Exercise Referral and Prescription                                                      Danielle Gatherar

 Patient Screening

Physical activity schemes require assessments in order to measure health outcomes, this is due to an element of risk that coincides with partaking in physical activity in all individuals regardless of fitness level, expertise and intensity etc. The assessments are also used to monitor improvements and progress for the client. Certain tests can be carried out in order to indicate level of fitness for the client. For example, maximal oxygen consumption provides an elaborate insight into fitness and is considered the ‘gold standard’ method (Cataneo and Cataneo, 2007). However, it is not always ethical to implement this method on clients who are classed according to the risk stratification as high/dangerous risk etc and therefore, sub maximal estimations should be favoured in this given situation.

Siconolfi Test

The Siconolfi test is a step test which is suitable for clients who are unfit and is used to predict their sub maximal aerobic capacity. It requires a calculation (220-age)0.65 to work out 65% of age predicted maximum heart rate (APMHR) and a 10 inch step bench. The client is asked to wear a heart rate monitor before setting the metronome at 68 to a four count beat. The subject then puts one foot up on the step to the first beat, then the other foot up on the second beat, then one foot down on the third beat and finally the other foot down on the fourth beat. This process is repeated for three minutes with the heart rate recorded in the last 30 seconds. If heart rate is more than 65% APMHR then the test is concluded. If the client’s heart rate is less than 65% APMHR then the client rests for 1 minute and test is repeated with the metronome set at 104 beats per minute. Again if the heart rate exceeds 65% of APMHR then the test is terminated and if the heart rate is less than 65% APMHR then the test continues with the metronome set at 136 beats per minute. Use the nomogram (see appendix 2) to estimate O2max and then the following age correction factors for the gender of the client:

Females: O2max (L/min) = 0.302 x (nomogram value) – 0.016 x (age) +1.593

Males: O2max (L/min) = 0.348 x (nomogram value) – 0.035 x (age) +3.011

Advantages of this test are that it is quick, simple and portable. On the contrary, limitations of this test are that it is a relative prescription and not absolute, i.e. a taller client would find this activity easier to complete than a shorter client of similar fitness level. Additional limitations include differing performance levels despite being fit, for example, a rower would have greater upper body strength where as a cyclist would have greater lower body strength and consequently would perform better than the rower on the test.

Astrand –Rhyming Test

The Astrand-rhyming test is also a sub maximal test requiring the client to wear a heart rate monitor. The seat of the Monark cycle is to be adapted to suit the client and their weight is recorded. The client should then start cycling at 50 rev/min and depending on the client either a 2kg weight is to be added to the cradle for females (including the 0.5kg of the actual cradle) and 3kg for males. The client will then exercise for 6 minutes (or 7 minutes if the client did not reach a steady state). In the last 15 seconds of each minute, the client’s heart rate should be recorded. Using the average of the heart rates recorded in the 5th and 6th minute, O2max is estimated on the condition that the difference between them is no more than 5 beats/min. If the recordings do exceed 5 beats/min then the client should exercise for a further minute and the average should be calculated using the recordings taken in the 6th an 7th minute. The O2max is estimated using the table below:

The estimated maximum oxygen uptake is taken from table 1 (see appendix1) and is then corrected for age by multiplying the L/min value by the age correction factor from the table below:

Then use the table below to distinguish level of fitness for the client taking their age and sex into consideration:

Classifications of Fitness for Females

O2max (mL/kg/min)

Classifications of Fitness for Males

O2max (mL/kg/min)

Limitations of the Astrand-rhyming test are similar to those of the Siconolfi test as individuals who have greater lower body strength will perform better than clients who have greater upper body strength and that generalisations are made with regards to estimates and conversions. It is also costly to use this method on large groups or on a regular basis. However, when this method is implemented correctly it is extremely accurate, appropriate and short in duration.

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Non Exercise Estimations of O2max

Questionnaires can be used to predict a client’sO2max to gain insight into their physical activity levels and fitness. George et al (2007) used a method where an equation was used to predict O2max from the client’s BMI, gender, self rated functional ability (see appendix 3) and self rated physical fitness (See appendix 4) using the formula below:

O2max (mL kg-¹ min-¹) =


Gender: Female = 0, Male =1

BMI=Weight (kg) /Height (m)²

PAR= Habitual Physical Activity (0-10)


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