Exercise Testing

Introduction

Exercise is dependent on the effective integration of respiratory, cardiovascular, neuromuscular and metabolic functions in humans.  Clinical manifestations of a disease state or abnormality may not become apparent until functional capacity is markedly impaired, because the organs involved in these functions have sizeable reserve.  When this occurs, patients often experience shortness of breath with activity and/or exercise limitation.  Exercise Testing has therefore secured an essential role in our practice of clinical medicine by allowing the clinician to objectively evaluate these important functions and symptoms.  The results from exercise testing more accurately parallel functional capacity and quality of life than resting measurements and correlate with various important outcomes, including mortality.

While exercise testing has been previously viewed as merely interesting (in the hands of a few individuals), clinically meaningful findings from recent work and studies have now facilitated the use of exercise testing in mainstream clinical practice.  Data obtained from exercise testing has been shown to correlate with clinical outcomes in patients with chronic obstructive pulmonary disease (COPD) (1), in COPD patients being considered for lung-volume reduction surgery (2), and in patients with primary pulmonary hypertension (3), interstitial lung disease (4) and congestive heart failure (5).  Exercise testing is utilized to assess the effectiveness and functional mechanisms of newer pharmacologic therapies  (6, 7).  These recent findings have led to international task forces to advocate for the greater use of exercise testing in clinical practice (8).

Recognizing these realities, this review focuses on compiling a Best of the Web for sites that help to better understand, perform, interpret and undergo exercise testing.

Last Update: February 2010

Search

A Google™ yielded 92,400,000 sites for the words “exercise testing”, 10,700,000 sites for the words “clinical exercise testing” and 144,000 sites for the words “cardiopulmonary exercise testing”.  The first 100 sites from each of the above searches were reviewed in detail, while others beyond that initial list were scanned for relevance and utility.

In general, the overall quality of the sites reviewed in these topic areas was disappointing and most sites would be of limited utility or value.  For example, very few sites were specifically designed or optimized for web use, most were narrow adaptations of otherwise available print material.  Numerous sites and webpages were for retail sales, conferences, or for paid links to articles, books and services.  Many sites only provided limited viewing, requiring a paid subscription to fully access.  This included sites for a variety of professional organizations, which were not accessed as their audience would be very limited and, as such, their utility compromised.  In the past few years there appears to have been little innovation or new developments in web-based material for this clinical area.  Links or websites with primary information older than 5 years were not accessed.  The following websites were the most appealing and informative for those interested in exercise testing.

Best Websites

American Heart Association

This site provides access to the most recent scientific statements from the AHA, targeting the cardiovascular aspects and viewpoints of exercise testing. The site contains useful material for practicing clinicians, investigators, physicians-in-training and other health care professionals. It is easy to navigate and has numerous useful links close at hand.

1. Authority: The AHA is very well respected and a recognized and accepted authority on cardiovascular issues in this field. It has helped to facilitate and enable scientific reviews of important topics relating to cardiovascular views and aspects of exercise testing. More recently, it has expanded clinical guidelines coverage to address more varied clinical areas of interest and need. Rating: 5

2. Currency: The site contains the most up-to-date published statements, although some statements are more than 5 years old. Links and access to multiple statements for both adults and children are updated as new material is compiled, the most recent updated material listed in 2009. Rating: 4

3. Accuracy: The material provided has been reviewed and published in the peer-reviewed literature, and represents the combined efforts of individual experts from the specific areas of expertise. Reference material addressing indications, methodology and interpretation is provided. Rating: 5

4. Navigation & Readability: The site is easy to navigate, downloads are straightforward to complete and useful links are available for many other related topics. Rating: 5

5. Utility: Readily assessed and free of charge. The material addresses a variety of needs and is of pivotal importance for those involved in this area. Rating: 5

Summary: N/A

American Thoracic Society

This site provides access to the most recent joint ATS/American College of Chest Physicians (ACCP) Statement on Cardiopulmonary Exercise Testing. The document is also linked to by many other websites.

1. Authority: The ATS and the ACCP are world-recognized leading organizations in this field and the document was compiled by a large group of world experts. It represents the most comprehensive guideline effort to date in this area. Rating: 5

2. Currency: The document was published in 2003, and has not been updated since the original publication in the American Journal of Respiratory and Critical Care Medicine. Rating: 3

3. Accuracy: The material is a very comprehensive guideline and consensus statement on cardiopulmonary exercise testing, including case examples of test reports and interpretation strategies. The material covered includes areas of technical importance, clinical indications and relevance, and interpretation strategies. Some recent advances (i.e., flow-volume curve analysis) have not been incorporated into the case studies. Rating: 4

4. Navigation & Readability: This is an easily-navigated PDF file, although no heading or subject links/shortcuts are provided. A print document has been adapted for use in this site, rather than the site having been specifically customized or designed for web use and navigation. Rating: 3

5. Utility: Easily accessed and free of charge. The material is a required source and reference document for everyone studying, performing and involved in exercise testing. Rating: 4

Summary: N/A

Clinical Exercise Physiology Consortium (VA Palo Alto Medical Center and Stanford University)

This is a site and homepage for the individuals involved in the sports medicine program and the cardiology clinical exercise laboratory at their institution. The authors have extensive experience in this area, and are well respected in the field. They are well published in both printed books and the peer-reviewed literature. Predictably, the site is more directed towards cardiovascular aspects of exercise testing, but significant and useful overlap exists with other areas, in both clinically practical and scholarly ways.

1. Authority: The individual authors are respected investigators and clinicians in the field, and are housed at and supported by Stanford University. Their work has significantly advanced our understanding in the field. Rating: 4

2. Currency: The material cited is relatively recent, although it appears that much of the site has not been updated since 2007. While the section “News Hearticles” is potentially novel, most of the links have expired. Rating: 2

3. Accuracy: The information provided, including calculators and tools for testing and assessment are referenced and derived from recognized sources. The information presented and discussed is based on published literature or guideline statements. Rating: 4

4. Navigation & Readability: While many links are provided and easy to follow, travel within the site is not particularly fluid. The font could be increased and the site re-designed to improve both readability and navigation. Rating: 3

5. Utility: Easily accessed and free of charge. The site also could also function as a limited homepage for those interested in being directed to articles in this area. Rating: 3

Summary: N/A

Children's Hospital of New York-Presbyterian (Columbia University Medical Center)

This site is directed towards patients and their families. In undertaking this review, it became readily evident that there was a surprising paucity of material available on the web in this area specifically directed towards those undergoing testing. Although the purpose of the site is to provide information to children undergoing various testing procedures, it is also directed to their adult parents. As designed, the content is deficient in many other areas of exercise testing, but it capably addresses a significant deficiency in the lack of knowledge and understanding of those undergoing testing in exercise laboratories.

1. Authority: The content represents the views of the laboratory director and staff at the Children’s Hospital of New York-Presbyterian. The director is published in the peer-reviewed literature in this area, and has worked with other respected investigators in this area. Expert content directed to health professionals is not presented. Rating: 3

2. Currency: Although a date when the site was last revised is not listed, the material is less susceptible to being out of date, and as such, seems both current and appropriate. Rating: 3

3. Accuracy: The site has done an admirable job of striking a balance in providing the right amount and detail of information in a means that is patient friendly. The language used is of an appropriate level, although is clearly directed towards parents and older children. Rating: 4

4. Navigation & Readability: Navigation is minimal as the pertinent information is provided on a single page. The section on frequently asked questions (which could be linked to an expanded menu at the top of the webpage to minimize scrolling) is very effective and addresses important areas not covered in the preceding text in a practical issue-related fashion. Rating: 3

5. Utility: Links or maps to content for health professionals are not provided, but would be meaningful. Other useful links and menu-driven content for patients and their families (i.e., national organizations) would also enhance the utility of the website. Rating: 3

Summary: N/A

Exercise Prescription on the Net

This site provides resources directed towards those both performing and undertaking various forms of exercise testing. It is integrated within a much larger, comprehensive site that addresses many aspects of exercise, fitness and bodybuilding beyond aerobic conditioning and testing. The site is supported by individuals working at or those with relationships to Kansas State University. The content is less directed towards those involved in better understanding exercise testing. The site is fine for addressing practical issues for those who are already comfortable with the area and who undertake testing, but requires a degree of understanding about how best to implement and utilize the various calculators, protocols and information provided.

1. Authority: The listed authors have stated personnel and working experience in the areas of human performance, bodybuilding, nutrition, kinesiology and exercise. Some of the authors have published in the peer-reviewed literature. The site is not officially endorsed or supported by any national organization or learning institution. Rating: 3

2. Currency: The content and links appear to be relatively up to date, although the site was last updated in June 2008. For the most part, individual pages are not dated as to when they were completed or compiled. Rating: 3

3. Accuracy: Some of the tables, calculators and material provided are taken from either the peer-reviewed medical literature or accepted sources of information in this area. Other material is not cited, and it is therefore difficult to fully appreciate the validity of some of the information provided. I did not find examples of significant inaccuracies in content, although much of the material represents the personnel views of the authors. Rating: 3

4. Navigation & Readability: The site is easy to navigate and the menus are intuitive. This aspect could also be significantly improved if a larger text font would be utilized. Rating: 3

5. Utility: Easily accessed and free of charge. The site represents a good compilation of information, although much of the material covered would not be of direct benefit to our readership. Rating: 3

Summary: N/A

Disclaimer

The author has no personal or financial interest in any of the websites discussed above. The author has no financial interests in any of the websites reviewed and/or discussed in this article. Dr. Marciniuk was a co-author in the joint ATS/ACCP Statement on Cardiopulmonary Exercise Testing noted above.

References

1. Oga T, Nishimura K, Tsukino M, Sato S, Hajiro T. Analysis of the factors related to mortality in chronic obstructive pulmonary disease: role of exercise capacity and health status. Am J Respir Crit Care Med 2003;167:544-549.
2. National Emphysema Treatment Trail Research Group. A randomized trial comparing lung-volume surgery with medical therapy for severe emphysema. N Engl J Med 2003;348:2059-2073.
3. Wensel R, Opitz CF, Anker SD, Winkler J, Hoffken G, Kleber FX, Sharma R, Hummel M, Hetzer R, Ewert R. Assessment of survival in patients with primary pulmonary hypertension: importance of cardiopulmonary exercise testing. Circulation 2002;106:319-24.
4. Kawut SM, O’Shea MK, Bartels MN, Wilt JS, Sonett JR, Arcasoy SM. Exercise testing determines survival in patients with diffuse parenchymal lung disease evaluated for lung transplantation. Respir Med 2005;99:1431-1439.
5. Oliveira RB, Myers J, Araújo CG, Arena R, Mandic S, Bensimhon D, Abella J, Chase P, Guazzi M, Brubaker P, Moore B, Kitzman D, Peberdy MA. Does peak oxygen pulse complement peak oxygen uptake in risk stratifying patients with heart failure? Am J Cardiol 2009;104:554-8.
6. Maltais F, Hamilton A, Marciniuk D, Hernandez P, Sciurba FC, Richter K, Kesten S, O'Donnell D. Improvements in symptom-limited exercise performance over 8 h with once-daily tiotropium in patients with COPD. Chest 2005;128:1168-78.
7. O'Donnell DE, Sciurba F, Celli B, Mahler DA, Webb KA, Kalberg CJ, Knobil K. Effect of fluticasone propionate/salmeterol on lung hyperinflation and exercise endurance in COPD. Chest 2006;130:647-56.
8. ERS Task Force, Palange P, Ward SA, Carlsen KH, Casaburi R, Gallagher CG, Gosselink R, O'Donnell DE, Puente-Maestu L, Schols AM, Singh S, Whipp BJ. Recommendations on the use of exercise testing in clinical practice. Eur Respir J 2007; 29:185-209.