Cardiopulmonary Exercise Test (CPET) Evaluation Report Name: Sally Alpha Date: Test 1 November 29, 2015 Test 2 November 30, 2015 Findings: Sally Alpha demonstrates poor functional capacity and early onset of anaerobic metabolism. This will severely limit her ability to engage in the normal activities of daily living and preclude her from full time work of even a sedentary/stationary nature. These findings are inconsistent with poor effort or primary depressive disorder. Indication: The patient attended our clinic for global functional evaluation examining metabolic, cardiovascular function after experiencing physical stress. She underwent a cardiopulmonary exercise test. She is 25 years old, 154 cm tall and weighs 85 kg. Diagnosis: Chronic fatigue syndrome/ Myalgic encephalomyelitis- ME/CFS Postural Orthostatic Tachycardia Syndrome/Multiple Chemical Sensitivities Procedure: The patient performed symptom limited 15 W/min ramping protocols on a bicycle ergometer while expired gases were collected for determination of oxygen consumption, carbon dioxide and pulmonary ventilation. The heart rate, blood pressure and arterial oxygen saturation were assessed throughout the tests. Pulmonary function testing was performed before the exercise tests to establish baseline-resting values. Appropriate measures were taken to calibrate and test the accuracy and reliability of the testing equipment. The test was performed to determine functional capacity and assess the recovery response to a standardized physical stressor. In the fields of exercise science and medicine cardiopulmonary exercise testing (CPET) is considered the gold standard for measuring and evaluating functional capacity and fatigue. Position statement and/or guidelines for the performance of this testing are available form the American College of Sports Medicine, American Heart Association, American College of Chest Physician s, American Thoracic Society and the American Medical Association, among others. All endorse this method of testing and acknowledge peak oxygen consumption, only available with CPET, as the most accurate measurement of functional capacity. The clinic has adopted this standardized, reliable and accurate tool to evaluate disability in fatigue related disorders. 1
Conclusions: 1. Assessment of Effort: Normal The patient was cooperative and gave very good effort during the exercise test. There is no evidence of malingering. Cardiopulmonary exercise testing provides objective measures that can clearly distinguish between indolence and true disability. See page 3, #1 Assessment of Effort. 2. Metabolic Response: Abnormal Oxygen consumption at the ventilatory/anaerobic threshold was reduced by 19% Test 1 to Test 2 which is abnormal. Measured values meet criteria for moderate to severe disability using the Weber/New York Heart Association guidelines. The test two value of only 32% of the predicted value, suggests functional impairment (expectedvalues are between 40 and 60% of peak) From anotherperson s report: The ventilator/anaerobic threshold occurred at 32% of predicted oxygen consumption (expected value is between 50 and 65% of peak). The ventilary/anaerobic threshold indicates moderate to severe impairment (i.e. 8 to 11 mlkg -1 min -1 ), which place this patient in Weber s Functional Class C. A ventilator/anaerobic threshold of less than 40 % of predicted oxygen consumption indicates pathology. 3. Workload: Abnormal Workload values at the ventilator/anaerobic threshold were extremely low. They would be insufficient to sustain work activity at any level. From another person s report: The low workload values at the ventilator/anaerobic threshold indicate an inability to sustain physical activity at any intensity above a sedentary level. 4. Cardiovascular Responses: Abnormal Ventilatory/anaerobic threshold values below 40% of predicted peak oxygen consumption may indicate a cardiac, pulmonary or other limitation in O2 supply to the tissues, or underlying mitochondrial abnormality (e.g. muscle dysfunction in cardiopulmonary diseases, mitochondrial myopathies, etc.). Elevated diastolic blood pressures may indicate risk for hypertension. From another persons report: The patients ECG was within normal limits during rest and with exercise stress. The patient s high resting heart rate combined with a low heart rate at the ventilatory/anaerobic threshold provides a very small operating window, for cardiac activation before reaching and exceeding the ventilatory/anaerobic threshold. This decreased capacity limits the ability to maintain work. 2
5. Recovery Response: Abnormal A recovery time of 24 hours or less and minor muscle soreness is considered normal following exercise testing. This patient was still suffering diarrhea, fatigue, and flu like symptom exacerbation for a month after the test, which should be considered and extreme reaction to physical activity. 6. Reproducibility Abnormal Exercise test-retest reproducibility is a cornerstone of cardiopulmonary exercise testing. These tests are both valid and reliable. Day to day test variability for metabolic processes is less than 8% for health individuals. Abnormally high variability for these measures indicates a disruption of homostasis during physical activity. 7. Pulmonary function Abnormal A ratio of 38-40:1 for minute ventilation to CO2 output (VE/CO2) is considered high. Partial pressure of end-tidal CO2 (PetCO2) at 32 30 mmhg was low. Both measures are indicators of possible risk factors for cardiovascular and/or pulmonary disease. The observed failure to achieve predicted peak ventilation and abnormally low breathing reserve are further indication of risk for pulmonary disease. RESULTS: 1. Assessment of Effort The American Heart Association cite peak respiratory exchange ratio (RER) as the most accurate and reliable gauge of subject effort. A peak RER of greater or equal to 1.10 is generally considered to an indication of excellent patient effort during cardiopulmonary exercise testing. Test Criteria Test 1 Test 2 Criteria Met T1/T2 RER > 1.10 Yes Yes Yes/Yes RPE > 17 Yes Yes Yes/Yes Plateau in VO2 Yes Yes Yes/Yes RER = Respiratory Exchange Ratio RPE= Rate of Perceived Exertion VO2 = Volume of Oxygen Consumed T1 = Test One T2 = Test Two 2. Peak and V/AT Values Peak Test 1 Test 2 % Change Reproducible 3
values VO2 21.0 22 + 1 Yes VE (l/min) 88 87-1 Yes Workload (W) 125 128 + 3 Yes V/AT Values Test 1 Test 2 % Change Reproducible VO2 10.5 8.5-19% No VE (l/min) 19.2 16.8-13% No Workload (W) 16 15-1 Yes VO2 Volume of Oxygen Consumed HR- Heart rate VE- Ventilation SBP Systolic Blood Pressure Bpm- beats per minute l/min litres per minute W watts mmhg millimeters of mercury 3. Metabolic Responses Peak Values Oxygen consumption (ml/min) Oxygen Consumption (ml/kg/min) Test 1 1635 22 83 Test 2 1670 22 85 V/AT Values Oxygen consumption (ml/min) Oxygen Consumption (ml/kg/min) Test 1 777 10.5 39 Test 2 633 8.5 32 Percent predicted (%) Percent predicted (%) ml/min millilitres per minute ml/kg/min millilitres per kilogram per minute 4. Work in Watts Workload V/AT (W) Peak (W) Percent Predicted (%) Test 1 16 123 89 Test 2 15 128 93 W- Watts 4
5. Cardiovascular Responses Heart rate Resting Seated (bpm) V/AT (bpm) Peak (bpm) Percent predicted (%) Test 1 88 129 187 101 Test 2 95 121 185 100 Blood Pressure Resting Supine Resting Seated Peak (mmhg) (mmhg) (mmhg) Test 1 116/88 126/94 152/88 Test 2 106/78 114/86 162/86 bpm beats per minute mmhg millimeters of mercury 6. Lung Function Ventaltion MVV (L/min) FVC (L) FEV1 (L) Respiratory rate (br/min) Peak (L/min) Test 1 98 3.2 2.48 45 88.1 10 Test 2 103 3.28 2.54 42 87.3 15 L/min litres per minute L- Liters Br/min breathes per minute FVC forced vital capacity FEV1 forced expiratory volume in one second MVV maximun voluntary ventilation 7. Recovery Response Ventilatory Reserve (%) The patient maintained a post exercise test log. Following the test, the patient reported feeling fatigued with headaches, joint aches, insomnia. The patient did not recover to the pre-exercise test level of functioning for at least four weeks. Summary: Sally Alpha exhibits cardiopulmonary abnormalities and reduced functional capacity. Her Test 2 ventilatory/anaerobic threshold of 8.5 ml.kg-1min-1 indicates a decreased capacity for physical activity. With values adjusted for her gender, age, height and weight, oxygen demands for everyday tasks such as washing/dressing, grocery shopping, preparing a meal and sweeping floors fall in the range of 8.54 to 14.95 ml.kg-1min-1. A light exercise activity such as mild stretching (e.g., yoga) with energy demands of 10.68 ml.kg-1min-1 is beyond the limit of Ms. Alpha aerobic capacity. Engaging in normal activities of daily living presents a significant challenge 5
for Ms. Alpha. This is both a demonstration of physical impairment and a quantifiable limitation of her ability to function in a work environment. Another persons report: Sally Alpha s early onset of the ventilatory/anaerobic threshold points to significant metabolic impairment. Sally Alpha s Test 2, ventilatory/anaerobic threshold of 8.5 mlkg -1 min -1 indicates that even low level physical activity will demand more energy than can be aerobically generated. Oxygen demands for everyday tasks such as washing/dressing, grocery shopping, preparing a meal and sweeping floors fall in the range of 7.35 to 11.55 mlkg -1 min -1. After experiencing physical stress there is a very small cardiovascular window before the ventilatory/anaerobic threshold is exceeded at very low levels of work. Merely engaging in normal activities of daily living will demand more energy that Ms. Alpha is able to generate aerobically. Performing such tasks on a consistent basis is a challenge that will likely precipitate the onset/exacerbation of symptoms, including excessive fatigue and pain. This is both a demonstration of physical impairment and a quantifiable limitation of her ability to function in a work environment. NOTE: The ventilatory/anaerobic threshold is an important index of the amount of work that can be sustained. Work intensities above the ventilatory/anaerobic threshold require energy production derived form anaerobic sources limiting the duration at which intensities of effort can be maintained, causing cumulative fatigue and extending recovery time. Most activities of daily living (reading, walking at normal pace, computer use, office-type work, etc.) are aerobic in nature and healthy individuals are able to perform, such activities for prolonged periods of time with no meaningful physical fatigue. If the ventilatory/anaerobic threshold occurs at low oxygen consumption, normal daily activities may exceed the energy demands that can be met through oxidative metabolism, thus requiring anaerobic metabolism to provide energy. This results in early onset fatigue and prolonged recovery. References ACSM s guidelines for exercise testing and prescription / American College of Sports Medicine ; senior editor, Linda S. Pescatello ; associate editors, Ross Arena, Deborah Riebe, Paul D. Thompson. 2014 Arena R, Sietsema KE. Cardiopulmonary exercise testing in the clinical evaluation of patients with heart and lung disease. Circulation 2011;123:668-680. American Medical Association, & Rondinelli, R (2007). Guides to the Evaluation of Permanent Impairment (5 th ed.), Chicago: American Medical Association. American Thoracic Society & American College of Chest Physicians, (2003). ATS/ACCP Statement on cardiopulmonary exercise testing. American Journal of Respiratory and Critical Care Medicine, 167(2), 211-277. 6
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