Exercise Physiology for Graded Exercise Testing: A Primer for the Primary Care Clinician

  • Francis G. O’Connor
  • Matthew T. Kunar
  • Patricia A. Deuster

Exercise testing is an advanced clinical procedure used by providers to assess functional capacity for the purpose of guiding cardiovascular and pulmonary diagnoses and therapies. Numerous clinical guidelines, texts, and consensus statements have been published to assist clinicians in the identification of indications and criteria for treadmill stress testing, as well as procedures for test performance and interpretation [1-4]. However, the physiology of exercise testing, which is the foundation for exercise testing, is often overlooked in resource publications, as well as during the clinical training of providers. Education in exercise physiology is largely limited to the pre-clinical years, despite the fact that progress in cardiovascular exercise physiology is ongoing. This chapter functions as a primer for the primary care clinician who conducts exercise testing: core concepts pertaining to energy metabolism, skeletal muscle physiology, and cardiovascular and pulmonary physiology are reviewed. Additionally current concepts pertaining to testing for maximal aerobic power, factors that influence both test performance and results, and the physiology of myocardial ischemia and ST-segment depression are discussed.


Stroke Volume Respiratory Exchange Ratio Exercise Physiology Blood Lactate Level Maximal Aerobic Power 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Gibbons RJ, Balady BG, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing. Summary article: A report of the ACC/AHA task force on practice guidelines. J Am Coll Cardiol 2002;40:1531.PubMedCrossRefGoogle Scholar
  2. 2.
    Fletcher GF, Balady GJ, Amsterdam EA, Chaitman B, Eckel R, Fleg J, Froelicher VF, Leon AS, Pina IL, Rodney R, Simons-Morton DA, Williams MA, Bazzarre T. Exercise standards for testing and training: A statement for healthcare professionals from the American Heart Association. Circulation 2001;104:1694–740.PubMedCrossRefGoogle Scholar
  3. 3.
    Balady GJ, Berra KA, Golding LA, editors. ACSM’s Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia: Lippincott, Williams & Wilkins; 2000.Google Scholar
  4. 4.
    Whaley MH, Brubaker PH, Otto RM, editors. ACSM’s Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore: Lippincott, Williams & Wilkins; 2006.Google Scholar
  5. 5.
    Tesch PA, Thorsson A, Essen-Gustavsson B. Enzyme activities of FT and ST muscle fibers in heavy-resistance trained athletes. J Appl Physiol 1989;67:83–7.PubMedGoogle Scholar
  6. 6.
    Li JL, Wang XN, Fraser SF, Carey MF, Wrigley TV, McKenna MJ. Effects of fatigue and training on sarcoplasmic reticulum Ca(2+) regulation in human skeletal muscle. J Appl Physiol 2002;92:912–22.PubMedGoogle Scholar
  7. 7.
    Beltman JG, de Haan A, Haan H, Gerrits HL, van Mechelen W, Sargeant AJ. Metabolically assessed muscle fibre recruitment in brief isometric contractions at different intensities. Eur J Appl Physiol 2004;92:485–92.PubMedCrossRefGoogle Scholar
  8. 8.
    Beltman JG, Sargeant AJ, Haan H, van Mechelen W, de Haan A. Changes in PCr/Cr ratio in single characterized muscle fibre fragments after only a few maximal voluntary contractions in humans. Acta Physiol Scand 2004;180:187–93.PubMedCrossRefGoogle Scholar
  9. 9.
    Sargeant AJ, de Haan A. Human muscle fatigue: the significance of muscle fibre type variability studied using a micro-dissection approach. J Physiol Pharmacol 2006;57 Suppl10:5–16.PubMedGoogle Scholar
  10. 10.
    Kosek DJ, Kim JS, Petrella JK, Cross JM, Bamman MM. Efficacy of 3 days/wk resistance training on myofiber hypertrophy and myogenic mechanisms in young vs. older adults. J Appl Physiol 2006;101:531–44.Google Scholar
  11. 11.
    Putman CT, Xu X, Gillies E, MacLean IM, Bell GJ. Effects of strength, endurance and combined training on myosin heavy chain content and fibre-type distribution in humans. Eur J Appl Physiol 2004;92:376–84.PubMedCrossRefGoogle Scholar
  12. 12.
    Neary JP, Martin TP, Quinney HA. Effects of taper on endurance cycling capacity and single muscle fiber properties. Med Sci Sports Exerc 2003;35:1875–81.PubMedCrossRefGoogle Scholar
  13. 13.
    Beltman JG, Sargeant AJ, van Mechelen W, de Haan A. Voluntary activation level and muscle fiber recruitment of human quadriceps during lengthening contractions. J Appl Physiol 2004;97:619–26.PubMedCrossRefGoogle Scholar
  14. 14.
    Whaley MH, Brubarker PH, Otto RM, editors. ACSM’s Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore: Lippincott, Williams & Wilkins; 2006.Google Scholar
  15. 15.
    Kushmerick MJ, Moerland TS, Wiseman RW. Two classes of mammalian skeletal muscle fibers distinguished by metabolite content. Adv Exp Med Biol 1993;332:749–60; discussion 60–1.PubMedGoogle Scholar
  16. 16.
    Stallknecht B, Vissing J, Galbo H. Lactate production and clearance in exercise. Effects of training. A mini-review. Scand J Med Sci Sports 1998;8:127–31.Google Scholar
  17. 17.
    Bell DG, Jacobs I. Muscle fiber-specific glycogen utilization in strength-trained males and females. Med Sci Sports Exerc 1989;21:649–54.PubMedGoogle Scholar
  18. 18.
    Jacobs I, Kaiser P, Tesch P. Muscle strength and fatigue after selective glycogen depletion in human skeletal muscle fibers. Eur J Appl Physiol Occup Physiol 1981;46:47–53.PubMedCrossRefGoogle Scholar
  19. 19.
    McArdle WD, Katch FI, Katch VL. Exercise Physiology: Energy, Nutrition & Human Performance. 6th ed. Baltimore: Lippincott, Williams and Wilkins; 2007.Google Scholar
  20. 20.
    Levine BD. Exercise physiology for the clinician. In Thompson PD. editor. Exercise and Sports Cardiology. New York: McGraw Hill; 2001.Google Scholar
  21. 21.
    DeBusk RF, Blomqvist CG, Kouchoukos NT, Luepker RV, Miller HS, Moss AJ, Pollock ML, Reeves TJ, Selvester RH, Stason WB, et al. Identification and treatment of low-risk patients after acute myocardial infarction and coronary-artery bypass graft surgery. N Engl J Med 1986;314:161–6.PubMedGoogle Scholar
  22. 22.
    Blair SN, Kohl HW, 3rd, Paffenbarger RS, Jr., Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality. A prospective study of healthy men and women. Jama 1989;262:2395–401.Google Scholar
  23. 23.
    Duncan GE, Li SM, Zhou XH. Cardiovascular fitness among U.S. adults: NHANES 1999–2000 and 2001–2002. Med Sci Sports Exerc 2005;37:1324–8.CrossRefGoogle Scholar
  24. 24.
    Carnethon MR, Gulati M, Greenland P. Prevalence and cardiovascular disease correlates of low cardiorespiratory fitness in adolescents and adults. JAMA %R 101001/jama294232981 2005;294:2981–8.CrossRefGoogle Scholar
  25. 25.
    Victor RG, Secher NH, Lyson T, Mitchell JH. Central command increases muscle sympathetic nerve activity during intense intermittent isometric exercise in humans. Circ Res 1995;76:127–31.PubMedGoogle Scholar
  26. 26.
    Correia LC, Lakatta EG, O’Connor FC, Becker LC, Clulow J, Townsend S, Gerstenblith G, Fleg JL. Attenuated cardiovascular reserve during prolonged submaximal cycle exercise in healthy older subjects. J Am Coll Cardiol 2002;40:1290–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Williams MA, Fleg JL, Ades PA, et al. Secondary prevention of coronary heart disease in the elderly (with emphasis on patients > or =75 years of age): An American Heart Association scientific statement from the council on clinical cardiology subcommittee on exercise, cardiac rehabilitation, and prevention. Circulation 2002;105:1735–43.PubMedCrossRefGoogle Scholar
  28. 28.
    Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol 2001;37:153–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Astrand PO, Ryhming I. A nomogram for calculation of aerobic capacity (physical fitness) from pulse rate during sub-maximal work. J Appl Physiol 1954;7:218–21.PubMedGoogle Scholar
  30. 30.
    Myers JN. The physiology behind exercise testing. Prim Care 2001;28:5–14.Google Scholar
  31. 31.
    Andersen P, Henriksson J. Capillary supply of the quadriceps femoris muscle of man: adaptive response to exercise. J Physiol 1977;270:677–90.PubMedGoogle Scholar
  32. 32.
    Duncan GE, Howley ET, Johnson BN. Applicability of VO2max criteria: Discontinuous versus continuous protocols. Med Sci Sports Exerc 1997;29:273–8.PubMedGoogle Scholar
  33. 33.
    Howley ET, Bassett DR, Jr., Welch HG. Criteria for maximal oxygen uptake: Review and commentary. Med Sci Sports Exerc 1995;27:1292–301.PubMedGoogle Scholar
  34. 34.
    Myers J, Walsh D, Sullivan M, Froelicher V. Effect of sampling on variability and plateau in oxygen uptake. J Appl Physiol 1990;68:404–10.PubMedCrossRefGoogle Scholar
  35. 35.
    Taylor HL, Buskirk E, Henschel A. Maximal oxygen intake as an objective measure of cardio-respiratory performance. J Appl Physiol 1955;8:73–80.PubMedGoogle Scholar
  36. 36.
    Day JR, Rossiter HB, Coats EM, Skasick A, Whipp BJ. The maximally attainable VO2 during exercise in humans: The peak vs. maximum issue. J Appl Physiol 2003;95:1901–7.Google Scholar
  37. 37.
    Kyle SB, Smoak BL, Douglass LW, Deuster PA. Variability of responses across training levels to maximal treadmill exercise. J Appl Physiol 1989;67:160–5.PubMedGoogle Scholar
  38. 38.
    Fielding RA, Frontera WR, Hughes VA, Fisher EC, Evans WJ. The reproducibility of the Bruce protocol exercise test for the determination of aerobic capacity in older women. Med Sci Sports Exerc 1997;29:1109–13.PubMedGoogle Scholar
  39. 39.
    Gürsel Y, Sonel B, Gok H, et al. The peak oxygen uptake of healthy Turkish children with reference to age and sex: A pilot study. Turk J Pediatr 2004;46:38–43.PubMedGoogle Scholar
  40. 40.
    Astrand PO. Quantification of exercise capability and evaluation of physical capacity in man. Prog Cardiovasc Dis 1976;19:51–67.PubMedCrossRefGoogle Scholar
  41. 41.
    Astrand PO, Saltin B. Maximal oxygen uptake and heart rate in various types of muscular activity. J Appl Physiol 1961;16:977–81.PubMedGoogle Scholar
  42. 42.
    Astrand PO, Rodahl K. Textbook of work physiology: Physiological bases of exercise. 4th ed. Canada: Human Kinetics; 2003.Google Scholar
  43. 43.
    Cumming GR, Borysyk LM. Criteria for maximum oxygen uptake in men over 40 in a population survey. Med Sci Sports 1972;4:18–22.PubMedGoogle Scholar
  44. 44.
    Stachenfeld NS, Eskenazi M, Gleim GW, et al. Predictive accuracy of criteria used to assess maximal oxygen consumption. Am Heart J 1992;123:922–5.PubMedCrossRefGoogle Scholar
  45. 45.
    Issekutz BJ, Birkhead NC, Rodahl K. Use of respiratory quotients in assessment of aerobic work capacity. J Appl Physiol 1962;17:47–50.Google Scholar
  46. 46.
    Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377–81.PubMedGoogle Scholar
  47. 47.
    Borg GA, Noble B. Perceived exertion. In Wilmore J editor. Exercise and Sport Science Reviews. Wilmore JH ed. New York: Academic Press; 1974, 131–53.Google Scholar
  48. 48.
    Eston RG, Davies BL, Williams JG. Use of perceived effort ratings to control exercise intensity in young healthy adults. Eur J Appl Physiol Occup Physiol 1987;56:222–4.PubMedCrossRefGoogle Scholar
  49. 49.
    Glass SC, Knowlton RG, Becque MD. Accuracy of RPE from graded exercise to establish exercise training intensity. Med Sci Sports Exerc 1992;24:1303–7.PubMedGoogle Scholar
  50. 50.
    Hamel P, Simoneau JA, Lortie G, et al. Heredity and muscle adaptation to endurance training. Med Sci Sports Exerc 1986;18:690–6.PubMedGoogle Scholar
  51. 51.
    Mirvis DM GA. Electrocardiography. In Zipes DP LP, Bonow RO, Braunwald E editor.Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. Philadelphia: Elsevier Saunders; 2005.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Francis G. O’Connor
    • 1
  • Matthew T. Kunar
    • 2
  • Patricia A. Deuster
    • 3
  1. 1.Department of Military and Emergency Medicine, Consortium for Health and Military PerformanceUniformed Services University of the Health SciencesBethesdaUSA
  2. 2.4th BCT, 82nd Airborne DivisionFort BraggUSA
  3. 3.Department of Military and Emergency MedicineUniformed Services University, Consortium for Health and Military PerformanceBethesdaUSA

Personalised recommendations