Assessment Fitness Health Related Test Articles & Resources

Pretest screening has been used as a means to ensure the safety of testing or A screening method such as an interview or a self-administered health status questionnaire is necessary to identify pertinent health limitations. The Physical Activity Readiness Questionnaire26,27 has been successfully administered as a screening instrument in conjunction with the Canadian Home Fitness This screening method is sensitive in identifying persons with potential health risks, but it excludes a large number of .la,28 This method may be counterproductive, because persons with chronic diseases should be encouraged to participate regularly in moderate-intensity

Since 1991, the UKK Institute has developed a field-based HRFI test battery (ie, the tests do not require sophisticated equipment, and they can be conducted under conditions available in ordinary communities) for working-aged adults with no major The test battery consists of body composition, cardiorespiratory, musculoskeletal, and motor components (Appendixs9-39), as suggested by Oja and Tuxworth5 and Bouchard and The structure of the battery is based on the available evidence on the relationships among different aspects of fitness and 7 Cardiorespiratory fitness has consistently been shown to influence health positively. It is associated with decreased mortality from coronary heart disease4 and with decreased death due to all Motor fitness, as assessed by balance tests, is proposed to have relevance to falls among elderly persons42 and possibly to back pain and injury in middle-aged Musculoskeletal fitness (flexibility, muscle force, and endurance) is known to be associated with functional ability and musculoskeletal symptoms. In older adults, mobility restriction can cause limitations in daily Restricted spinal flexibility has been proposed as a risk factor for low back dysfunction,44 but a protective role of mobility has not been Endurance of the back muscles is the bestdocumented fitness factor in the prevention of back Lower-extremity force has been shown to correlate with mobility functions such as stair The reliability of measurements obtained with the proposed UKK Institute's HRFI test battery has been established

The aims of our study were (1) to evaluate the safety and feasibility of the UKK Institute's HRFI test battery in an adult population and (2) to present a practical health screening procedure for non-physician fitness testing personnel to use for safe and effective application of HRFI testing.

Method

Subjects

The study sample was selected from specified age brackets of the residents of Tampere, Finland, who had previously attended preventive health examinations arranged by the municipal primary health care center. On average, 80% of the residents had annual examinations. About 80% of those residents had given consent for their personal data to be used for research purposes. Of these individuals, five age groups-subjects born in the years 1955 (age 37 years), 1950 (age 42 years), 1945 (age 47 years), 1940 (age 52 years), and 1935 (age 57 years)-for each gender formed our study population. A random sample of 437 men and 389 women, equal in size in each age cohort, were invited to participate in the study. Fifty-six percent of the invited men (n=246) and 65% of the invited women (n=254) participated in the fitness testing. About 50 persons (range=46-54) were included in each age group. The age-specific participation rates, from youngest to oldest age groups, were 57%, 58%, 52%, 59%, and 57% for the men and 62%, 63%, 68%, 66%, and 68% for the women. All subjects signed an informed consent statement, which contained detailed information about the study and the terms of participation.

Representativeness of the Sample

A questionnaire, administered in the municipal health examinations and accessible to two age groups (47 and 52 years), was used to compare the participants (62%) and the nonparticipants (38%) of the sample (Tab. 1). Using a five-category scale ("very poor," "poor," "average," "good," and "very good"), the nonparticipants rated their health status somewhat lower than the participants did. In addition, more nonparticipants used prescription medications and were smokers and fewer nonparticipants exercised briskly compared with the participants.

Procedure

The subjects attended two measurement sessions at the UKK Institute. During the first visit, the pretest health screening was conducted by laboratory technicians and fitness testing personnel (see "Screening for Health Limitations" section). During the second visit, individual assessment of HRFI was conducted by three fitness testers (see "Health-Related Fitness Assessment" section). The laboratory personnel and fitness testers of the institute work mainly for research purposes, and the repeatability of their measurements can be assumed to be good even though the reliability of the measurements was not assessed in our study. All testers had master's degrees in sport or health sciences and were trained to perform standardized measurements during two preliminary studies of 76 subjects. A test manual was prepared to further enhance the quality of the measurements. In case of emergency during fitness testing, a physician, nurses, and equipment for cardiopulmonary resuscitation were available.

Health-Related Fitness Assessment

The HRFI assessment consisted of a balance test for motor fitness; three flexibility tests and five muscle force and endurance tests for musculoskeletal fitness of the upper body, trunk, and lower extremities; and a 2-km walk test, developed at our institute,29 for cardiorespiratory fitness. Motor and musculoskeletal fitness was assessed first in a standard order, followed by 10 minutes of rest before the walk test. Brief descriptions of the fitness tests and the specific contraindications for each test are presented in the Appendix. More detailed descriptions of the methods have been reported Only tests that provided relatively reliable measurements, as reported elsewhere,s2932,33 were included in the battery (Appendix). In summary, the interrater intraclass correlation coefficients (ICCs), based on a one-way analysis-of-variance model, for one-leg balance, trunk side-bending, push-up force, and lowerextremity muscle tests ranged from .86 to , and the test-retest coefficients of variation ranged from % to %.8 The test-retest reliability, as measured with the Pearson correlation coefficient (r), was reported to be .89 for the Sorensen test of back muscular endurance32 and .99 for active range of motion in knee In the walk test, the test-retest correlation coefficients (r) for predicted maximal oxygen uptake (in milliliters per minute per kilogram) were .98 and .94 for men and women,

Screening for Health Limitations

Pretesting health assessment included measures of body mass and height to calculate body mass index (BMI) and measures of systolic and diastolic blood pressure (auscultation method with a mercury sphygmomanometer after 5 minutes of rest in a sitting position). The pretesting health assessment also included the modified Physical Activity Readiness Questionnaire (MPAR),26,27 a question on perceived health status, and an assessment of current level of physical activity, including the intensity of exercise (rated "none," "light," "moderate," and "high") and a single-item self-assessment of leisure-time physical activity (rated "vigorous activity twice or more a week," "vigorous activity once a week and some lightintensity activity," "some activity each week," and "no regular weekly activity").48 Descriptive results of the health assessment are presented in Table 2. The personnel conducting the testing used this information (1) to refer subjects with severe diseases or symptoms (Tab. 3) to a physician for a health examination or (2) to exclude them from selected fitness tests according to predetermined safety instructions generated by the three physicians of the research group (Fig. 1).

Subjects were allowed to participate in all fitness tests if the following conditions were met: (1) there were no "yes" answers to questions in the MPAR-Q, (2) systolic and diastolic blood pressure values were less than 160/ 100 mm Hg, and (3) the subjects were not obese (BMI

Assessment of Safety

The testers recorded all acute musculoskeletal injuries or symptoms and cardiovascular complications during the fitness testing. Delayed-onset muscle soreness was assessed with a questionnaire that was completed 4 to 6 days after testing. The questionnaire included questions about (1) the experience and severity of DOMS, (2) the location of the pain or soreness, (3) the possible test performance that caused the DOMS, and (4) the functional consequences of DOMS in usual daily activities. Cardiovascular exertion was evaluated by recording the heart rate immediately after each test, as indicated by continuous heart rate The subjects without medication that affects the heart rate were included (n=435). Exertion was expressed as the percentage of age-predicted maximum heart rate (%HRmax), which was calculated according to Arstila et al,49 as follows: 205 - x age. In addition, the percentage of subjects with heart rates higher than 85% of their age-predicted maximum heart rate was calculated.

Assessment of Feasibility

The exclusion rate of the subjects from each fitness test on the basis of health limitations was recorded. The reasons for interrupting the tests and statements by the subjects who were unwilling or unable to participate in a given test also were recorded. The time required to prepare, administer, and score each mot evaluated by three fitness testers on a five-point scale (1=very poor, 2=poor, 3=average 4=good, 5=excellent). Results are presented as the mean value of the individual ratings. In addition, the average time required to perform the complete test battery was estimated.

Results

Safety

Acute health problems. No major complications occurred during the testing. There were no symptoms leading to interruptions in the balance or flexibility tests. Two subjects interrupted the modified push-up test due to back pain, and two subjects interrupted the test due to arm pain. During the isometric back extension endurance test, the tester interrupted the performance of two subjects with a history of elevated blood pressure because their heart rate increased dramatically during the test. Three subjects interrupted the walk test because of lower-extremity pain, and one subject interrupted the test because of symptoms of influenza.

Delayed-onset muscle soreness. The response rate for the DOMS questionnaire was 95%. Sixty percent of the men and 78% of the women experienced some degree of DOMS. Five percent of the men (n=12) and 10% of the women (n=24) indicated that their DOMS was severe. Eighty-three percent of the subjects reported having severe pain in their thigh and gluteal muscles, and most of them assumed the one-leg squat test to be the cause. Few subjects reported having severe pain in their upper-body (n=6) or back (n=5) muscles. For 7% of the men and 12% of the women, DOMS caused difficulties in daily activities, especially stair climbing, squatting, and walking. Seventy-seven percent of the subjects who did not participate in leisure-time exercise or who exercised at a low intensity experienced DOMS (Fig. 2). Sixty-five percent of the subjects who exercised more vigorously experienced DOMS (Fig. 2). Seventyseven percent of the younger women and 67% of the older women experienced DOMS. Severe DOMS was experienced by 14% of the women in the low-intensity exercise group and by 8% of the women in the highintensity exercise group. A different trend was found in men: 9% of the men in the high-intensity exercise reported having severe DOMS; the percentage of men who experienced severe DOMS in the other groups ranged from 2% to 4%.

Cardiovascular exertion. The cardiovascular exertion of the fitness tests assessed by the heart rate recordings is presented in Table 4. In general, the range of heart rate values after all tests was large. The mean %HRmax did not differ more than 5% among the age groups. The highest levels were recorded after the walk test. The %HRmax after this cardiorespiratory fitness test was 84% in men and 82% in women. The heart rate was higher than 85% of the maximum level in 43% of the men and 37% of the women. Of the musculoskeletal fitness tests, the highest heart rate levels were recorded after the muscle endurance tests. The mean %HRmax after the modified push-ups was 77% in men and 79% in women. The heart rate was higher than 85% of the maximum level in 19% of the men and 24% of the women. After the isometric back extensor endurance test, the mean %HRmax was 67% in both men and women, and the heart rate values of few subjects (3%) exceeded 85% of the maximum level. In the lower-extremity extensor muscle tests, the mean %HRmax values were between 60% and 62%, and four women had heart rates that exceeded 85% of the maximum level. In the balance, flexibility, and handgrip tests, the mean %HRmax values were lower than 60% and no subjects' heart rates exceeded 85% of the maximum level.

Feasibility

Subject exclusion and limitations to fitness testing. The fitness testing personnel referred 8 subjects (2%) to the physician prior to testing. One individual was excluded from all tests because of multiple diseases and mental instability. All other subjects participated in one or more tests. Five of the 272 subjects who had not reported any health problems (54%) on the MPAR

The test-specific exclusion rates were variable, as shown in Figure 4. Fewer than 5% of the subjects in any of the five age groups were excluded from the balance, flexibility, and handgrip tests. Severe dizziness (n=3) was the main health limitation to balance testing. Three subjects were excluded from one or more flexibility tests due to musculoskeletal problems. No more than 10% of the subjects in any age group were excluded from the lower-extremity extensor muscle tests (jump and reach and one-leg squat). Pain in the lower back or the lower-extremity joints (n=8) and obesity (n=3) were the main reasons for excluding subjects from the jump and reach test. Nine subjects with pain in the lower back or the lower-extremity joints and 6 subjects with severe heart disease were excluded from the one-leg squat test. A larger proportion of subjects over 50 years of age (up to 27%) were excluded from the muscle endurance tests.

The greatest number of subjects were excluded from the modified push-up test (n=60). Heart disease (n=22) and high blood pressure (n=20) were the main reasons for exclusion. Seventeen subjects were excluded due to musculoskeletal symptoms of the back or arms, and 1 subject was excluded due to incorrect performance technique. Heart disease (n=15), high blood pressure (n=18), and severe back problems (n=6) were the main reasons that subjects were excluded from the isometric back extension endurance test. Over 95% of the subjects (n=481) completed the walk test. Nine subjects were excluded due to musculoskeletal problems, 6 subjects were excluded due to severe heart disease, and 2 subjects were excluded due to severe dizziness. One subject was not willing to participate after the warm-up. Maximal oxygen uptake could not be predicted for 17% (n=83) of the subjects who finished the walk test because they were taking medications that affected their heart rate. Practicality in terms of time requirements. The fitness testers rated the jump and reach test as the most practical test (mean= points). The mean scores for the one-leg standing balance, shoulder-neck mobility, handgrip, modified push-up, and isometric back extension tests ranged from to . The mean scores for the trunk side-bending and one-leg squat tests were and , respectively. The knee extension range-ofmotion test was rated as the least practical test (mean= points). The average time to perform the whole test battery was 80 minutes. This time included 40 to 45 minutes for the motor and musculoskeletal testing, 10 to 15 minutes for resting before the walk test, and 20 to 25 minutes for performing the walk test.

Discussion

Safety of Assessing Health-Related Fitness in an Adult Population

Health-related fitness assessment is indicated primarily for middle-aged, often unfit and physically inactive, person. In our study, 35% of the men and 30% of the women were classified as inactive (Tab. 2). The health risks of heavy physical exertion are increased among this Thus, the subjects' health status and physical activity level, as well as their physiological exertion in each fitness test and during the whole testing period, are important factors affecting the safety of HRFI testing. Extensive health examinations in large-scale fitness programs or population surveys are often difficult to conduct due to the time needed and financial costs. We believe, however, that a standard health screening procedure should be an integral part of any HRFI 50 In our study, the fitness testing personnel used a standard protocol to refer the subjects with potentially consequential health problems to a physician and standard instructions for themselves to exclude subjects with minor health limitations from selected fitness tests. With this procedure, the testers referred only 8 of the 500 subjects to a physician for further health examination, yet no major health hazards occurred. The results indicate that, among middle-aged adults, HRFI assessment can be safely and effectively performed with minor physician participation.

Most of the subjects experienced some DOMS. Women experienced DOMS more often than men did, and physically inactive individuals experienced DOMS more often than physically active individuals did. Occurrence of severe DOMS, with impaired function, was our major concern. The one-leg squat test seemed to cause severe DOMS and difficulties in mobility among a small number of subjects. The finding that inactive women were the most prone to severe DOMS is in accordance with findings that training may prevent or reduce muscle damage and Four subjects who reported severe knee problems (arthrosis, pain, surgery) during the health screening were excluded from the squat test. Their exclusion probably explains the finding that there were no acute or delayed experiences of pain in the knee.

The one-leg squat test was developed to assess restrictions in the lower-extremity A maximum of five squats for each lower extremity, with increasing external load relative to the subject's body weight, were performed (Appendix). Only 23% of the women were able to perform the test with the highest load (40% of their body weight) in contrast to 74% of the men. Thus, for most of the women, the squat required substantial effort, including a high amount of eccentric contractions during the downward phase. To avoid or minimize the DOMS in inactive women, we suggest that only loads up to 20% or 30% of body weight be used. In addition, subjects should be informed about the possibility of DOMS. These precautions might minimize the possibility of subjects developing negative attitudes toward fitness testing and training.

Despite the risk of DOMS, inclusion of the lower-extremity test in the HRFI test battery is warranted because it may be an indicator of mobility and functional independence in older ,53 There is a well-validated lower-extremity performance test for elderly We developed the squat test when we could not find any other easily administered test of lower-extremity muscle force designed for middle-aged adults. Suni et al] have established the reliability of measurements obtained with the test (interrater ICC=.86, coefficient of variation=%). Further studies are needed to ensure the safety of the test in terms of DOMS.

Heart rate is a good indicator of cardiovascular exertion in tests requiring movements of large muscles. The mean %HRmax values after the 2-km walk test (84% in men and 82% in women) were within the recommended levels for submaximal aerobic fitness testing5 and were optimal for the walk Forty-three percent of the men and 37% of the women exceeded 85% of their maximum heart rate. Similar heart rate levels during a (1-mile) walk test were reported by Porcari and When pretest health screening has been included in submaximal aerobic fitness tests, no complications other than minor muscle injuries have been reported,18 despite the relatively high heart rate levels. After the modified push-up test, mean heart rate values were about 78% of the maximum level, and the heart rates of about 20% of the subjects exceeded 85% of the maximum level. Because the cardiac load in the push-up test, as well as the isometric back extension test, is predominantly of the "pressure" type as opposed to "volume" type in the walk test, the cardiovascular health risks are expected to be more substantial than in the more dynamic walk test. The mean %HRmax values were around 60% in the lower-extremity function tests and were lower in all other tests, indicating a small risk of cardiovascular complications. Heart rate alone may not be an optimal indicator of cardiovascular stress during isometric muscle contractions. Blood pressure measurements during this type of testing would provide further information about physiological exertion and related cardiovascular Another, more accessible possibility to assess physiological strain during field testing would be the ratings of perceived exertion, which indicate how close the subject is to maximal ,56

Feasibility

Proportion of subjects qualified for the tests. Ninety percent or more of the subjects in each age group were qualified to perform the balance, flexibility, and short-term muscle tests. The low exclusion rates are in accordance with those reported in the Allied Dunbar National Fitness Survey,57 but they are somewhat lower than in an earlier population study in A substantial proportion of the subjects over 50 years of age were not qualified for the modified push-up test (22%) or the isometric back extension muscle endurance test (16%). The exclusion rates are similar to those reported in surveys assessing cardiorespiratory fitness of adults by submaximal ,ls,ss Prevalence of the most important health limitations (elevated blood pressure, self-reported heart disease) to testing was much higher in the two oldest age groups than in the younger age groups (Tab. 2). Due to the isometric contractions needed for the push-up and back extension tests, a large number of subjects with coronary heart disease or high blood pressure were excluded, although most of them were allowed to perform the walk test. Only 4% of the subjects were excluded from the walk test. Thirty-eight percent of the subjects in the oldest age group and 24% of the 52-year-olds were taking medications that affected their heart rate, which limits the use of the walk test for the prediction of maximal oxygen uptake and caused the population estimates of maximal oxygen uptake to be too high. To avoid this selection bias, walk time could be a preferred population estimate of aerobic fitness in adults over 50 years of age, because only 6% of the 52-year-olds and 7% of 57-year-olds in our study were not qualified to perform the test.

Time requirements for health-related fitness testing. The only test we used that took a considerable amount of time was the test of range of motion in knee extension, which we measured with a Myrin inclinometer.+ Standardization of subject positioning required careful preparation and continuous surveillance during the test. These characteristics may be overcome in individual fitness or clinical-type test situations, but they limit the use of the test in larger populations. Adding extra loads during the one-leg squat test was somewhat time consuming. We used a special weight belt with additional cuffs. The equipment helps to keep the extra load near to the center of body mass. All other motor and musculoskeletal fitness tests (one-leg balance, shoulder-neck mobility, trunk side-bending, handgrip, modified pushup, isometric back extension, jump and reach) were quick and easy to administer. The average time needed to perform the complete HRFI test battery was 80 minutes. The time needed for health screening is not included in that estimate because health screening was administered during a prior visit of the subjects. In practice, health screening is typically administered immediately prior to testing. The approximate time required for the screening procedure described was 15 minutes, and additional time was required for subjects needing further medical examination. To reduce the time cost, a shorter test battery could be selected according to the health of the subject group and the purpose of the testing.

A Safety Model for Health-Related Fitness Assessment

A safety model for HRFI assessment conducted by nonphysician testing personnel was developed on the basis of our results (Fig. 1). The model includes (1) standard screening for health limitations, (2) standard instructions to refer subjects with severe health limitations to a physician for further examination, and (3) standard instructions to exclude subjects with minor health limitations from selected fitness tests. The model could serve as an example of the elements needed in the safe and effective assessment of HRFI in adults. Because medical policies and regulations and practical needs vary greatly from one country to another, no strict guidelines for safety procedures can be

General Applicability of the Test Battery

The test battery was designed to assess the HRFI of adults with no known health problems. The study sample was selected, to some extent, in the same manner that study samples were selected in other fitness The participants had somewhat higher education and were healthier and more physically active than the nonparticipating part of the population (Tab. 1). This selection bias may raise the question of whether the test battery is safe and feasible for less healthy and more sedentary middle-aged persons. Despite the method of selection of subjects for our study, our study sample included subjects with chronic diseases and physically inactive lifestyles who were successfully screened to prevent severe complications. The selection bias of the sample, however, may cause the population estimates of fitness, if used as norm-referenced values, to be too high. The bias will be larger in those tests and age groups from which a large proportion of subjects are excluded. If this test battery is applied to older subjects, or to some patient groups, the context of health screening, the role of the physician, and the criteria to exclude subjects need to be reconsidered to ensure safety.

This HRFI test battery was designed to be used in the context of health-related physical activity promotion. It is a method for ( 1 ) assessing the status of HRFI of individuals and populations in order to evaluate the amount and type of physical activity needed to promote health, (2) monitoring the changes in HRFI and evaluating the effects of interventions, and (3) motivating individuals for regular physical activity. Interpretation of test results and exercise recommendations are important parts of HRFI assessment. Currently, the HRFI test battery provides an individual fitness profile based on age- and gender-specific norm-referenced values derived from the sample of the population described in this report. Our general exercise recommendation is that those components of fitness that are lower than the average level should be enhanced. In addition, health limitations to exercise, current physical activity level, existing knowledge of dose-response relationship of different types of exercises to fitness and health, personal resources, and the motivation and goals of the individual are considered to ensure an effective and feasible physical activity program, with good adherence.

Interpretation of the test scores according to the healthrelated fitness concept7 is aimed to give feedback to the individual in terms of the adequacy of fitness with respect to health The health criteria relate to disease prevention or functional adequacy and More studies with representative samples are needed to assess the relationships of different components of fitness to health and functional ability. As a first step toward this goal and to examine the validity of our test battery, we have studied the associations of the proposed tests with selected health outcomes (cardiovascular risk factors, perceived health, mobility, and backrelated functioning and symptoms) in this particular study population. These results will be published elsewhere.

In addition to relevant assessment methods, we believe that there is a need for training of testers to ensure reliable, safe, and useful HRFI testing, with proper interpretation and exercise recommendations for health promotion. The fitness testers need to be well acquainted with the testing procedures, appreciate the strict standardization of procedures, and understand the rationale for each test and for interpretation of the results according to the HRFI concept. In addition, they have to be able to screen the health limitations of the subjects and refer them to a physician when necessary. According to our experience, professionals in health care and physical education, including physical therapists, have optimal qualifications to conduct HRFI testing.

Summary and Conclusions

The proposed test battery offers a safe and feasible method for HRFI assessment of adult populations, with some reservations. In older subjects, coronary heart disease and hypertension limit their participation in isometric-type muscle endurance tests considerably, and to some extent in lower-extremity muscle testing at a near-maximal level. In addition, the high prevalence of medication affecting the heart rate in older age brackets hinders the prediction of maximal oxygen uptake in the walk test. Inactive women are prone to DOMS during the one-leg squat test at near-maximal levels. Most subjects in all age groups are qualified for the balance, flexibility, muscle force, and walk tests. Some musculoskeletal symptoms may limit the participation in these tests selectively. The results of our study highlight the importance of a standard health screening procedure. Safe testing is ensured, minor physician participation is needed, and most individuals qualify for the majority of tests.

"The President Urho Kaleva Kekkonen (UKK) Institute for Health Promotion Research Tampere, Finland

^ Polar Sport Tester

^^ Vinkelmatare Myrin, LIC, Rehab Vardrum, Solna, Sweden Sec SF-Sportfire Weight Belt, Urheiluareena, Tampereen Valtatie 19, 33100 Tampere, Finland

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JH Suni, PT, is Researcher, The President Urho Kaleva Kekkonen Institute for Health Promotion Research (UKK Institute) Tampere, Finland (). Address all correspondence to Ms Suni