All right, while we are kind of on the topic of cardiovascular endurance or cardiovascular capacity, which is basically what we're using that treadmill test for. That is basically we're trying to get an idea of the individual's cardiovascular system, what sort of shape it is in. Because obviously the way that their heart rate responds to increasing levels of physical activity is indicative of what shape their cardiovascular system is in. So if you have a person who is in very good aerobic shape, you have a person who is in How much potato shape?
You put them both on the treadmill and you have them do the exact same routine where they're going from 1.7 and 0% grade up through these three minute stages. Which one would you expect to have the faster heart rate response as far as heart rate climbing? out of shape person or the in shape person.
55 shots, quote. Out of shape. And why is that?
Kind of talked a little bit about that last piece. Mainly because the in shape person is going to have a much higher level of stroke volume. Which, of course, stroke volume, as we've talked about, is how much blood we're ejecting from the heart of each individual piece.
And you multiply that by heart rate, which is beats per minute, and that's going to give you your cardiac output. Your cardiac output, of course, is liters of blood pumped per minute. And so generally, depending on the exercise intensity, the cardiac output needs for your out-of-shape person and your in-shape person are going to be somewhat close. Probably going to be a little bit less for your in-shape person. a cardiovascular boost because they're just in better shape, produce energy at a much more efficient rate, but the cardiac output is basically going to be similar, but the way that that cardiac output is generated is going to be different.
The out-of-shape person is going to have a higher heart rate and a lower stroke volume. The in-shape person is going to have a higher stroke volume and a lower heart rate. I think we mentioned last week.
There are lots of endurance athletes out there that have resting heart rates that are between 35 and 40 beats per minute. That was one of the things that Lance Armstrong, former Punta Central cancer survivor, was famous for. It was the fact that at the height of his Tour de France powers, his resting heart rate was around 35 beats per minute. Now, if any of you guys are ever doing an assessment or you're having an exercise session, and any of your participants have a heart rate...
that is registering at 35 beats per minute, do not say, wow, you must be in as good a shape as Lance Armstrong. What's your next move at that point? Yes, call 911 and get the ambulance here as quickly as possible, because clearly something is wrong within their cardiovascular system. Either they're not getting enough electrical stimulation, or perhaps they might be on some sort of a beta blocker or some form of autonomic nervous system.
Diminisher or control blood pressure or to ease the stress on the cardiovascular system for one reason or another And they may have taken too much of that or maybe they can switch their medications and their body is still adjusting to it Regardless a heart rate that low and someone who's not in extremely good aerobic physical condition is a sign that maybe something is not appointed on corporate. Occasionally we'll have people in our program that will have resting heart rates that are in the 60 to 65 range. That's not super unusual. In some cases, it's folks that aren't even in that great of physical condition from an aerobic standpoint, but for some reason their autonomic nervous system is not as stimulatory.
And they often will have some issues with maintaining exercise intensities that are a little bit higher. Because they don't have that stimulation on heart rate, that stimulation on contractility, that helps to pump more blood. during physical activity. But in general, you're going to have a situation where out of shape versus heart rate is going to rise faster.
Theoretically, they will get to their target heart rate at a sooner stage or a lower stage than the person who is in better physical condition. And when you're comparing treadmill tests, that's one of the primary things that you're comparing, is how long it took them to get to their target heart rate. And what you're hoping for, of course, is in the second assessment, like for instance, they start initially and then they do a second assessment 12 weeks later. You're hoping that if they got to stage two in their first assessment, maybe they'll get to stage three in their second assessment before they reach their target heart rate. Or maybe even stage four.
You never know. It all depends on how they adapt to the exercise program. So that's what we are looking for, and that's going to be a sign that we're doing what we need to do.
do for them aerobic exercise wise. That's going to be an indicator that we are accomplishing that particular goal. Or at least getting close to accomplishing that particular goal. Okay, so we mentioned that some people are on certain medications that diminish the influence of the autonomic system on their own purposes. And that's something that you should be aware of.
for your participants that you work with is that they may be on a calcium channel blocker or a data blocker or some form of medication that is going to slow down their autonomic nervous system and in that case their heart rate may not respond very readily to the stimulation of exercise. Okay so in that case you may need to use RPE primarily as your your valve. as your source of when they reach their highest level of exercise for that sub-max test. And in general, our rule is if you're using RPP, that 0 to 10 scale, if they reach a level of 5, which is an indication that they're exercising hard, then that is the top point.
That's their time on treadmill. That's what you write into that blank and then you take that cool down at that point. If you're using RPP.
for their exercise intensity. In most cases we're able to use heart rate successfully unless they're on a very very high dose of some sort of autonomic nervous system control medication or if they have a pacemaker. And we mentioned pacemakers before when we were talking about our bioelectrical impedance device that we're using for body composition. Remember that Bioregulam impedance is based off of sending a low level electrical current through the body and determining how much resistance there is to that particular current. And the more body fat you have, the more resistance there's going to be.
The more muscle tissue, the more lean tissue you have, that's going to have more water in it, it's going to conduct that signal better, and you're going to have less resistance to that current. That's how that device in general works. Okay, so if they do have a pacemaker, obviously we're not going to be doing that body composition measurement because it's not a wise idea to use anything, even though very, very low level electrical current to send through the body, because it might interfere with the way that implantable device is working. But it's even more important from a heart rate standpoint, because you may not have, that person may not be able to go above a certain heart rate because the pacemaker will not allow it. It'll keep it at a certain.
level and that's why they have that that's one of the reasons why they have a pacemaker in there. Another reason is to stimulate their heart rate when it needs to be stimulated. Some people have cardiac dysfunction which causes their heart to skip beats or stop periodically and they get electrical stimulation from that pacemaker to help keep them on a more regular science rhythm for their for their heart rate because obviously if they're on a more regular science rhythm What does that mean for their cardiac output? That means their cardiac output is going to be more regular.
They're going to be able to deliver more oxygen, re-transmute tissues. They're going to be able to put up more waste. And that's going to be better for them from an overall quality of life standpoint. Then I talked to you guys about the, I think it was the third assessment or fourth assessment that I did with a woman who did have a pacemaker and her heart rate wouldn't go above like 110. And we were up to like stage... five on the treadmill.
She was in pretty decent shape and she wasn't like, it wasn't like she was struggling. But her heart rate had been at 110 since stage three. And I was like, what is going on here? And I said, well, I think we're going to have to stop because your heart rate is not climbing any higher than 110. She said, oh, that's probably my pacemaker.
I'm like, have you guys ever seen the movie The Wedding Singer with Drew Barrymore and Adam Sandler? It's kind of an older movie. But there's a line Adam Sandler said where he said, yeah, that's it.
that could be useful to me yesterday and that's how I felt in that circumstance. She had not included that as a part of the medical history and you know it's not necessarily a question that you're going to ask a person do you have a pacemaker. It was listed on the medical history but she did not mark that or did not say anything about it so we had no idea that she had a pacemaker.
So in that situation you're using RPE as your primary guide for exercise and testing is going to be your best bet. Okay, no. Okay, that's so emotional.
Alright, another question regarding people who are in shape versus people who are on shape. When you do take them into cool down, okay, you take them into cool down and you bring the treadmill back down to flat, okay, if they're at stage four when they reach the target heart rate or decide to stop, We stop the test, keep them at 2.5 miles per hour, but flat treadmill for a minute, and bring it down to 1.7 miles per hour. And what are we measuring there?
We're measuring how long it takes them to get to within 10 feet per minute of their stage 1 heart rate. The in-shape person or the out-shape person, who is going to reach that mark or that level of 10 feet within 10 feet per minute faster? the in shape person or the out of shape person the other 50 50 shot title yeah say that again the out of shape one more time the in shape the in shape person yes exactly yeah so the way that your heart rate responds to exercise is an indicator of cardiovascular fitness and in general heart rate is going to respond more slowly on the way up but when intensity comes back down an indicator of cardiovascular health or cardiovascular capacity is if your heart rate responds to that decline in intensity. And if you think about it, when we're doing the test, we start off at 1.70% grade for three minutes, then we go to 5% grade, then we go to 10% grade, then we go to 2.5% and 12%. That's across the course of time of how long?
Three minutes per stage, roughly nine to 12 minutes of time. So you're going to expect a slow, gradual rise in heart rate, right? But when we go into cool down, what happens?
We take away that incline of the treadmill, which for a lot of people, that's the toughest part of the treadmill test. Take that down to flat. Within, you know, how long does it take when you punch the incline from 12 down to zero?
How long does it take that treadmill to come down? What, 10 seconds at the most? So you're going from...
that exercise intensity of 12.5 and 12 percent or excuse me 2.5 and 12 percent back down to 2.5 and 0 percent a lower intensity in a very short period of time. So you would expect if that person's cardiovascular system is responsive the person who's in shape is going to respond faster it's going to adjust faster to that lower exercise intensity. And what you'll also find too is that You're going to be watching their heart rate throughout each of those three-minute stages. What you'll find is that the people who are in shape, their heart rate is going to level out in each stage more quickly. So for instance, when you go from 1.7, 0% grade to 1.7, 5% grade, you're going to see their heart rate typically.
And by the in-shape person, their heart rate is going to level out faster. probably within the first 30 to 45 seconds, as opposed to the out-of-shape person. It's going to take them a little longer. You're going to have a lot more variability in heart rate until it's going to settle out at what their exercise heart rate is for that particular state. And that's all about cardiovascular system's ability to be able to adjust to different levels of physical activity.
The better shape you're in, the better your heart is going to adjust. So we're looking at two different things. One is... how fast it rises and then how fast it comes back down. The in shape person is going to have a better chance of having a slower rise but then a quicker recovery in that circumstance.
So, if we get back to thinking about what we discussed on the, or what was discussed on my recording of the second half of the slides, where we talked about chemotherapy particularly, and also radiation of the chest wall, and how that can dictate a high level of cardio toxicity, and what's that going to do to that person's ability to adjust to exercise intensity. It's not going to do anything favorable, is it? It's not going to do anything good for their cardiovascular capacity or their cardiovascular performance. And that, in the long run, is something that we are trying to improve with our exercise program. We're trying to get their cardiac performance to be more consistent and to be more like a healthy person, as opposed to someone who is in therapy and who may have been through a fairly long period of time.
of sedentary behavior where both of those things are going to work together to diminish what the cardiovascular system is giving you. Alright, have I beaten the treadmill test of death? Is that horse completely down now and not getting up? You guys can shake your head yes if you want, that's fine.
Alright, so while we're in this section of the assessment, this is a good time to talk about alternate ways to evaluate cardiovascular. Pass it. And one of those is to use the recumbent bicep. Head is open about five times. Four.
So, why would we use the recumbent... Well, first of all, before we get to that, what is a recumbent bicep? It's a bike where the person is sitting back and their legs are more straight out, so you're putting less weight on your legs. Yes.
So, a traditional stationary bike. is more vertical, right? It's kind of like a bike that you would ride, you know, normally on a mountain bike or a racing bike or whatever. It typically is going to have a seat that will probably not be super comfortable, although they do have some pretty comfortable seats now for for stationary bikes. And that's primarily because with a very overweight or obese population, they often are unable to do walking exercise for any sort of aerobic capacity, improving and trying to diminish their body fat percentage and body weight.
So they're often needing to use a bicycle. And having them sit on a traditional bike seat, not a good plan. So they do have some wider seats now that are more accommodating for that. But a recumbent bike is often much more comfortable for a lot of people.
Because even if you have a more comfortable stationary bike, See, it's still at some point, it's not going to be a very comfortable place to sit. Whereas the recumbent bike, it's like you're sitting in a chair basically. And like Ali said, you're pedaling a little more out front of you than you are vertically, which can be a little more challenging for some people if they're used to a regular bike where they're, you know, they're kind of using the force of gravity to bring the, uh, to bring the pedals around, as opposed to a recumbent bike where you actually have to fight gravity a little bit. to keep your legs elevated so that you can pedal that bike forward. But for a lot of people, that's not the part they're concerned about.
They would rather be sitting comfortably while they're pedaling that bike as opposed to sitting on a stationary bike. So that's why we have the recumbent bike in our lap. Now why would we use the recumbent bicycle?
We've already mentioned one situation. If you have someone who is extremely overweight, extremely obese, they may have walking may not be the type of exercise they need to do, so they might use the recumbent bike then. What might be some other reasons why we want to use the recumbent bike test as opposed to the treadmill test?
Not as intense. Okay, not as intense. Okay, what makes, I'll follow up with you on this one, Cole, what makes the treadmill test more intense than the recumbent one? more weight in your body.
Okay, you have to support your own weight, right? You've got to maintain more core stability on the treadmill because you're supporting your own weight in that circumstance. You're going to have more balance in that circumstance.
There's more muscular involvement on the treadmill than there is on the proponent, right? Okay, so less intense from a number of different perspectives. Good one.
Okay, what other reasons why... would be why you would use a public light test as opposed to a terminal test. Balance issues. There you go.
Okay. Kind of alluded to that in the discussion of Cole's point, but that should be its own separate point, right? Because if you have someone who's struggling with their balance, even if they can hang on to the safety rails of the treadmill, it still may not be a very safe way for them to exercise because it's a moving belt. And there are a lot of safety issues with that situation. that you can negate a little bit by using the recumbent bite rather than having them in that position.
And do we have balance issues in our, especially in our cancer survivor population? Yes, we do. Do we have it in our caregiver population? We often do because why?
Because the caregivers are often the same age as the survivors, and the survivors are often in their 60s, 70s, and 80s. And balance as you age does not tend to improve as time goes by. neurologic problems or neurologic issues, musculoskeletal issues, lots of different things contribute, but cancer treatment of course is going to exacerbate all of those problems and you may see some pretty significant balance challenges.
You may have folks that just should not be exercising at least immediately on a treadmill. That may be something you want to work up to as a part of your exercise program. That may even be one of their quality of life goals is to be able to walk. independently to be able to walk or feel comfortable walking so that they can go for a walk around their neighborhood and not have to feel like they have to have somebody there with them to make sure that, you know, if they fall over that, you know, they have somebody there to call 911 if necessary.
And for a lot of people, is that a huge component of independence that's lost? And that's our path is. Now think about that. Think about if you couldn't leave the house by yourself because it wasn't safe for you to go out walking by yourself. That'd be a big blow to your ego, wouldn't it?
Yeah, absolutely. And what we're trying to do is we're trying to boost egos as much as possible. And a big way that we can do that is by working on core strength, working on leg strength, working on balance, so that those individuals can do that type of exercise more effectively. But balance can be a problem.
Any other reasons why you'd want to use this recumbent pipe rather than the treadmill? You alluded to another reason a second ago. I think that like if you're sitting down your heart rate wouldn't go up quite as fast or stay lower in general. Okay it's definitely going to stay lower on the recumbent pipe.
One of the main reasons for that is because you're using less musculature. And generally your effort... tends to be less. You're not going to be supporting your own body weight in that circumstance. So it may be, from a cardiovascular standpoint, it may be a safer way for that individual to exercise, especially if they've had a cardiovascular event or they have evidence of cardiovascular toxicity.
If they have joint issues, obviously a lot of older people have that. A lot of people who are overweight oldies have that, and in some cases people who have a perfectly normal body weight are older and younger. Sometimes they have joint or muscular disbalancing issues that may be beneficial for them to use the recombinant bite test.
Most of the time, I mean I don't have these numbers specifically, but if I were to guess, probably 90% of our participants do the treadmill test and maybe 10%, that's probably even a little bit high, use the recombinant bite test as a part of the assessment. But it's there to be able to use. Alright, so we've got a couple of differences in addition to the difference between the treadmill itself and the exercise bike. What else is different? Look at this one compared to the treadmill.
You've got your laptop, you can probably pull them up side by side. That's probably something that I need to do. Hey Dr. Anton, you know what?
You can do that as well. I like how I talk to myself. Some people find it charming. Let's see if I can focus on it.
What do you guys give me if I'm able to do this? Okay, we're almost there. Okay, close enough.
Hide the top, so like that little arrow. Go. Yeah. Take care of this one, will ya? I should probably watch what you're doing, so I can do it myself.
Pretty secure, you can see this. Don't have to do it. If you want to see it. Alright, now, let's look at both of these side by side.
You've got the pipe on the top, treadmill on the bottom. What's different? The equation. Yeah, the equation.
What part of the equation is different? What you can multiply it by. Yes, the percentage.
The percentage of their heart rate reserve is what that's called. Instead of 0.65, we use 0.45. Why do we use a lower percentage?
Because as we've already established, their heart rate's not going to climb as fast, and it's not going to climb as high when they're seated, and we're not using as much musculature. So it makes sense to use a target heart rate that is lower for the recumbent bite as opposed to the treadmill. What else is different? I mean the way you're measuring the increases between RPM and speed.
Okay, so instead of miles per hour, we're doing revolutions per minute, how fast that bike is going. And on that recumbent bike, very convenient, it's got a nice little display on there. And RPM is one of the things that they aren't able to see.
Now, can you keep an exercise bike at exactly 30 RPM's or 40 RPM's or 50 RPM's? No, it's like trying to hold... your heart rate exactly the same heart rate. It's nearly impossible to do.
But as long as they're within four or five RPMs of that target, that's what you're looking for. You may have to remind them, like for instance, they sort of slow down a little bit, so they're in stage three, and all of a sudden their pedal has got 40 RPMs. You'd be like, okay, you've got to pace just a little bit and you hang with it.
And that might be an indication that it may be time to go into cool down at that point. point on the recumbent bike. If they're unable to sustain that particular exercise, that's for a lot of people, they got on their recumbent bike, and what do they do? As opposed to the treadmill. Treadmill, their speed is controlled by the belt.
But on the recumbent bike, they can pedal as slow or as fast as they want. What do they typically do? They go above this, and that's sometimes keeping them a little lower is a bit of a challenge.
Instead of grade, obviously instead of the incline, we're looking at level, getting it in control, the level of resistance that their pendulum is. And we gradually increase that across the course of time. And then the last thing that's different, of course, is the time of each stage.
And that's not listed on the treadmill test because we know that it's a three minute per stage situation. In this case, only two minutes per stage. Why can we get away with... Even with people who aren't as good as Shay, how come we can get away with doing two minutes per stage as opposed to three?
Is your heart rate going to level out faster on an exercise bike than it will on a treadmill? Are you changing intensities? Yeah. One of the main reasons? Because you're seated.
Because you don't have to adjust the way that your body is pulling itself together on the exercise bike like you do. on the treadmill so we can lower the amount of exercise time a little bit on the bike. Okay, so we have the same issues that we have on the treadmill. We're trying to reach the target heart rate or we decide that it's time to go into the tool down or they decide that it's time to go into the tool down. Same rules apply as far as if they're not feeling well.
you can take them to the massage table and have them lie down for a while. That's all perfectly fine, but if possible, have them go into that cool down and measure how long it's going to take them, or how long it does take them, to get within 10 beats per minute of that stage one heart rate. And once again, no matter what you use as your endpoint, you've got to write in a number in this blank. Time on recumbent bicycle to restart your heart rate, or to you stop the test or for them to stop the test. Okay, any questions about when and how to use the recumbent pipe for the assessment?
Pretty good with that. Okay, so close out of that one and let's bring up the elliptical machine. Yes, that's right. Okay.
So, there's a couple of notes out there, at least one note, that says only use with individuals who are in a very decent shape. And why is that? Because the elliptical is a very specific type of exercise, and it's not easy for a lot of people to do.
What would be some reasons why you might use the elliptical instead of the treadmill for their test? And I would say, of all of the cardiovascular capacity tests that we have, this one is the one that's been used the least. I would say probably since we've had that elliptical, which was, got that in 2010, we've had a little over 10 years, I would say probably maybe three people have used it as a part of an assessment. Plenty of people have used it during their exercise sessions, but only maybe three people have used it for their exercise test. But it's there as an option.
Who might be a candidate to use the elliptical? Obviously, someone who's in better shape. What might be another criteria why they want to use the elliptical rather than treadmill?
They have joint problems. That's probably going to be, of all the ones that discussed for the bike test, that's going to be the leading candidate for using the elliptical. A lot of people walking on a treadmill or just walking in general can be somewhat painful because you're having to support your own weight, you're getting a lot of pressure on those joints, whereas with elliptical, the machine itself is helping support your weight and it's a little bit easier.
What else would you want to have? What other criteria would you want to have them meet before you use the elliptical for their test? Do you think they have to be someone hard of hearing to be able to use the elliptical? No, they have to have probably used one before because if they're getting on the elliptical for the first time for an assessment, And that may be something that you want to do as an experiment at some point, sure. But for something like this where you're trying to evaluate the cardiovasculary capacity, probably not the best idea if they've never been on elliptical before.
Because it's, like you said, it's a very specific type of exercise. It does mimic the actions of running. But the way that it mimics them is it's not exactly like running. I had a physical therapist friend of mine for...
who used to call the elliptical machine the snow drift machine. Because she said it felt like as she was moving forward or moving backward, it felt like she was moving through snow, like trying to plow through the snow. That's actually somewhat accurate because you're feeling that resistance as you are moving forward.
I personally love the elliptical machine as a method of exercise. And we have one at home. I use it quite a bit.
Yeah. It's my favorite type of aerobic activity. I do run periodically, but I have to really kind of mentally talk myself into going for a run as opposed to lifting over it. It's kind of fun because I can put myself on the teepee in front of me, I play some music. Which you can do that when you're outside running or you're running on a treadmill, but for some reason it seems more monotonous to me to exercise in a treadmill.
But regardless, I want to make sure they have the best experience. Alright, so instead of revolutions per minute, what do we have? SPM, what are you supposed to S stands for? Strides.
Strides. Strides per minute or steps per minute, sometimes you see a list like that. Okay, level obviously is the resistance that they are snow plowing through.
And once again, we are reducing the amount of time on that device per stage, that would be about two minutes. And look at our calculation factor. rather than 65 or up to 75. The reason for that is that generally heart rates rise faster on the elliptical than they do on a treadmill. And because of the type of exercise, because you're moving through the snow drip, you generally won't be exerting yourself at a little bit higher level and thus we're going to have higher heart rate. Otherwise you're going to get your heart rate at stage 1. Okay, same rules apply.
and you're going to look for that cool down time, and you're going to write down the amount of time that it takes them to get to the target. Now if you do end up using one of these alternate tests, either the recumbent bite or the elliptical, they are on the computer in the lab, and you can print out or you can use one of the pre-printed assessment forms, print one of these out, and then on the assessment form, just write, used electrical machine for this particular test and then to staple it to the back of assessment. And that way we know what they did for the particular test. Now, might there be a situation, we kind of alluded to this earlier, but let's say you have someone who uses the recumbent bite for their first assessment.
12 weeks later, you've worked quite a bit on their balance, you work quite a bit on their leg strength, you work quite a bit on their joint health, and they're better able to walk. Do you want to do the treadmill test instead of the bike test? The second time around. The coal ship has said no, and he has the correct answer there. You want to do that bike test, because what if you don't?
What have you got to prepare to do? Can you compare the results of a treadmill test to a bike test? I mean, vaguely, but not really that strong.
What might be an option? Maybe do the bike test. the day of the assessment. And the next time that they come in for an exercise session after that, after you get a little bit, actually before you get warmed up, because the warm-up is kind of is kind of put into the, or is a part of the treadmill test, you can actually have them do a treadmill test.
Try to repeat the same conditions as closely as possible, and even have them actually do a treadmill test, and then potentially the next time they do an assessment, do another treadmill test as long as their walking capacity is still the same. Then you got options whether or not you want to do the do it the same way again with the bike test one day, a couple days later do the treadmill test. It just increases the complexity a little bit because they have to be a little bit more, a little bit more aware of their diet and their activity for a longer period of time and because you want it to be similar 28 hours a day. 24 to 48 hours preceding the second assessment and then 24 to 48 hours preceding the treadmill test. But it certainly is an option for you.
And they might want to do that, right? They might want to get an idea of what their cardiovascular capacity is like on the treadmill. Because are they going to be riding an exercise bike around when they're going from place to place, going to the store or whatever? Walking is going to be their primary way of getting around. So that's going to be better from a activities and daily living standpoint.
Okay, let us. Whenever I say let us, I always, like in my brain, I went to so many church services when I was growing up and my dad was a minister. I almost immediately want to say, right, because that's what my dad used to say.
Sorry to offend anybody who feels like I was somehow being blasphemous at that point, but my dad is one of the most blasphemous people that's ever been ministered to for 40 years. So, there you go. Alright. Next test is our lift and carry.
And on Wednesday, we would like to go down to the plantar rehab lab and start working on doing this actual test. But what we do with the lift and carry is we have a, I guess, a course set up so to speak. It's basically just a down and back.
And the down is 20 feet and the back is 20 feet. Start at one end, pick up a crate that's got 10 pounds in it, carry it to the other end, you set it onto a low shelf, put your hands at your side, pick it back up, bring it back back, set it back down, come to the other side, pick it back up. Okay, this is one of the primary points of confusion on the assessment, has been for a long time, but we have always counted repetitions as being 1 down, 2 back, 3, 4, 5, 6, 7, 8, 9, 10. So it's 5 down and backs equals your 10 repetitions. But we view...
repetition as being able to complete the course one time. So you're completing it going down to the shelf to set the crate and you're completing it to come back and set it down on the floor then pick it back up. Okay so what is the lift and carry about?
It's evaluating their ability to carry objects efficiently for a short period of time. They're trying to do it as quickly as they can without running. And that's the primary data point that we pick up out of this, is their ability to be able to complete those 10 repetitions, how long it takes them.
And obviously the faster that they can do it, typically the more efficient they are, the better they're able to move, the better their mobility is, the better they're able to hold their core, the better they're able to sustain holding that crate. And only holding 10 pounds. Which for most of us is like, 10 pounds, that's nothing.
But for a person who's been through cancer, who is just finishing chemotherapy, might be 7 or 8 years old, 10 pounds may actually be too much. We may actually have to take a 5-pound plate out of there or take both plates out of there and take zero pounds in order for them to be able to do that test. And also, if you've got someone who's got severe lymphedema issues, You may want to reduce the amount of weight that they're carrying just from that standpoint.
Think about it. You're carrying that crate. You pick it up. And how do you carry it?
You carry it just like this, right? You try to carry it as snug to the body as possible. If you carry it way out like this, it puts a lot of pressure on the little back.
So if you're carrying a child or you're carrying a load of laundry or groceries, you're generally going to carry it close to your body. But look at my arm position. If I was like this.
would you be as concerned about lymphedema? Not as much. But when you're contracting the arms, and you're restricting the flow of fluid, that could potentially be a problem, and that's going to be more of a problem if you've got 10 pounds in that crate for that person who has lymphedema.
Now, you may have plenty of people who are afflicted with lymphedema who are perfectly capable of doing that 10 pounds, because in many cases that's the limit. that they were given at the very first time point after their surgical procedure is don't lift more than 10 pounds with this arm or whatever arm they had with those were moved from. And so that 10 pounds is usually not a problem, but there's no issue with modifying that.
Like you said at the very outset of this whole assessment thing, we are modifiers and we always will modify whatever necessary whenever it is warranted. But what do we have to do on our data collection form? Write it down.
Write it clearly so that the next person, if it's not you, or even if it is you, 12 weeks later, can you remember exactly how you did something 12 weeks later? No, I can't. No way.
So if I have it written down, I know how I did it. I know that I can repeat it the same way. Okay.
What might be some other ways? that we would modify the lift and carry test besides the amount of weight. How many breaths per day?
So, in your sort of pre-game speech before the lift and carry, you're going to give a little pre-game speech prior to each one of these assessment tests where you're going to be explaining the test, you're going to demonstrate it, you're going to remind them. We want you to do the very best you can, but if you get to your third... down and back, and you're feeling it, and you're like, you know what, I don't know if I can do this a couple more times, that's where we'll stop the test.
That will be your time to complete six repetitions, as opposed to ten. You go down and back three times. Or maybe, excuse me, maybe you go down and back, down and back, and then down, you set it on the shelf, and you're like, I'm done. Time to complete. five repetitions.
So what do you got to do on your data collection form? Scratch out that 10, write in five, and then hop to the side, say test was stopped at five repetitions. And if you want to be even more clear than that, you can say they stopped it after they set it on the shelf for the fifth repetition. Okay. So that's perfectly fine.
They can stop the test whenever they want. Most of the time, I... It's pretty rare that we haven't had someone who's been able to do the entire test.
Now do they move quickly? Some people don't. But they're able to complete it down at bat five times, usually without too much difficulty. But the option is always there to modify.
Now the common mistake of course is what? Down at bat ten times. And I've often been going through data to an ant.
to analyze it for a paper or a presentation or whatever. And I get to the lift and carry, and it's taken someone like three minutes to do it. I'm thinking, okay, this person is 65 years old. They're not in the greatest shape in the world, but they're not in that bad of shape. I'm like, oh, I trained all of them.
I follow up their trainer. So when you do the assessment, how many times did they go back? Well, I did 10, just like it says.
Oh, remember your training, young Padawan. You have to make sure that you're following that training. Now, if they do it 10 times down and back, that's fine. That's not the end of the world.
and you're making them work a little harder than they need to for purposes of the assessment, that's okay. What are you going to do for the next assessment? What would be a good way to give a little bit of a modification that might allow you to be able to shorten the test the next time the assessment is done? Do you want to have them do 10 times down and back again? Tyler's shaking his head no.
Unlike Cole, who was shaking his head no, I'm afraid you're incorrect. You want to have them be tapped out of that 10 times again. Why?
So that you can have a number compared to the times to complete that 10 repetitions. But what can you note on your stopwatch and create a collection form so that you can shorten the test on the subsequent assessment? And it takes something to describe the actual thing.
And you want to say the same thing at the same time? Yes. Yeah, the actual thing. So when they go down and back five times, note that time, write it down in your data collection form, and the next time an assessment is done on that person, then they can just do it the regular five times.
And you can compare it to that number. Now, is that going to be absolutely perfect? No, because they're counting on the fact that they're going to do it ten times. So their speed may be adjusted for those extra repetitions. Would you ever do something like this?
You could, but... there probably isn't any specific reason to unless what they're doing activities ability wise requires them to carry heavier loads on a regular basis like for instance if they work at a you know uh like a lowe's or home depot or whatever and they're constantly carrying around 20 pound bags or 40 pound bags and stuff and then maybe yeah maybe put 40 pounds in the crate have them do the test that way that way they're getting a better idea from their actual... So there could be a reason to do that.
As long as you don't hate it, all good. Perfectly fine. Okay?
Alright, any questions on the lift to carry? Now, before I get to that, post-test heart rate. When they finish that fifth down and back, or that tenth repetition, they set the crate down, they stand up, we want to get their heart rate immediately at that point. Okay?
So if you're having to do it via palpation, you've got to be ready to go at that point. Why do we want to get their heart rate immediately, not wait 15 to 20 to 30 to 40 seconds after they finish? Why would that be crucial for us? What are we trying to evaluate with that post-test heart rate?
With your abdomen, that's right. Yeah. what their heart rate is, what their actual exercise heart rate is, right? If you get it right when they stop, that's going to be as close as you're going to get to getting it while they're moving. And it's honestly hard to do it while they're moving because, you know, they're moving.
So when they stop, immediately get that post-test heart rate. If you wait 30 seconds, what's the problem? Yeah, why? Because you're going to be moving down, your intensity is dropped.
So your cardiovascular system does what? It adjusts. And you're going to get a mixture of exercise heart rate and standing heart rate.
You're probably not going to get a pure standing heart rate with 30 seconds of time, but you're going to get a mixture. And so you want to make sure you get that post-test heart rate, then write down how long. So stopwatch, get heart rate, boom, you've got everything that you need for that test. Alright, any questions on Olympic Carry? I'm going to go a little bit longer than we normally do before we start our exam.
If you do have to go, go to the bathroom or get up and move around, please feel free to. Alright, the one foot stand test. This is placed in the middle of the assessment so that we give them a little bit of a break from the more physically exertive exercise. The treadmill, the Olympic Carry, sit the stand. Stereoclimate, that all involves a little more cardiovascular involvement, a little more physical exertion.
Whereas the one-foot stand test, not to say it's not challenging, for a lot of people it's more challenging than the huge assessment. But it is a little bit a little bit less of a detergent from part of your vasovaginal. So we put it right there in the middle, but it doesn't if you're doing them out of order. It's okay. Don't don't worry about that Don't think that it's not the middle.
It's not where it's supposed to be. The order is the order that you put them in. As much as possible try to keep it towards the middle. All right, so why do we test one foot balance.
Why do we train one foot balance? The answer to that question is basically the same. Yeah, but why?
What's the point of doing it on one foot? That was my main question. Why don't we test balance on two feet or have them stand on a balanced pad? Why don't we test it on one foot?
You can see where they might have any discrepancies or where they're up. Working harder on one side. Okay, first part of the answer is you're looking for imbalance between left and right. And usually most people will have an imbalance. And the sport that people play that gives the most imbalance is, unfortunately, I'm sorry, it's basketball.
Why? Because what does a basketball player do if they are right-handed? Are they better at doing a left-handed layup or a right-handed layup?
Right-handed. what leg do they go up to do the layup with left. So generally for basketball players, if they're right-handed, their left leg balance is generally superior than it is to their right leg balance, unless they've really been working hard at both sides of the basket. But most people, depending on their handedness, tend to be stronger on one side of the body or the other, because if they're right-handed, if they're reaching for something, They have to reach up on one foot. What are they going to do?
Probably going to reach with the right hand. They're going to go up on their left foot and try to extend themselves as much as they can. So generally your balance is going to be reflected of what hand you are.
What other reasons would you have for testing balance on one foot? Differences from one side to the other? What else? How often are we on one foot during our activities of daily life? Okay, we already mentioned one when you're trying to reach for an object, so that might be a reason to do it.
But what else are you on one foot where injury might be a consequence? Stairs? Stairs? To a certain extent, yes, because you step up and you've got to launch yourself with one leg.
to get the other one up there. But generally of course you've got that handrail there for the most part on most spirit cases. So that makes it a little bit more safe. So yeah, that's one potential. Okay, getting out of the shower or if you are losing your balance.
And honestly when you're getting out of the shower, okay, you are trying to maintain balance on one foot. But if you're losing your balance at some point in the process of falling, all your body weight is on one foot. And if you're able to right the shift, if you're able to hold your core steady enough, if your balance is good enough that you can get that other foot back on the floor, your chance of falling doesn't go away completely because in some cases you might be leaning one way and come back the other way and all of a sudden you've got a problem going the other direction.
But in most cases, if you can get back on two feet, your chance of falling is... minimize. So that's one of the reasons why we test it. One of the reasons why we train it is because when you are falling at some point, you're going to have all your weight on that one foot and your ability to right the shift is key to avoiding that fall. All right, so for our one foot stand test, we generally do this at a specific area of the lab that is next to the yellow exercise.
I'll never remember it obviously. But there's sort of a corner back there where you can do this balance test that allows you for them to have one hand on the wall while they're getting in position and they're staring back into the corner rather than staring out into the open room. Why is that a smart thing to do if you're testing balance?
See that little letter? Sorry, I think it was a fan. It was a distraction.
Yes, distraction. That's exactly it. In the middle of the room, there's more objects that they can look at.
There may be people out there, so if they're staring back into that corner, less distraction, they're focused on you know, real look at their balance. But the one of the most important things is that you've got the hand on the wall. You can stand right here, so that if they have any instability, they've got the wall on one side and you on the other.
Okay, so when they're getting ready to do the test, I just want to step over here. That was what we were talking about here for a moment. Alright, so if they're balancing on the left foot, right hand's on the wall, okay? And get themselves in position, right leg is up, left leg is flat, right leg is made up of the wall, and start the stopwatch.
Okay? You want to have them keep their hand here, so just in case they lose their balance, they can put their hand back on the wall. What would be the reasons why we would stop the stopwatch for the balance test? Hands off the wall, okay? What would be one reason?
If the hand touches the floor, the test is over. If off foot hits the floor, the test is over. If off foot hits the other leg, the test is over. So I can stand like this for a pretty long period of time. I'm not going to show off, but I can.
Okay? If you take your foot away, that makes it harder. It's all on one foot at that point.
What would be the last reason why? would stop the balance test or stop your stopwatch. And take a hand off the wall, excessive sway. And that really honestly is the most subjective part of this particular test, is how much sway you're going to allow before they actually click the stopwatch to stop.
But for most people, once they start to sway a little bit before too long, The off foot has got to be the floor. You really need to stop and stop much at that point. Alright, first stage is eyes open and you test both the right and the left leg.
Keep the point in the same direction. Same hand, hand on the wall and you just shift, shift left. The afternoon equal.
For 30 seconds! You can't decide what to be more scared of, training or my voice. Alright, if they can make it for a full 30 seconds without their hand touching the wall, off-foot touching the floor, touching their leg, or sway, they have passed that stage of the test. At that point, let's say that they're able to do it with both legs, 30 seconds, then you can find a switch both ways. That is, you go back to your original leg and the wall, foot is up, and you add an extra layer of a squat.
As soon as you close your eyes, even if you're just sitting here, close your eyes for a second. A few of you have had your eyes closed at different times during the lecture this morning. But if you close your eyes, you kind of lose where you're at in space, right? It makes it more difficult to balance.
So that's an extra level of challenge. And I think we've had great people in the course of SRAM Survivors since 2005. who have been able to get past stage two, which is one foot, eyes closed. So it is a challenging thing to do. Now, let's say that you make it for 30 seconds on the right foot, but 19.5 seconds on the left foot.
Are you going to do eyes closed on both sides? The answer to that is no. Only on the right foot were you made it the full 30 seconds when you do the eyes closed. Because they didn't make it the full 30 seconds.
the left side. So you don't have to do the eyes closed unless they make it the full 30 seconds. If they do make it the full 30 seconds with eyes closed on either leg, then the next one is up on your toes and we've never had anybody be able to do this for 30 seconds.
If they can, get somebody that can do that at some point. What's the next stage? And if you can do that, it probably shouldn't be an impromptu match. Okay, any questions on the balance test?
We're obviously evaluating how long they can maintain that position, evaluating core, evaluating muscular system, evaluating muscular strength, evaluating tendon tissue strength, bone strength, all of those are being evaluated in that balance test. Alright, the sit to stand. We have a specific chair that we use for the sit to stand.
And in this case, one repetition is down and up, or up and down. Alright, so they start off seated, go up and down one, up, down two, all the way up to ten. Once again, you can reduce the number of repetitions.
They can use the arm rails of the chair if necessary to help get them out of that chair. a repetition or two or all 10 of the repetitions if they need to use those those those handrails if they're using their arms you just have to know whether or not they did and one what repetition did they use their arms first and if it's the very first one then very first repetition they use it for all of those repetitions for once again it's a time test How long does it take them to complete that test? And again, as soon as they're done, they sit down after that 10th rep, post-test heart rate immediately. Because even more than the lift and carry when they're standing, if they sit, their heart rate is going to fall even faster in that circumstance.
You really got to get that post-test heart rate evaluated relatively quickly. All right. Now, when they're in that chair.
You have that sit in a position that's comfortable for them. Usually for most people it's about shoulder width apart, but if they want to go real wide again, if they want to go real narrow, that's better for them. That's fine.
What you're going to measure is the width and depth of their feet. So width is outside of foot and outside of foot. There's a tape measure down there. We measure in centimeters.
So that is their measure. The depth is from the front leg of the chair. out to the front toe, front leg of the chair, out to the front toe. Okay, that is the depth of their feet.
Okay, so why do we want to measure where their feet are during this test? Why would we want to repeat that the same way during the second assessment, or the third assessment, fourth assessment? Why do we want to keep that a common point in our protocol? So you can compare it.
We're keeping the testing conditions the same. Because if they do it shoulder width apart the first time, then a little wider the second time, it gives them a little more power, or they're going to be able to go faster just because of that. Yes, we want to evaluate their leg strength in that same exact leg position.
So making sure that we render those things is going to be key for us. Alright, last one is a stair climb to the set. We have a specific stairwell that I'll show you on Wednesday where we do our stair climb to the set. Three times up and down of all the tests that we have to modify. This one is the one that has the most modifications because for some people they go up and down once and they're like, screw this, I'm done.
It's 12 steps. So for a lot of people that's relatively challenging. They have the choice of how they're going to go up and down. What most people will do is they'll go up one side, they'll turn around and they'll come back down the same side.
But they have the option if they want to go up, over, down, and make kind of a square as they are doing the test or do the opposite production. So the side of the stairwell is you facing the stairs. So if they go up the right side, they're using the right handrail, and they come down the right side, then it's upright, down right.
And if they go up the right side... Cross over, come down, then it's up, right, down, left. And pretty easy to do as long as you remember that you're facing the stairs when you're evaluating that. Once again, it's a timed test.
As quickly as they can do it without running. And you get that post-exercise heart rate whenever they're done. Whether it's after one repetition, two repetitions, or the full three repetitions of that test.
The main rule is that they have to keep their hand on the handrail all the time. Up and down. What a lot of people will try to do is this, right? And they'll try to go up the stairs using their arms.
Gotta keep the hand on the handrail for safety purposes. That kind of would never have anybody fall on the stair climbing ascent test. So make sure you remind them, even if they take it off for a second. Okay, Larry, put your hand back on the handrail, please.
Because some people will forget. They'll take their hand off the handrail, try to move a little bit. faster.
We've got to keep them in on the handrail the whole time. Alright, any questions about the assessment in general? I know we spent quite a bit of time on it, but it is something that we have to make sure we're doing properly so we can make sure we're we're getting accurate data when we're doing these assessments.
So we are recording this data in presentations or in papers and we know we're getting stuff that is that is that's good. Hi Heather, it's Dr. Phil with Strong Survivors and this is the beginning of your assessment tutorial. We start with the resting measurements and I'm going to flip my little camera around here.
There's Jeremy, your trainer. Say hey Jeremy. Hello Evan. All right and so the very first thing that we do with an assessment is resting measurements where we take a resting heart rate and I've described that in the document that I attached to the email.
Pretty easy, you just need to get as relaxed as you possibly can for three to five minutes. If you want to have your husband track your heart rate, that's great. And you can use a heart rate monitor, you can use an Apple Watch, you can use a Fitbit, or you can just do palpation where you're counting beats. And any of those will work. And obviously you can get yourself as relaxed as you possibly can.
You can take a short little three to five minute nap. But what you're looking for is where your heart rate kind of bottoms out, what the lowest, lowest value there is, and then you're going to use that in the calculation for the test we're going to have. Okay, so are you familiar with walking on the treadmill? Yes, I am.
Okay, great. So there's only three reasons that we would stop the test. One would be that your target heart rate is reached, or you would want to stop the test, or you would want to stop the test.
Your symptoms showing up like your skin color gets a little gray or you start to sweat or stumble or anything like that. Those are the only three reasons that we would stop the test. Okay. So the test is going to be a sub-maximal test. We're not going to push you to your hardest maximal heart rate.
There's three-minute stages and an incline and speed change for every stage. So I will ask. for your rate of perceived exertion after every stage and I will check your heart rate. So the treadmill pace starts slow and then it gets faster as you progress. You ready to try it?
Yes I am. Okay. All right. Okay, good.
So we'll go for three minutes, and at the third minute we'll raise the grade of the treadmill. But we won't raise the speed yet. Got it.
How are you feeling so far? Good. Good.
Yep. Weekend. Oh, fantastic. So glad to be in the Strong Survivors Program.
Yes. Very glad to have you too. Thank you, I appreciate it.
Did you more? Good and great. First stage.
So when it gets around the two and a half minute mark, I'm going to have you put your hands on the sensors just because we don't have a Fitbit or heart monitor hooked up to you. So it's going to tell us your heart rate, but normally we would have a Fitbit or something hooked up to you. We won't have you use your hands until you need to. Sure.
Yeah, I'm gonna have you go. Place your hands on there so you can get your heart rate. And then just when you see it flash, just go ahead and tell me and I'll write it down. Heart rate.
Okay, so I'll write it down on your sheet and now at three minutes we're going to go ahead and raise your grade to 0.5. So just hit that plus button for me there. Awesome.
We're going to do this for another three minutes. Alright. Okay.
How was that first stage for your RPE? Can you look at that scale? Right over there.
Alright, I'll do above 0.5. Okay, perfect. Write that down. Hi.
I'm having a busy week coming. Oh, always. Always on the grind. Oh, yeah.
It's a good one. Nice to meet you. For the second stage, we're not quite there yet, but we're only going to raise your grade again. We won't raise your speed yet, so we're only going to go up to 1.0 for your grade. Gotcha.
Put your hands on the treadmill again just to check your heart rate. 110. 110. Okay, doing great. Thank you. And then what would you say your scale of rated perceived exertion would be?
Probably still 0.5. I'm going to raise that. Okay. Right down. About 30 seconds and I'm going to have you just one more time.
Put your hands on there. We'll check your heart rate. Okay, so it seems you've reached your target heart rate.
We're going to go into the cool down phase now. So I'll have you lower your... Grade to zero. And we're gonna do this for one minute.
Okay. On Thursday, how would you say your RPE was? Just for those first few seconds. I don't know.
Let's do one. Okay. I'm gonna have you go ahead and hit that stop button for me.
And you are done with your graded treadmill test. Alright. Okay, we're gonna just take a couple laps around the room just to kinda get your feeling back into ya. Absolutely.
How was the cool down? Oh, it was good. Good. I pumped it all around. Okay.
What was your RPE for the cool down you think? I'll probably back down a point. Okay. Sounds good.
Alright, you mentioned you have a recumbent bicycle at home, so that's what we've sent you. Alright, you mentioned you have a recumbent bicycle at home, so that's what we've sent you as far as what you're going to use to measure your cardiovascular capacity. As you can see, Jeremy is pedaling away. Most important thing on a bicycle is that you get a reasonably full extension without completely straightening your leg out, so there should be a little bit of bend there.
And your bike probably, your bike console probably looks a little different than ours. On ours you just hit quick start. Then as long as you're pedaling, it's going to count down and get you started.
And the main things that you are looking for are something that tells you what the RPMs are and then something that tells you what the level is. And those are the two things that you'll control on your bike. And just follow the protocol as best you can until you reach that target heart rate, which, again, you can measure using a Fitbit.
You can... Use the Apple Watch heart rate monitor or you can just use your heart rate via Palpation. Okay, our next test is the lift and carry. Okay, and Jeremy has a crate that has 10 pounds in it. And if that's too much for you, you can certainly lower that amount.
You can usually use a cardboard box if that works better for you too. So when Jeremy's ready, he's going to start the test. He'll pick it up using proper lifting procedure.
He's going to carry it across the room. 20 feet. He'll set it up on top of the shelf, put his hands to his sides.
He's going to pick it back up and he's going to carry it back across the room. And he'll set it down using proper lifting procedure and then he would repeat that. Alright, I'm going to have Jeremy do this now at more of a test speed.
So Jeremy, whenever you're ready, go. Carry it across the room without running. Set it on top of the shelf, hands to the side. He's going to pick it back up. He's going to bring it back over.
Set it back down. We're going to pretend this is his last one, and I would ask Jeremy what his heart rate was at that point. All right, this is the balance test.
It's a one-foot balance test. We start with eyes open. You're going to do it on both feet. And you mentioned that balance is something that you want to work on, so we're definitely going to test it, and then we'll work on it with your exercise sessions. So you can see Jeremy has his hand against the wall to steady himself.
He's going to go ahead and lift his right leg up so he's balancing on his left foot. And what we're looking for here is any excessive sway or his up leg touching the ground or his up leg touching the other leg or his hand touching the wall. So as soon as he's ready, he's going to take his hand off the wall. He's going to balance. He's going to keep that hand there.
Just to make sure if he loses his balance, he's got that wall right there. And it might be a good idea to have your husband standing on the other side, just in case you lose your balance. And if you can make it the full 30 seconds, you can put your foot back down, Jeremy.
If you make it the full 30 seconds on either foot, then you're going to do the test with your eyes closed. Everything is exactly the same, except your eyes are closed. folks have a difficult time making the full 30 seconds. Okay this is the sit to stand test it's Time test, you're trying to do it as quickly as possible. So Jeremy has positioned his feet.
We've measured from the front part of the chair out to the toe and then from the outermost toe on one side to the outermost toe on the other side. And he's going to complete 10 of these. If you can't get 10, that's fine. Just time however many you can do consecutively. So Jeremy, whenever you're ready, go.
He's keeping his back nice and straight. That's two. 3, 4, 5, 6, 7, 8, 9, 10. And then I would ask Jeremy what his heart rate was at that time.
This is the last test. It's the stair climb and descent test. And find a stairwell that has at least 12 stairs.
And it has a handrail and what you're going to do once again, it's a time test You're going to up and down three times if you can't make it the full three times. That's okay Just time however many times you can you can make it so whenever Jeremy is ready You can go ahead and head on up. He's going to keep his hand on the handrail the whole time up and down He'll turn switch his hands good come back down And again, it's a time test, so you're moving as quickly as you can, and you would end up doing that three times. Alright, and that completes the assessment.
So, say goodbye, Jeremy. Bye, Heather. Yay! Yay! One love!
Yay! Yay!