Exercise Testing

     A.   Sub Max Tests
          1.   Use the ACSM sub max test
          2.   220 - age has some variance
               a.   some people may stop at 70 or even 100 %
          3.   The ACSM test has different endpoints
               a.   85 % of HR max
               b.   pre determined exercise intensity
               c.   achieve a certain RPE
          4.   VO2 max is an unreliable measure
          5.   Not is good for diagnosis, as need to go a high
               intensity
          6.   used best for intraindividual differences

     B.   The test itself
          1.   measured in ml/min and is non-weight bearing
          2.   bigger (muscled or resistant trained) people have
               an advantage
               a.   may therefore overestimate their VO2max
          3.   Considerations for the protocol
               a.   weight
               b.   activity status questionnaire
                    (1)  works for both the test and the
                         prescription
          4.   Monitor HR during the test
               a.   the last 15 sec of ea.stage for 2-3 stages
          5.   Test termination
               a.   70 % is okay for older pop.(35-40), but may
                    not be a high enough intensity for older
                    people
          6.   Calculation of VO2
               a.   use the axis derivation
               b.   or use 2 KGM + 300
                    (1)  used for non-weight bearing activities
                         that only have one point
                         (a)  ex: if the max is 200 watts, then
                              200 W = 1200 kgm., so 2*(1200) + 300
                              = 2700 ml/min
               * read the acsm manual for the cycle max protocol

I.   Legal Aspects
     A.   "Exercise testing in adults"; JOHPERD, June, 1975, p. 17-
          19.
     B.   Legal and procedural considerations
          1.   Standard of care 
               a.   The AMA, American Heart Assoc.,the ACSM, the
                    American PT assoc. all publish standards for
                    professional standards of care
                    (1)  should be familiar with all of them
          2.   Providing a safe test
               a.   what constitutes a safe test for the
                    participant
          3.   Legal risks associated with tests
               a.   what risks from the test are for the
                    participant
     C.   What constitutes Liability
          1.   Negligence
               a.   failure to conform ones conduct to a generally
                    accepted std. of duty
               b.   failure to give due care to protect the
                    patient
                    (1)  if you are supposed to do so
               c.   the failure to protect proximally caused the
                    injury
               *    in general
                    (1)  must have to protect
                    (2)  must have the resp. to protect
                    (3)  prove proximal cause from the failure to
                         protect
          2.   Other parameters (if omitted)
               a.   monitoring ECG, HR, BP, RPE, etc.
               b.   pre-screening (risk factor ass.) or medical
                    screening
          *    ALSO
               c.   with more education, are held more resp.
               d.   still held accountable for std. of care if
                    have just a little knowledge
               e.   cannot practice medicine without a licence (or
                    will be in violation of a civil and a 
                    criminal law)
                    (1)  cannot diagnose and prescribe ECG's
     D.   To minimize risks
          1.   Exercise due care consistent with common
               professional standards
               a.   will be determined by a jury in a civil court
               ***  not avail for medical exer. testing***
          2.   Execute a consent form
               a.   it is an assumption of some of the risks by
                    the subject
     E.   Conducting an Informed Consent
          1.   Subject must be legally capable of giving consent
               (adult)
          2.   must know and fully understand risks consenting to
          3.   must know all facts and related dangers in order to
               make an informed decision
          4.   must give the consent voluntarily, under no duress
     F.   Further considerations
          1.   Be aware of organizations that publish standards
          2.   Ask questions regarding activity habits
          3.   know of local medical practices and nat'l std's
          4.   add knowledge of risks to consent form (adapt it to
               population)
          5.   have a legal council and a medical director
          6.   MUST have liability insurance
          7.   If you suggest your program is a preventative
               program, then it is a medical program
          8.   See the state statutes on informed consent
          9.   Have a physician answer questions from participants
               
          10.  obtain consent by audio/video tape
          11.  keep copies of records (questions and responses)
          12.  Document the emergency procedures
          13.  Inspect the physical site (w/ written records)
          14.  Institute people how to use equipment
          15.  keep records on personal certifications 
          16.  evaluate employees periodically, check out
               references