Field exercise tests The pro s and the Cons

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Field exercise tests The pro s and the Cons

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2. Field exercise tests The pro’s and the Cons Sally Singh University Hospitals of Leicester NHS Trust & Coventry University

3. Exercise tests & physical activity

4. Pro’s and Cons Why use an exercise test What field tests are available The pro’s (& their clinical usefulness) The con’s Discussion

8. ‘The gold standard’

9. Additional monitoring During exercise test Metabolic & ventilatory responses Heart rate monitoring Oxygen saturation Symptoms Additional performance measures Strength

10. The six minute walk test (6MWT)

11. The six minute walk test (6MWT) Unobstructed course (variable distance) Standardised instructions (own pace, ? habitual pace) A least two practice walks Standard encouragement Supervise from behind Monitor oximetry/ heart rate End exercise Borg Results in metres

14. 6 MWT or the SWT ? Aim – to compare pulmonary gas exchange response to the 6MWT and the ISWT. Assumption- the ISWT may more accurately reflect maximum exercise capacity & the 6MWT endurance capacity. Results – SWT linear increase with cardio-respiratory parameters, 6MWT exponential increase - SWT provides data close to laboratory tests (peak VO2 r=0.86) - if issues around endurance capacity , 6MWT may be test of choice (? Comparison of the 6MWT and the ESWT) Onorati P et al Eur J Appl Physiol 2003;89:331-336

15. Physiological responses to exercise tests

16. The Pro’s Simple to conduct Reproducible Cheap Response compares well to laboratory based test But – are they clinically useful

17. Field exercise tests - Distance Definition of disability Threshold for surgery Prescription of exercise programme Outcome measure Prescription of oxygen Response to bronchodilators Prognostic value

19. Minimum clinically important difference Six minute walking test 54 m (95% CI: 37 to 71 m)- to stop rating themselves as "about the same" and start rating themselves as either "a little bit better" or "a little bit worse" (n = 112, mean age = 67 yr, mean FEV1 = 975 ml) Redelmeier DA et al Am J Crit Care Med 1997;155:1278-82

24. Comparison of the 6MWT & ESWT to pulmonary rehabilitation

26. Walking versus cycling: sensitivity to bronchodilation in chronic obstructive pulmonary disease Pepin V et al Am J Respir Crit Care Med 2005 No consensus for exercise testing to evaluate functional impact of bronchodilator therapy N=17 ESWT and cycle endurance test at 80% Prior administration of ipratropium bromide (randomised, double blind) Cycling time did not improve, despite increase in FEV1

28. Assessment for surgery Walking distance may be a pre-operative indicator for surgery. Prior to lung volume reduction surgery (LVRS) less than 200m on the 6MWT or 150m on the ISWT predicts an unacceptable operative risk. Prognosis

29. Prognostic value of field exercise tests The 6 minute walk distance: change over time and value as a predictor of survival in severe COPD. Pinto-Plata V et al Eur Respir J 2004 23:28-33 N= 198 patients with severe COPD, 41 age matched controls Followed up for 2 years 6MWT distance decreased from 238m to 218m Non survivors (42%) had a more pronounced change in distance (-40m/year vs –22m/year) despite similar decline in FEV1 Conclusion- 6MWT independently predicts for survival after accounting for age, BMI , FEV1 and other co-morbidities ILD – desaturation on exercise test below 88% associated with higher mortality (lama et al 2003) CHF – SWT higher predictive value than the 6MWT for event free survival

32. The con’s

33. The problems

34. Variability in performance of timed walk tests in pulmonary rehabilitation programs Elpern EH et al Chest 2000;118:98-105

35. Variability in performance of timed walk tests in pulmonary rehabilitation programs Elpern EH et al Chest 2000;118:98-105

36. Six minute waking distance in chronic obstructive pulmonary disease- reproducibility and effect of walking course layout and length. Sciurba F et al Am J Resp Crit Care Med 2003;167:1522-1527 6 mwt completed on 761 pts for the NETT LVRS trial. 476 repeated test on a second day (mean difference 66.1 feet, p<0.0001, average 7.0%, 70% of patients increased. 14.9%) Circular or oval course resulted in increase of 92.2ft compared to course back and forth along corridor!!

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