriately calculate HRR, a person’s maximal
controlled. As stated earlier, persons with mobility impair- heart rate needs to be known. However, actual maximal
ments may be able to exercise at higher workloads and heart rate is not obtained with the SXTT. As discussed ear-
thus be able to optimize exercise adaptations and benefits lier, the practice to substitute AAMHR is not appropriate for
by completing overall higher training volumes when per- most clients seen in the physical therapy clinic. However,
forming combined arm-leg-ergometry. Some may require an appropriate, safe, and effective training intensity can be
special equipment accessories or modifications such as leg derived from the measurements and observations obtained
stabilizers for persons with lower extremity muscle imbal- during the SXTT. As described in the section above, the
ance, full foot plate strap-in pedals for persons with motor experienced tester will have a good sense of the maximal
control problems and tremors or grip-assist devices for per- work capacity and maximal heart rate of the subject after
sons with poor grip (see Figures 2 and 3). observation and analysis of the stage-by-stage progression
Current standards recommend 2.5 to 5 hours of mod- of heart rate and work load during the test as well as physi-
erate-intensity or 1.25 to 2.5 hours of vigorous-intensity ological and subjective indicators of effort throughout the
aerobic physical activity per week for adults to achieve and test and especially during the last stage of the test. Based
maintain good health/fitness and decrease the risk of dis- on this estimate of maximal heart rate (HRmax-estimate)
eases related to a sedentary life style. Moderate-intensity and work load (WLmax-estimate), the tester then deter-
aerobic exercise is defined as exercise between 40% and mines the intensity prescription for moderate-intensity ex-
59% of aerobic capacity reserve that is comparable to 40% ercise (40-60% WLmax-estimate or 40-60% of HRR based
to 59% of heart rate reserve (HRR) and vigorous-intensity on HRmax-estimate) for the initial training phase. This ex-
exercise is considered to be at a training heart rate above ercise intensity may be gradually progressed to vigorous-
60% HRR (equivalent to > 60% aerobic capacity reserve). intensity exercise (60-80% WLmax-esimate or 60-80% of

24 Cardiopulmonary Physical Therapy Journal Vol 23 v No 2 v June 2012

HRR based on HRmax-estimate) if tolerated well through-
out the prescribed training duration without undue fatigue
or exacerbation of clinical signs or symptoms. Ideally, after
completion of the exercise evaluation, the patient is moni-
tored during a subsequent actual exercise training session
performed at the prescribed exercise parameters. Depend-
ing on the physiological and subjective responses during
this practice training session, the exercise prescription can
be adjusted if indicated.
Guidelines recommend that moderate-intensity exer-
cise is performed for at least 30 minutes at least 5 times
per week or vigorous-intensity exercise for at least 20 to 25
minutes at least 3 times per week.2(p vii),8(p155) For severely
deconditioned clients with chronic disease or disabilities,
this volume of exercise will most likely be unrealistic--at
least during the initial conditioning phase--and duration Figure 4. Submaximal Clinical Exercise Tolerance Test -
and frequency must be adjusted according to the individual Case Example 1 (Jerry)
capacity. It is crucial to start with a conservative exercise
volume to avoid the development of overuse injuries. It
is always easier to increase an overly conservative train- years ago. Two years ago his diagnostic classification was
ing load than to be forced to reduce training parameters changed to secondary progressive MS. His EDSS (Expanded
or even abort the exercise program to allow for recovery Disability Status Scale) score is 7.0, which is defined as “un­
from overuse injuries. We usually start new clients with able to walk beyond approximately 5 meters even with aid,
a conservative estimate of exercise duration based on our essentially restricted to wheelchair; wheels self in standard
observations of exertion and subjective fatigue during the wheelchair and transfers alone; up and about in wheelchair
SXTT with a recommended frequency of 3 times per week some 12 hours a day.”38 He has been sedentary since time
with a rest day between exercise sessions. We tell clients to of MS onset and presents with a referral for participation
expect to be moderately tired after the exercise session, but in the University of Utah Multiple Sclerosis Rehabilitation
that we expect them to recover within a couple of hours af- and Wellness Program. His risk factors include overweight,
ter exercise. If fatigue or any signs of discomfort persist into past smoking history, pre-hypertension, inactivity, and age/
the next day, we recommend a reduction of exercise pa- gender (older male). He has an otherwise unremarkable
rameters. Depending on the specific diagnosis, severity of medical history except complaints of intermittent palpita-
disease, and level of disability additional special consider- tions for the past several months. His medication list in-
ations may affect the exercise management of the physical cludes a MS disease-modifying agent, an antispasticity
therapy patient. For example, patients with diabetes, espe- agent, and an antidepressant. None of these medications
cially if dependent on exogenous insulin, will require more are known to affect the cardiovascular response to exercise.
frequent glucose monitoring and medication adjustments His physical therapy examination reveals normal strength
to compensate for the effects of increased physical activity. and function in his upper extremities and marked weakness
Patients with neurodegenerative disease such as multiple and spasticity in his lower extremities.
sclerosis, may experience symptom modification or a tem- Based on his clinical impression the tester selects the
porary worsening of neurological symptoms in response to Schwinn AirDyne™ arm/leg cycle ergometer as testing
an exercise induced increase in core temperature. A dis- mode for the SXTT with an individualized testing protocol
cussion of all these special disease-specific clinical consid- starting at 20 Watts with a 20 Watt progression per 2 min-
erations is beyond the scope of this paper and readers are ute intervals. Due to the patient’s risk profile and history of
referred to relevant literature such as the ACSM’s Exercise palpitations, the evaluator chooses to monitor the patient’s
Management for Persons with Chronic Disease and Disabil­ ECG at rest and during exercise. Exercise test data are sum-
ities.11 Finally, the physical therapist needs to remain aware marized in Table 6. Jerry’s resting heart rate is 68, his rest-
about the potential day-to-day variability in the health sta- ing ECG displays a normal sinus rhythm, his resting blood
tus and energy level of persons with chronic disease and pressure is 136/76, which is slightly above ideal. During
disability that requires ongoing reassessment and adapta- his first test stage, his heart rate increases to 94 and his RPE
tion of program parameters and education on appropriate rating is one (“very light;” Borg 1-10 scale). His workload
self-assessment and self-adjustment by the patient. is increased to 40 Watts which causes a heart rate increase
to 107. His blood pressure is recorded just slightly above
PATIENT CASE EXAMPLE 1 (see Figure 4 & video resting at 138/78 and his RPE rating is 2 or “light.” The ECG
online at: http://stream.utah.edu/m/show_grouping. displays sinus tachycardia without abnormalities. During
php?g=3f55168646473e2292) stage 3 at an intensity of 60 Watts, it becomes obvious that
Jerry relies primarily on his arms to maintain the work load.
Jerry is a 59-year-old architect who received a diagno- His heart rate increases to 117 and his RPE rating is 4 or
sis of definite relapsing-remitting multiple sclerosis (MS) 8 “somewhat hard.” His exercise ECG remains normal. The

Vol 23 v No 2 v June 2012 Cardiopulmonary Physical Therapy Journal 25

Table 6. Submaximal Clinical Exercise Tolerance Test - Case this stage, he would probably reach volitional fatigue with
Example 1 (Jerry) an RPE rating of 9 or 10 (very, very hard or maximal) and
would most likely not be able to continue to the next stage.
The tester also estimates that his heart rate, which increased
Mode: Schwinn AirDyne™ Cycle Ergometer
Resting HR: 68 AAMHR: 162*
quite linearly during the first 3stages and then increased in
Resting BP: 136/76 85%AAMHR: 138* slope during stage 4, may have risen another 20-25 bpm
Min Workload HR BP RPE during maximal effort. Based on this SXTT, he thus pre-
0-2 20 W 94 1
dicts a maximal workload of approximately 100 Watts and
a maximal heart rate of approximately 160 bpm.
2-4 40 W 107 138/78 2
Based on these estimates he determines the follow-
4-6 60 W 117 4
ing exercise prescription: Target Heart Rate (THR) Range:
6-8 80 W 136 152/80 7 105-125 bpm (40-60% HRR based on HRmax-estimate,
rounded to nearest 5) with recommended THR: 115 bpm
Test Interpretation:
Moderate intensity arm/leg ergometry tolerated well.
(50% HRR); initial work load: 50 Watts (50% WLmax-es-
Peak WL: 80 Watts timate). Recommended RPE during training: 3-4 (moder-
Peak HR: 136 (resting + 68, 84% AAMHR) ate to somewhat hard), not to exceed 4 (somewhat hard).
Peak BP: 152/80 (resting +16/4) Initial duration: 15 minutes plus 2-3 minutes warm-up and
Peak RPE: 7 (very hard) cool-down, gradually increased as tolerated to 30 minutes.
Reason for test termination: tester decision, desired endpoints
achieved.
Initial frequency: 3 times per week with at least one rest day
between exercise days. Jerry will be closely monitored dur-
Exercise Prescription: ing his first training session and exercise parameters may be
Intensity: THRR: 105-125, THR: 115; initial work load: 50 Watts; modified if necessary.
RPE: 3-4/10.
Duration: initially 15 min plus warm up & cool down, gradually
increase as tolerated to 30 min.
PATIENT CASE EXAMPLE 2 (see Figure 5 & video
Frequency: 3/wk
online at: http://stream.utah.edu/m/show_grouping.
php?g=3f55168646473e2292)
*Note by author: The AAMHR and 85% AAMHR are listed on the test record for purpose
of reference and as endpoint for submaximal testing. This should not suggest that AAMHR
can be used as a valid estimate of maximal heart rate in this patient population.

work load is further increased to 80 Watts for stage 4 of the

test. Jerry is obviously exerting significant effort at this in-
tensity, which is also reflected in his RPE rating of 7 or “very
hard.” His heart rate increases to 136 bpm and his blood
pressure is recorded at 152/80. Mild to moderate exercise
induced dyspnea is evident, rated by the tester as 2 (5-point
scale: “mild, some difficulty;” see Table 3). The ECG contin-
ues to show sinus tachycardia without any abnormal wave-
forms. At this point it is obvious to the tester that Jerry has
reached a workload clearly above a reasonable training in-
tensity for his current fitness level. One of the objectives of
the SXTT has thus been achieved: since there have been no
abnormal signs or symptoms observed throughout the test,
the assumption, that Jerry will be “safe” when exercising at
the (lower) intensity, which will be later prescribed for his
exercise program, should be warranted.
Based on the tester’s integrated assessment of the stage-
by-stage observations of the physiological and subjective
indicators of subject effort (heart rate, dyspnea level, tes-
ter observation of patient effort, RPE rating), the tester also Figure 5. Submaximal Clinical Exercise Tolerance Test -
feels quite confident at this point to provide a good esti- Case Example 2 (Linda)
mate of Jerry’s maximal exercise capacity thus meeting the
second objective of the SXTT. Based on the stage-by-stage Linda is a 53-year-old research pharmacologist who
observation of subject effort by the tester, consistent with received a diagnosis of definite relapsing-remitting MS
the apparently reasonable RPE ratings given by the subject, 24 yrs ago. Several years ago her diagnostic classification
the tester has the impression that Jerry would be able to was changed to secondary progressive MS. Based on her
advance to and probably complete the next 2-minute stage walking ability her EDSS score is 6.5, which is defined as
at an intensity level of 100 Watts. However, by the end of “constant bilateral assistance (canes, crutches, braces) re­

26 Cardiopulmonary Physical Therapy Journal Vol 23 v No 2 v June 2012

quired to walk about 20 meters without resting.” 38 She uses Table 7. Submaximal Clinical Exercise Tolerance Test - Case
a manual wheelchair or electric scooter for energy-efficient Example 2 (Linda)
ambulation when she leaves her home. In the past she has
been moderately active, however, she became more seden- Mode: NuStep™ Recumbent Cross Trainer
Resting HR: 57 AAMHR: 167*
tary when she started to use a wheelchair one year ago and Resting BP: 108/60 85%AAMHR: 142*
now presents with a referral for participation in the Univer-
sity of Utah Multiple Sclerosis Rehabilitation and Wellness
Min Workload Watts HR BP RPE
Program. Except for MS she has an unremarkable medical
0-2 110-L1 40 75 0.5
history. Her medication list includes a MS disease-modifying
agent, an analgesic drug, and multiple dietary supplements. 2-4 110-L2 50 76 112/62 1
None of these medications are known to affect the cardiovas- 4-6 110-L3 60 79 2-3
cular response to exercise. Her medical history and physical 6-8 110-L4 70 97 132/60 3-4
examination do not reveal any significant heart disease risk 8-10 110-L5 80 103 5
factors, however, she reports a “history of PVCs” (premature 10-12 110-L6 90 103 138/64 7
ventricular contractions) on her health history questionnaire.
Her physical therapy examination reveals normal strength Test Interpretation:
and function in her upper extremities and marked weakness Moderate intensity arm/leg ergometry tolerated well.
Peak WL: 90 Watts
and mild spasticity in her lower extremities.
Peak HR: 103 (resting + 46, 62% AAMHR)
Based on his clinical impression the tester selects the Peak BP: 138/64 (resting +30/4)
NuStep Recumbent Cross Trainer as testing mode for the Peak RPE: 7 (very hard)
SXTT with an individualized testing protocol starting at 40 Reason for test termination: LE fatigue (“Legs gave out”)
Watts with a 10 Watts progression in 2 minute intervals.
Exercise Prescription:
Due to the patient’s self-reported history of PVCs, the tes-
Intensity: THRR: 85-95; initial work load: 50 Watts; RPE 3-4/10
ter chooses to monitor the patient’s ECG at rest and dur- Duration: initially 15 min plus warm up & cool down, gradually in-
ing exercise. Exercise test data are summarized in Table 7. crease as tolerated to 30 min
Linda’s resting heart rate is 57, her resting ECG displays a Frequency: 3/wk
normal sinus rhythm, her resting blood pressure is 108/60.
*Note by author: The AAMHR and 85% AAMHR are listed on the test record for purpose of
She tolerates the gradual increase in work load from stage reference and as endpoint for submaximal testing. This should not suggest that AAMHR can
1 to 5 well, which is reflected in her RPE rating that gradu- be used as a valid estimate of maximal heart rate in this patient population.

ally increases to 5 (“hard”) by stage 5. Her blood pressure

response is appropriate with a workload-related increase of
the systolic value as expected. Her ECG displays a sinus sult in a further significant increase in heart rate. The other
rhythm without abnormal waveforms or beats. Her heart possibility may be the absence of an appropriate heart rate
rate response is blunted from stage 1 to 3, then rises sig- response in spite of the increased effort suggesting chro-
nificantly during stage 4 followed again by only a small notropic incompetence, possibly due to an MS-related
increase during stage 5, in spite of a considerable increase autonomic neuropathy. As expected, Linda is exerting
in effort by the client (see Table 7 and video). At this point in significant effort at this intensity (see video), which is also
the test Linda is working quite hard, as can be observed by reflected by her RPE rating of 7 (“very hard”). She is rely-
the tester and as reflected by her RPE rating (5, “hard”). The ing heavily on her arms to maintain the workload. Mild to
tester may consider terminating the test at this point. The moderate exercise induced dyspnea is evident, rated by the
subject is obviously working at a higher workload/intensity tester as 2 (“mild, some difficulty”). The ECG continues to
than she will train in the future based on the exercise pre- show a regular sinus rhythm without abnormal waveforms.
scription she will receive later today. One of the objectives However, there is no further increase in heart rate, in spite
of the SXTT has thus been achieved: since there have been of the valiant effort of the client, who reaches volitional
no abnormal signs or symptoms observed during the test, fatigue (“my legs gave out”) by the end of the 2 minute test
the assumption that Linda will be “safe” when exercising at stage. This SXTT thus evolved into a maximal exercise test
the (lower) intensity, which will be later prescribed for her that provides the following information: peak work load =
exercise program, should be warranted. However, the tes- 90 Watts, peak HR = 103 bpm.
ter has difficulty interpreting the non-linear, blunted heart Based on these measurements, the tester determines the
rate response of this client. At the end of stage 5, in spite following exercise prescription: Target Heart Rate Range:
of significant effort, her heart rate is only 103 bpm, which 85-95 bpm (60-80% HRR, rounded to nearest 5; based
is only 62% of her AAMHR. He decides to continue the on his clinical judgment the evaluator determines that the
test and progress to stage 6 with a work load increase to “vigorous intensity” range is most appropriate in this case);
90 Watts, which will be very strenuous for Linda. Based initial work load: 50 Watts (55% peak work load). Recom-
on his experience, he anticipates two possible responses mended RPE during training: 3-4 (moderate to somewhat
which would reveal valuable clinical information impor- hard). Initial duration: 15 minutes plus 2-3 minutes warm-
tant for test interpretation. One possibility may be that the up and cool-down, gradually increased as tolerated to 30
increased sympathetic stimulation associated with the in- minutes. Initial frequency: 3 times per week with at least
creased effort necessary to produce this workload may re- one rest day between exercise days. Linda will be closely

Vol 23 v No 2 v June 2012 Cardiopulmonary Physical Therapy Journal 27

monitored during her first training session and exercise pa- clinical application and interpretation. Phys Ther.
rameters may be modified if necessary. 2000;80(8):782-807.
This second real-life case presented by the author was 8. American College of Sports Medicine. ACSM’s Guide­
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