heal hca e
A icle
Adap ed Ches e S ep Tes Can Ha e Maximal Response
Cha ac e is ics o he Assessmen o Exe cise Capaci y in
Young Women
Rui Vila inho 1,2,* , Ana Ri a Mendes 3, Ma iana Gomes 3, Rui Fe ei a 3, Fabíola Cos a 3, Ma cela Machado 3,
Má cia Ne es 3, Cá ia Canei as 2,4 and An ónio Mesqui a Mon es 1,5


Ci a ion: Vila inho, R.; Mendes, A.R.;
Gomes, M.; Fe ei a, R.; Cos a, F.;
Machado, M.; Ne es, M.; Canei as, C.;
Mon es, A.M. Adap ed Ches e S ep
Tes Can Ha e Maximal Response
Cha ac e is ics o he Assessmen o
Exe cise Capaci y in Young Women.
Heal hca e 2021,9, 308. h ps://
doi.o g/10.3390/heal hca e9030308
Recei ed: 7 Feb ua y 2021
Accep ed: 7 Ma ch 2021
Published: 10 Ma ch 2021
Publishe ’s No e: MDPI s ays neu al
wi h ega d o ju isdic ional claims in
published maps and ins i u ional a il-
ia ions.
Copy igh : © 2021 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
1Cen e o Rehabili a ion Resea ch (CIR), Depa men o Physio he apy, Poly echnic Ins i u e o Po o,
School o Heal h, 4200-072 Po o, Po ugal; [email p o ec ed]
2Heal hca e Depa men , Nippon Gases Po ugal, 2600-242 Lisbon, Po ugal; [email p o ec ed]
3P i a e P ac ice, Poly echnic Ins i u e o Po o, School o Heal h, 4200-072 Po o, Po ugal;
[email p o ec ed] (A.R.M.); [email p o ec ed] (M.G.); [email p o ec ed] (R.F.);
[email p o ec ed] (F.C.); [email p o ec ed] (M.M.);
[email p o ec ed] (M.N.)
4Mic obiology Resea ch Labo a o y on En i onmen al Heal h (En iHeal hMic oLab), Facul y o Medicine,
Ins i u e o En i onmen al Heal h (ISAMB), Uni e si y o Lisbon, 1649-028 Lisbon, Po ugal
5Depa men o Physio he apy, San a Ma ia Heal h School, 4049-024 Po o, Po ugal
*Co espondence: [email p o ec ed]; Tel.: +351-222-061-000
Abs ac :
Ches e s ep es (CST) es ima es he exe cise capaci y h ough a submaximal esponse,
which can limi i s applica ion in he p esc ip ion o exe cise. This s udy aimed o assess whe he
an adap a ion o he CST (wi h a p og essi e p o ile) can ha e maximal esponse cha ac e is ics
in young women and compa e i o he inc emen al shu le walk es (ISWT). Ano he aim was o
de e mine i s wi hin-day es – e es eliabili y. A c oss-sec ional s udy was conduc ed wi h 25 women
(
20.3 ±1.5 yea s
) who pe o med he ield es s wice on wo di e en days (48 h apa ). The maximal
e o a ainmen was assessed by he hea a e (HR), pe cep ion o exe ion (Bo g scale), and blood
lac a e concen a ion. Fo he pe o mance a iables, Pea son’s co ela ion and in aclass co ela ion
coe icien (ICC
2,1
) we e used. In he bes es , mean alues o maximal esponse we e obse ed in
he adap ed CST (94.0
±
6.5% o age-p edic ed HR
max
, 11.3
±
4.5 mmol/dl o blood lac a e, and
18.4 ±1.5
o Bo g a ing). The co ela ions be ween he adap ed CST and he ISWT we e weak
o mode a e (0.38
≤
≤
0.55; p< 0.05). Fai o good eliabili y was ound o he adap ed CST
(ICC2,1 = 0.48–0.61
). The adap ed CST showed mean alues o maximal esponse, weak o mode a e
associa ion wi h he ISWT, and low wi hin-day es – e es eliabili y in young women.
Keywo ds:
ca dio espi a o y i ness; exe cise p esc ip ion; maximal e o ; physical i ness; s ep es
1. In oduc ion
The concep o exe cise capaci y includes he physiological maximal esponse o an
exe cise ole ance es wi h he assessmen o ca dio espi a o y i ness [
1
,
2
]. S ep es ing is
one o he mos inexpensi e and easible op ions o assess exe cise capaci y [
3
]. Howe e ,
mos s ep es s we e de eloped o es ima e he exe cise capaci y h ough submaximal
esponses [
4
]. An adap a ion o he Ches e s ep es (CST), a submaximal s ep es [
5
,
6
], o
a new and p og essi e es can be a good op ion o explo e. Fu he mo e, a p og essi e
es allows he p esc ip ion o exe cise, especially endu ance aining, h ough i s maximal
wo k a e achie ed [
3
,
7
,
8
]. Taking as example he inc emen al shu le walk es (ISWT) [
9
],
his alid ield es can e lec he maximal ca dio espi a o y esponse p o oked by a
ca diopulmona y exe cise es (CPET) [
10
–
12
] allowing he p esc ip ion o exe cise [
3
].
The e o e, i is impo an o con i m in a new and p og essi e ield es whe he i s peak
wo k a e in pe o mance e lec s a maximal physiological esponse.
Heal hca e 2021,9, 308. h ps://doi.o g/10.3390/heal hca e9030308 h ps://www.mdpi.com/jou nal/heal hca e
Heal hca e 2021,9, 308 2 o 10
The measu emen o maximal oxygen up ake (VO
2
max), wi h he e i ica ion o i s
pla eau, is he mos impo an a iable o assess he physiological maximal esponse
[3,8,13]
.
Howe e , when i is no e i ied, a clus e o o he a iables can be used o e i y he maxi-
mal esponse o a es , such as he espi a o y exchange a io (RER) peak, he achie emen
o he age-p edic ed hea a e (HR) maximum, he blood lac a e concen a ion, and he
a ing pe cep ion o exe ion [
3
,
14
,
15
]. The assessmen o HR, blood lac a e, and pe cep ion
o exe ion can be conside ed a simple , inexpensi e, and no ime-consuming clus e o
measu es o con i m maximal esponse.
The e o e, he aim o he p esen s udy was o assess whe he an adap a ion o he
CST can ha e maximal esponse cha ac e is ics, h ough he maximum HR, blood lac a e
concen a ion, and a ing pe cep ion o exe ion in young adul s, and compa e i o he
ISWT. Ano he aim was o de e mine and compa e he wi hin-day es – e es eliabili y o
he adap ed CST o he ISWT. The hypo hesis is ha he adap ed CST can be conside ed a
maximum es wi h a good co ela ion wi h he ISWT, bu hei physiological esponses may
be di e en because o hei dis inc modes o es ing (s epping s. walking). Consequen ly,
di e en physiological esponses can a ec he eliabili y alues o he es s.
2. Ma e ials and Me hods
2.1. S udy Design, Rec ui men , and S udy C i e ia
A c oss-sec ional design s udy was de eloped in ol ing olun ee s’ s uden s (young
adul s) om a uni e si y. The s udy was ad e ised a he uni e si y, h ough emails sen
o he s uden s’ ins i u ional accoun s, so in e es ed pa icipan s could con ac he esea ch
eam di ec ly. Only young adul s we e ec ui ed o educe he p obabili y o excluding
in e es ed pa icipan s wi h disabili ies and acu e o ch onic diseases since hei p e alence
inc ease wi h age [
16
] and ha hey can in luence he maximal esponse o an exe cise
es [
3
]. The e o e, eligibili y c i e ia we e: age be ween 18 and 30 yea s, bo h gende s,
body mass index be ween 18.5 and 29.9 kg/m
2
; and physically inac i e (who did no
pe o m physical ac i i y o 30 min o mo e a leas h ee imes pe week) [
3
]. Pa icipan s
wi h sel - epo o acu e o ch onic diseases, smoking habi s, p egnan women, lu-like
symp oms, o espi a o y in ec ion up o ou weeks be o e he s udy, and cu en ly use o
any ype o medica ion we e excluded.
This s udy ecei ed e hical app o al by a Resea ch E hics Commi ee and w i en
in o med consen (Decla a ion o Helsinki) was ob ained om all pa icipan s.
2.2. Measu es
The s udy was pe o med be ween Janua y and May o 2019. Each pa icipan pe -
o med he adap ed CST and he ISWT on di e en days (48 h apa ), andomly. The o al
ime o each collec ion day o each pa icipan was one hou . Each ield es was pe o med
wice ( es 1 and es 2) wi h a es in e al o a leas 30 min. Speci ic ins uc ions we e
gi en o he pa icipan s: a oid physical ac i i y and any in ake o ca eine and alcohol in
he 24 h p io o es ing, o ge a leas 8 h o sleep he nigh be o e, o ea a ligh meal and
o inges 500 mL o wa e in he wo hou s be o e he es s. Since he s udy was conduc ed
du ing a pe iod o classes, i was no possible o pe o m he es s a he same pe iod o he
day o all pa icipan s.
In addi ion, on he i s day, he i s p ocedu e was he assessmen o he body
composi ion wi h a segmen al bioelec ical impedance analysis (Tani a BC-545 N, Tani a,
Ams e dam, The Ne he lands), by weigh , body mass index (BMI), body a pe cen age, and
muscle mass measu es. Fo hese measu es, pa icipan s emp ied hei bladde immedia ely
be o e he s a o he measu emen s. Howe e , he absence o ood o liquid in ake o a
leas 2 h be o e he measu emen s was no possible.
2.3. The Adap ed Ches e S ep Tes and he Inc emen al Shu le Walk Tes
The ISWT was pe o med acco ding o he Ame ican Tho acic Socie y ecommenda-
ions [
9
] using a 10-m co ido . Howe e , a p o ocol o 15 le els was used (1500 m) o
Heal hca e 2021,9, 308 3 o 10
e alua e adul s wi hou disabili ies, o p e en he ceiling e ec [
10
]. The es was inished
when he pa icipan was no able o main ain he equi ed speed (mo e han 0.5 m om
he cone), when eques ed by he pa icipan , o o some o he epo ed symp oms o
exe ion in ole ance (dyspnea, leg a igue, dizziness, e igo) [9].
In i s u n, ou s ep es was adap ed om he CST [
5
,
6
], using a Max Ae obic s ep
(Mambo, Tissel , Belgium), wi h a 0.2 m heigh . The o iginal es has 5 le els, each o 2 min
du a ion, and he s ep wo k a e is se wi h a me onome, which s a s a 15 s eps/min and
inc eases by 5 s eps/min e e y 2 min: s age 1 (15 s eps/min), s age 2 (20 s eps/min), s age
3 (25 s eps/min), s age 4 (30 s eps/min), and s age 5 (35 s eps/min). Fo he adap a ion, i
was applied he same ini ial s ep wo k a e as he Ches e s ep es (15 s eps/min), bu he
inc emen in e e y 2 min was only by 2 s ep/min. I was also added he same numbe o
le els as he inc emen al shu le walk es (15 le els), wi h a maximum wo k a e achie able
o 43 s ep/min. The c i e ia o s op he es we e: no able o main ain he equi ed wo k
a e o 10 s, eques ed by he pa icipan , o o some o he epo ed symp oms o exe ion
in ole ance (dyspnea, leg a igue, dizziness, and e igo) [5,6].
2.4. Measu emen s du ing he Adap ed Ches e S ep Tes S ep and he Inc emen al Shu le
Walk Tes
HR and pe cep ion o exe ion we e moni o ed a es and du ing each ield es using
a ca dio equencime e (Pola
®
FT7, Oy, Finland), and a Bo g Ra ing o Pe cei ed Exe ion
Scale ( ange 6–20) [
17
], espec i ely. Pa icipan s we e asked o a e hei exe ion on he
Bo g scale combining all sensa ions and eelings o physical s ess and a igue, dis ega ding
any one ac o such as leg pain o sho ness o b ea h [
18
]. Fo he analysis o he esul s, HR
and pe cep ion o exe ion was eco ded immedia ely a e he end o each es . P edic ed
maximum HR (HR
max
) was calcula ed by he equa ion HRmax = 220
−
age [
19
], o he
calcula ion o he age-p edic ed HR
max
(%). Blood samples we e d awn immedia ely
a e each es by inge -p ick capilla y using a lance and coded yellow es s ip wi h
a eagen chemical subs ance. Blood lac a e was analysed by pho ome y (Accu end
®
,
Roche Diagnos ics, Basel, Swi ze land) [20].
The pe o mance a iables o he adap ed CST we e he numbe o s eps (p ima y
ou come), maximum wo k a e eached, and o al es ime. In i s u n, he pe o mance
a iables o he ISWT we e he dis ance (p ima y ou come), gai speed eached, and o al
es ime. These pe o mance a iables we e eco ded and p esen ed acco ding o he bes
es pe o med by he pa icipan s, and also in he i s and second a emp s ( es 1 and
es 2).
T ained physio he apis s, wi h expe ience in applying hese es s, collec ed he da a.
2.5. Da a, S a is ical Analysis
Desc ip i e and in e en ial s a is ical analysis was pe o med using he IBM’s S a is i-
cal Package o he Social Science
®
so wa e, e sion 26.0 (IBM Co po a ion, Chicago, IL,
USA), wi h a signi icance se a 0.05. All a iables we e es ed o no mali y using Shapi o–
Wilk es . Desc ip i e da a was exp essed as mean (s anda d de ia ion) o quan i a i e
a iables, and absolu e and ela i e equencies o quali a i e a iables.
Maximal e o a ainmen o he adap ed CST and he ISWT was analyzed wi h
he manda o y ul illmen o he ollowing h ee c i e ia sugges ed by he li e a u e: (1)
a ainmen o age-p edic ed maximum hea a e (HR
max
) > 90%; (2) pos -exe cise blood
lac a e concen a ion > 8 mmol/dL; and (3) a Bo g Ra ing o Pe cei ed Exe ion >17 [
3
,
14
,
15
].
Pai ed - es was used o e alua e wi hin-g oup di e ences o pe o mance and maxi-
mal e o a ainmen be ween es 1 and es 2 o each ield es . The same s a is ical es
was used o analyze he di e ences in maximal e o be ween ield es s, in he bes es , in
es 1 and in es 2.
Pea son’s co ela ion coe icien s we e calcula ed be ween he adap ed CST and he
ISWT in hei bes es . The s eng h o co ela ions has been classi ied acco ding o B i ish
Medical Jou nal guidelines, which ega d signi ican co ela ion coe icien s o 0–0.19 as
Heal hca e 2021,9, 308 4 o 10
e y weak, 0.2–0.39 as weak, 0.4–0.59 as mode a e, 0.6–0.79 as s ong, and 0.80–1 as e y
s ong [21].
The sample size was no calcula ed p io o his s udy. Howe e , o he associa ion o
he adap ed CST o he ISWT, we ake in o conside a ion he ecommenda ion o Da id
(1938), as ci ed in Bonne and W igh (2000), whe e he use o Pea son’s co ela ion can be
used only i he sample size is equal o supe io o 25 [22].
Rela i e and absolu e wi hin-day es – e es eliabili y was de e mined o he aCST
and ISWT pe o mances. Rela i e eliabili y be ween es s ( es 1 and es 2) was de e mined
by in aclass co ela ion coe icien (ICC) model 2 ( wo-way andom e ec s), absolu e
ag eemen , wi h a single a e (ICC
2,1
), and wi h 95% con idence in e als [
23
]. ICC
2,1
alues we e assigned as ollows: mo e han 0.75 = excellen , 0.40–0.75 = ai o good, and
less han 0.40 = poo [
24
]. Absolu e eliabili y was de e mined by he s anda d e o o
measu emen (SEM), and he smalles eal di e ence (SRD) [25]. These wo las measu es
also we e exp essed as pe cen ages (%SEM and %SRD). The SEM was calcula ed using
he equa ion:
SEM = SD ×√(1 −ICC) (1)
whe e SD is he s anda d de ia ion o he pe o mances ob ained om all pa icipan s, and
ICC is he in a a e eliabili y coe icien . The %SEM was calcula ed as
%SEM = (SEM/mean) ×100 (2)
whe e “mean” is he mean o he pe o mances ob ained in es 1 and es 2. The SRD a
he 95% le el o con idence was calcula ed using he equa ion:
SRD = 1.96 ×SEM ×√2 (3)
The %SRD was calcula ed as
%SRD = (SRD/mean) ×100 (4)
whe e “mean” is he mean o he pe o mances ob ained in es 1 and es 2. An %SRD
below 30% has been sugges ed as an accep able le el o eliabili y [26].
3. Resul s
O he 68 olun ee s, 27 pa icipan s (25 emales and 2 males) comple ed da a collec-
ion. A o al o 41 pa icipan s we e excluded due o hei physical ac i i y le els (n= 20),
sel - epo o ch onic diseases (n= 10), lu-like symp oms in he pas ou weeks (n= 6),
and smoking habi s (n= 5). Due o he p edominance o emale pa icipan s, he 2 males
we e excluded om he analysis o he esul s. Pa icipan s’ cha ac e is ics (n= 25) a e
shown in Table 1. The mean BMI was classi ied as no mal, acco ding o Wo ld Heal h
O ganiza ion c i e ia [27].
Table 1. Gene al cha ac e is ics o pa icipan s (n= 25).
Cha ac e is ics Young Women
Mean ±SD
Age (yea s) 20.3 ±1.5
Body mass (kg) 61.7 ±9.7
Heigh (m) 1.7 ±0.1
BMI (kg/m2)22.4 ±2.6
To al a mass (%) 25.4 ±6.2
Lean mass (kg) 43.3 ±3.9
Da a a e exp essed as mean ±s anda d de ia ion. BMI, body mass index.
Heal hca e 2021,9, 308 5 o 10
3.1. Pe o mance and Maximal E o A ainmen o adap ed Ches e S ep Tes and Inc emen al
Shu le Walk Tes
The mean alues o pe o mance and maximal e o o he adap ed CST and he ISWT
a e p esen ed in Table 2. The pe o mance alues we e signi ican ly highe in es 1 in
bo h es s (p< 0.001). All pa icipan s pe o med be e in es 1 in he adap ed CST, and
23 pa icipan s (92%) pe o med be e in es 1 in he ISWT.
Table 2.
Pe o mance and maximal e o a ainmen esul s o he adap ed Ches e s ep es and
inc emen al shu le walk es .
Adap ed Ches e S ep Tes Bes Tes
Mean ±SD
Tes 1
Mean ±SD
Tes 2
Mean ±SD
pValue
be ween Tes 1
and Tes 2
Pe o mance
Numbe o s eps
To al es ime es (minu es)
602.8 ±103.3 602.8 ±103.3 523.5 ±87.9 <0.001
23.0 ±2.8 23.0 ±2.8 21.2 ±2.5 <0.001
Le el eached 11.2 ±1.4 11.2 ±1.4 10.3 ±1.3 <0.001
Maximal e o a iables
HRmax (% p edic ed) 94.0 ±6.5 94.0 ±6.5 91.1 ±6.0 0.001
HRmax (bpm) 187.7 ±13.0 187.7 ±13.0 182.0 ±12.3 0.001
Blood lac a e (mmol/dl) 11.3 ±4.5 11.3 ±4.5 10.0 ±4.5 0.236
Bo g a ing 18.4 ±1.5 18.4 ±1.5 17.9 ±1.9 0.103
Inc emen al Shu le Walk Tes Bes es
Mean ±SD
Tes 1
Mean ±SD
Tes 2
Mean ±SD
pValue
be ween Tes 1
and Tes 2
Pe o mance
Dis ance (m) 1066.2 ±149.9 1059.9 ±137.1 1011.0 ±136.5 <0.001
To al es ime es (minu es) 12.2 ±1.0 12.1 ±1.0 11.9 ±0.9 <0.001
Le el eached 11.8 ±1.0 11.8 ±1.1 11.6 ±0.9 0.06
Maximal e o a iables
HRmax (% p edic ed) 97.6 ±3.6 * 97.4 ±3.8 * 96.6 ±3.3 * 0.06
HRmax (bpm) 194.9 ±7.2 * 194.4 ±7.6 * 193.0 ±6.7 * 0.06
Blood lac a e (mmol/dl) 9.0 ±3.0 * 8.9 ±3.1 * 8.9 ±3.5 0.898
Bo g a ing 18.0 ±1.4 18.0 ±1.5 17.2 ±1.9 0.08
Da a a e exp essed as mean
±
s anda d de ia ion. HR
max
: maximum hea a e. * p< 0,05 o compa isons
be ween he adap ed Ches e s ep es and inc emen al shu le walk es in he bes es , in es 1, and in es 2.
Gi ing he c i e ia sugges ed by he li e a u e and acco ding o hei mean alues,
maximal e o a ainmen was obse ed in he bes es , in es 1, and in es 2 o each ield
es (Table 2). Signi ican di e ences we e ound in he a ainmen o age-p edic ed HR
max
be ween es 1 and es 2 in he adap ed CST (p= 0.001). Howe e , he ul illmen o he h ee
c i e ia o maximal e o in he adap ed CST es was obse ed in 19 pa icipan s (76%) in
he bes es , 19 pa icipan s (76%) in es 1, and 13 pa icipan s (52%) in es 2. In he ISWT,
he ul illmen o he h ee c i e ia o maximal e o was obse ed in 20 pa icipan s (80%)
in he bes es , 18 pa icipan s (72%) in es 1, and 14 pa icipan s (56%) in es 2 (Table 2).
Compa ing he maximal e o be ween he wo modes o es ing in he bes es , HR
was signi ican ly highe in ISWT (p< 0.001), blood lac a e concen a ion was signi ican ly
highe in he adap ed CST (p= 0.03), bu no signi ican di e ences we e obse ed in Bo g
a ing. In es 1, HR was signi ican ly highe in ISWT (p= 0.003), blood lac a e concen a ion
was highe in he adap ed CST (p= 0.04), bu no signi ican di e ences we e obse ed in
Bo g a ing (p= 0.273). On he o he hand, in es 2, HR was signi ican ly highe in ISWT
(
p< 0.001
), bu no signi ican di e ences we e obse ed in blood lac a e concen a ion
(p= 0.312), and in Bo g a ing (p= 0.08) (Table 2).
3.2. Co ela ions be ween he Tes s and In aclass Co ela ion Coe icien Values
Table 3shows he co ela ions be ween he bes es o he adap ed CST (numbe o
s eps and le el eached) and he ISWT (dis ance and le el eached). These a iables had
signi ican posi i e co ela ions classi ied as weak and mode a e (0.38
≤
≤
0.55; p< 0.05)
(Table 3).

Heal hca e 2021,9, 308 6 o 10
Table 3.
Co ela ions be ween he bes pe o mance o he adap ed Ches e s ep es and inc emen al
shu le walk es .
Va iables pValue
aCST numbe o s eps and ISWT dis ance
0.40 0.04
aCST le el eached and ISWT dis ance 0.55 0.005
aCST numbe o s eps and ISWT le el 0.38 0.04
aCST le el eached and ISWT le el 0.51 0.01
aCST, adap ed Ches e s ep es ; ISWT, inc emen al shu le walk es .
Table 4p esen s he ela i e and absolu e eliabili y esul s o he aCST and ISWT.
Acco ding o ICC
2,1
alues, we ound ai o good wi hin-day es – e es eliabili y o he
adap ed CST, and excellen wi hin-day es – e es eliabili y o he ISWT. Acco ding o
he %SRD, he aCST (numbe o s eps) p esen ed a alue highe han 30% sugges ing an
unaccep able le el o eliabili y (Table 4).
Table 4.
Resul s o eliabili y measu es o he adap ed Ches e s ep es and inc emen al shu le
walk es .
Va iables ICC2,1 (95% CI) SEM SEM (%) SRD SRD (%)
Adap ed Ches e S ep Tes
Numbe o s eps
0.48 (0.03 o 0.76) *
72.3 12.8 200.4 35.6
To al es ime (min)
0.61 (0.04 o 0.85) *
1.7 7.7 4.7 21.3
Inc emen al Shu le Walk Tes
Dis ance (m)
0.90 (0.27 o 0.97) *
42.7 4.1 118.4 11.4
To al es ime (min)
0.87 (0.50 o 0.96) *
0.33 2.8 0.91 7.6
ICC, in aclass co ela ion coe icien ; SEM, s anda d e o o measu emen ; SRD, smalles eal di e ence.
*p< 0.001.
4. Discussion
One o he main esul s o he p esen s udy showed ha he adap ed CST had mean
alues o maximal physiological esponse in young women. This inding sugges s ha
his adap a ion can be used o assess exe cise capaci y and an al e na i e o p esc ibe
exe cise aining h ough he maximal wo k a e. To he bes o ou knowledge, his
was he i s s udy o obse e he maximal e o a ainmen in an adap ed s ep es by
using he clus e o measu es HR, blood lac a e, and Bo g a ing [
3
,
14
,
15
]. Howe e , i
is impo an o men ion ha some pa icipan s did no each he maximal e o in ou
adap ed CST, as well as in he ISWT. The physical inac i i y o he pa icipan s may be
one o he main ac o s which con ibu es o ea ly-onse a igue and o he symp oms (i.e.,
muscle and join pain) [
28
], which leads o he inabili y o main ain he equi ed wo k a e,
and, consequen ly, in e up ion o he es s be o e ob aining maximal e o .
The di e ences ound be ween he adap ed CST and he ISWT in hei physiological
esponses we e expec ed due o he dis inc modes o es ing and also by he ype o
a iables used in he clus e o measu es, whe e a cen al a iable (HR) and a pe iphe al
a iable (blood lac a e) o he ca diopulmona y sys em we e included [
3
,
29
,
30
]. S epping
ask, as he s ai -ascending, equi es a high capaci y o he la ge high muscles, especially
he quad iceps, o bea he whole body weigh agains g a i y [
31
]. The highe blood lac a e
concen a ion obse ed in he adap ed CST may e lec his equi emen and also sugges s
g ea e ec ui men o ype II ibe s ( as - wi ch) in his modali y, since his ype o ibe s
a e p edisposed o p oduce la ge quan i ies o lac a e han ype I (slow- wi ch) ibe s [
32
].
Addi ionally, a high blood lac a e concen a ion e lec s mo e pe iphe al ac i i y, as muscle
me abolism [
33
], a he han ci cula o y esponses which a e mo e de ec ed by he aise
o ca diac a iables, like he HR. The e o e, acco ding o he ISWT esponse, i s highe
HR achie emen sugges s a highe cen al demand in he ca diopulmona y sys em [
34
].
Despi e hese esul s, no di e ence in Bo g a ing was e i ied be ween he es s, which
indica es ha he es s ep esen ed he same pe cei ed gene al e o by he young women.
This inding is explained by he ins uc ions applied in he Bo g scale, whe e pa icipan s
Heal hca e 2021,9, 308 7 o 10
we e asked o a e hei exe ion combining all sensa ions and eelings o physical s ess
and a igue, dis ega ding any one ac o such as leg pain o sho ness o b ea h [18,35].
One o ou in e es s in he de elopmen o his s udy was also o explo e he asso-
cia ion be ween he adap ed CST wi h he ISWT since his las one p esen s consis en
measu emen p ope ies and p oduces a maximal ca dio espi a o y esponse [
10
–
12
,
36
].
Howe e , al hough ou esul s demons a e ha hese es s a e associa ed, hei co ela ions
we e weak o mode a e.
Ano he main esul o ou s udy showed ha he ela i e eliabili y o he adap ed
CST was ai o good (ICC
2,1
), was lowe han he ISWT, and wi h an unaccep able le el
o absolu e eliabili y (%SRD), which means ha i s pe o mance was no ep oducible.
Fu he mo e, no lea ning e ec was obse ed since he mean alues o pe o mance we e
highe in es 1. E en so, we obse ed mean alues o maximal e o al eady in es 1,
which indica es ha some young women we e able o achie e a maximal esponse wi hou
a amilia iza ion o he es . The e o e, we sugges ha one a emp o he adap ed CST
seems o be enough o assess exe cise capaci y, bu he con i ma ion o i s maximal esponse
is necessa y. The leng h o he es (bes es : 23 min) and he high epe i i e and in ensi e
s epping o he adap ed CST, especially a he end o he es , can explain he lowe eliabili y
by he possible inadequa e compliance o pa icipan s on he second epe i ion, due o i s
demanding biomechanical ask. The pe o mance o his es can causes high con ac o ces
on join s, especially on he knees, which, consequen ly, demands he p oduc ion o g ea e
local muscula exe ions when compa ed o walking/ unning [
31
]. The e o e, his g ea e
exe ion can cause mo e local muscle a igue, especially in seden a y pa icipan s, and limi
he pe o mance o a second epe i ion o he adap ed CST. Acco ding o hese indings, we
sugges ha he es in e al be ween a emp s (30 min) in he adap ed CST may no be
su icien , so, mo e ime may be needed o ob ain be e eliabili y alues.
These low eliabili y alues ound in he adap ed CST do no e lec he e idence,
whe e highe alues o he wi hin-day eliabili y we e obse ed in o he s ep es s, espe-
cially o he 6-min s ep es in heal hy adul s (ICC = 0.88–0.90) [
37
,
38
]. One explana ion
is he di e en ypes o es s, whe e he 6-min s ep es is conside ed a submaximal es ,
so he e i ica ion o maximal e o a ainmen , especially highe blood lac a e concen-
a ion, is less obse ed. The submaximal cha ac e is ic also p o ides no di e ences in
pe o mance (numbe o s eps) be ween a emp s o he 6-min s ep es , and, consequen ly,
no lea ning e ec [
37
,
38
]. Ano he obse a ion is ha s ep es pe o mances in disease
popula ions, especially in ch onic obs uc i e pulmona y disease (COPD), p esen ed highe
ICC
2,1
alues han ou esul s (ICC > 0.91) [
39
]. These highe alues can be explained
by he ac ha he s ep es s applied in COPD a e mos ly submaximal. On he o he
hand, in e idence, he eliabili y o o he exe cise capaci y es s (e.g., 6-min walk es ,
and he unsuppo ed uppe limb exe cise es ) seems o be highe in disease popula ions,
namely in o he ch onic lung diseases [
40
–
43
] and ca dio ascula diseases [
44
,
45
], han in
heal hy o wi hou disabili ies pa icipan s [
38
,
46
,
47
]. One o he explana ions o hese
di e ences is he ec ui men p ocess o he samples, as al eady discussed by Oli ei a
and colleagues [
46
], whe e highe esul s can be obse ed in disease popula ions because
hese pa ien s a e gene ally ec ui ed om hospi als, which a e o en mo e homogeneous
in hei cha ac e is ics han people om he communi y. Howe e , in ou s udy, we ied
o con ol impo an con ounde s in people ec ui ed om he uni e si y, in ol ing only
young pa icipan s (18–30 yea s old), wi h BMI classi ied as no mal and o e weigh , and
physically inac i e.
As a limi a ion o ou adap ed CST, i s mean alue o o al es ime (bes es :
23.0 ±2.8 min
) was almos wice he ime o he ISWT (bes es : 12.2
±
1.0 min). This
obse a ion c ea es a con lic wi h he gene al ecommenda ions o he assessmen o
exe cise capaci y, which, in gene al, a es las ing 8–12 min is ideal [
14
]. This esul , adding
he sugges ion o p olong he es in e al be ween a emp s, can limi he applica ion o
he adap ed CST in clinical p ac ice by equi ing mo e ime. As ano he limi a ion, he
p e-s udy sample size was no calcula ed. Howe e , based on he associa ion be ween
Heal hca e 2021,9, 308 8 o 10
he adap ed CST and he ISWT, a pos hoc powe analysis was conduc ed. This analysis
was based on ou achie ed sample size (n= 25) and he obse ed e ec size (co ela ion
be ween he p ima y ou comes o he es s: numbe o s eps on adap ed Ches e s ep Tes
and dis ance on inc emen al shu le walk es , = 0.40 p= 0.04), ob aining a powe es
o 0.53. Al hough he powe es could ha e been g ea e , his cu en alue allowed he
e i ica ion o signi ican co ela ions be ween he pe o mances o he wo es s in hei
p ima y ou comes. E en so, he gene alizabili y o ou indings has o be con i med in a
la ge popula ion, including male pa icipan s, and also in a b oade ange o ages.
Ano he impo an sugges ion in u u e s udies is o adap o de elop s ep es s
wi h p og essi e p o iles in disease popula ions o explo e i s use ulness o assess exe cise
capaci y and i s applicabili y in exe cise aining in ehabili a ion p og ams. The assessmen
o in e - a e eliabili y should also be add essed in u u e s udies.
5. Conclusions
The adap ed CST showed mean alues o maximal esponse, has weak o mode a e
associa ion wi h he ISWT, and low wi hin-day es – e es eliabili y in young women.
The e o e, a ca e ul applica ion o his es in clinical p ac ice is necessa y o he assessmen
o exe cise capaci y. Fu he mo e, i equi es mo e ime o i s pe o mance han ISWT.
Fu u e s udies a e impo an wi h bo h gende s and people wi h diseases o explo e
i s use ulness.
Au ho Con ibu ions:
Concep ualiza ion, R.V. and A.M.M.; me hodology, R.V., A.R.M., M.G., R.F.,
F.C., M.M., M.N., and A.M.M.; so wa e, R.V., A.R.M., M.G., R.F., and A.M.M.; alida ion, R.V. and
A.M.M.; o mal analysis, R.V., A.R.M., M.G., R.F., F.C., M.M., M.N., and A.M.M.; in es iga ion, R.V.,
A.R.M., M.G., R.F., and A.M.M.; esou ces, R.V.; da a cu a ion, R.V. and A.M.M.; w i ing—o iginal
d a p epa a ion, R.V., A.R.M., M.G., R.F., F.C., M.M., and M.N.; w i ing— e iew and edi ing, C.C.
and A.M.M.; isualiza ion, C.C. and A.M.M.; supe ision, C.C. and A.M.M.; p ojec adminis a ion,
R.V. All au ho s ha e ead and ag eed o he published e sion o he manusc ip .
Funding: This esea ch ecei ed no ex e nal unding.
Ins i u ional Re iew Boa d S a emen :
The s udy was conduc ed acco ding o he guidelines o he
Decla a ion o Helsinki and app o ed by he Ins i u ional Re iew Boa d (o E hics Commi ee) o
School o Heal h-Poly echnic Ins i u e o Po o (p o ocol code E0134, da e o app o al: 13 Ap il 2020).
In o med Consen S a emen :
In o med consen was ob ained om all subjec s in ol ed in he s udy.
Da a A ailabili y S a emen :
The da a p esen ed in his s udy a e a ailable on eques om he
co esponding au ho .
Con lic s o In e es : The au ho s decla e no con lic o in e es .
Re e ences
1.
Bui, K.L.; Nybe g, A.; Mal ais, F.; Saey, D. Func ional Tes s in Ch onic Obs uc i e Pulmona y Disease, Pa 1: Clinical Rele ance
and Links o he In e na ional Classi ica ion o Func ioning, Disabili y, and Heal h. Ann. Am. Tho ac. Soc.
2017
,14, 778–784.
[C ossRe ] [PubMed]
2.
Ross, R.; Blai , S.N.; A ena, R.; Chu ch, T.S.; Desp és, J.P.; F anklin, B.A.; Haskell, W.L.; Kaminsky, L.A.; Le ine, B.D.; La ie,
C.J.; e al. Impo ance o Assessing Ca dio espi a o y Fi ness in Clinical P ac ice: A Case o Fi ness as a Clinical Vi al Sign: A
Scien i ic S a emen F om he Ame ican Hea Associa ion. Ci cula ion 2016,134, e653–e699. [C ossRe ] [PubMed]
3.
ACSM. Ame ican College o Spo s Medicine’s Guidelines o Exe cise Tes ing and P esc ip ion; Lippinco Williams & Wilkins:
Philadelphia, PA, USA, 2013.
4.
Benne , H.; Pa i , G.; Da ison, K.; Es on, R. Validi y o Submaximal S ep Tes s o Es ima e Maximal Oxygen Up ake in Heal hy
Adul s. Spo s Med. 2016,46, 737–750. [C ossRe ]
5.
Sykes, K.; Robe s, A. The Ches e s ep es —A simple ye e ec i e ool o he p edic ion o ae obic capaci y. Physio he apy
2004
,
90, 183–188. [C ossRe ]
6.
Buckley, J.P.; Sim, J.; Es on, R.G.; Hession, R.; Fox, R. Reliabili y and alidi y o measu es aken du ing he Ches e s ep es o
p edic ae obic powe and o p esc ibe ae obic exe cise. B . J. Spo s Med. 2004,38, 197–205. [C ossRe ] [PubMed]
Heal hca e 2021,9, 308 9 o 10
7.
Sp ui , M.A.; Singh, S.J.; Ga ey, C.; ZuWallack, R.; Nici, L.; Roches e , C.; Hill, K.; Holland, A.E.; La eau, S.C.; Man, W.D.;
e al. An o icial Ame ican Tho acic Socie y/Eu opean Respi a o y Socie y s a emen : Key concep s and ad ances in pulmona y
ehabili a ion. Am. J. Respi . C i . Ca e Med. 2013,188, e13–e64. [C ossRe ] [PubMed]
8.
Bel z, N.M.; Gibson, A.L.; Jano , J.M.; K a i z, L.; Me mie , C.M.; Dalleck, L.C. G aded Exe cise Tes ing P o ocols o he
De e mina ion o VO(2)max: His o ical Pe spec i es, P og ess, and Fu u e Conside a ions. J. Spo s Med. (Hindawi Publ. Co p)
2016,2016, 3968393. [C ossRe ]
9.
Holland, A.E.; Sp ui , M.A.; T oos e s, T.; Puhan, M.A.; Pepin, V.; Saey, D.; McCo mack, M.C.; Ca lin, B.W.; Sciu ba, F.C.; Pi a, F.;
e al. An o icial Eu opean Respi a o y Socie y/Ame ican Tho acic Socie y echnical s anda d: Field walking es s in ch onic
espi a o y disease. Eu . Respi . J. 2014,44, 1428–1446. [C ossRe ]
10.
Ne es, C.D.; Lace da, A.C.; Lage, V.K.; Lima, L.P.; Fonseca, S.F.; de A ela , N.C.; Teixei a, M.M.; Mendonça, V.A. Ca dio espi a o y
esponses and p edic ion o peak oxygen up ake du ing he shu le walking es in heal hy seden a y adul men. PLoS ONE
2015
,
10, e0117563. [C ossRe ]
11.
Lima, L.P.; Lei e, H.R.; Ma os, M.A.; Ne es, C.D.C.; Lage, V.; Sil a, G.P.D.; Lopes, G.S.; Cha es, M.G.A.; San os, J.N.V.; Cama gos,
A.C.R.; e al. Ca dio espi a o y i ness assessmen and p edic ion o peak oxygen consump ion by Inc emen al Shu le Walking
Tes in heal hy women. PLoS ONE 2019,14, e0211327. [C ossRe ]
12.
Gomes, A.L.; Mendonça, V.A.; Dos San os Sil a, T.; Pi es, C.K.V.; Lima, L.P.; Gomes, A.M.; Cama gos, A.C.R.; Ne es, C.D.C.;
Lace da, A.C.R.; Lei e, H.R. Ca dio espi a o y and me abolic esponses and e e ence equa ion alida ion o p edic peak oxygen
up ake o he inc emen al shu le waking es in adolescen boys. PLoS ONE 2018,13, e0206867. [C ossRe ] [PubMed]
13.
Balady, G.J.; A ena, R.; Sie sema, K.; Mye s, J.; Coke, L.; Fle che , G.F.; Fo man, D.; F anklin, B.; Guazzi, M.; Gula i, M.; e al.
Clinician’s Guide o Ca diopulmona y Exe cise Tes ing in Adul s. Ci cula ion 2010,122, 191–225. [C ossRe ]
14.
Mezzani, A. Ca diopulmona y Exe cise Tes ing: Basics o Me hodology and Measu emen s. Ann. Am. Tho ac. Soc.
2017
,14,
S3–S11. [C ossRe ] [PubMed]
15.
Robe gs, R.A.; Dwye , D.; As o ino, T. Recommenda ions o imp o ed da a p ocessing om expi ed gas analysis indi ec
calo ime y. Spo s Med. 2010,40, 95–111. [C ossRe ]
16.
Di o, M.J.; Ma inez, C.H.; Mannino, D.M. Ageing and he epidemiology o mul imo bidi y. Eu . Respi . J.
2014
,44, 1055–1068.
[C ossRe ] [PubMed]
17. Bo g, G.A. Psychophysical bases o pe cei ed exe ion. Med. Sci. Spo s Exe c. 1982,14, 377–381. [C ossRe ]
18. Williams, N. The Bo g Ra ing o Pe cei ed Exe ion (RPE) scale. Occup. Med. 2017,67, 404–405. [C ossRe ]
19.
Ka onen, M.J.; Ken ala, E.; Mus ala, O. The e ec s o aining on hea a e; a longi udinal s udy. Ann. Med. Exp. Biol. Fenn.
1957
,
35, 307–315.
20.
Balda i, C.; Bona olon à, V.; Eme enziani, G.P.; Gallo a, M.C.; Sil a, A.J.; Guide i, L. Accu acy, eliabili y, linea i y o Accu end
and Lac a e P o e sus EBIO plus analyze . Eu . J. Appl. Physiol. 2009,107, 105–111. [C ossRe ]
21.
Co ela ion and Reg ession. A ailable online: h ps://www.bmj.com/abou -bmj/ esou ces- eade s/publica ions/s a is ics-
squa e-one/11-co ela ion-and- eg ession (accessed on 8 Ma ch 2021).
22.
Bone , D.G.; W igh , T.A. Sample size equi emen s o es ima ing pea son, kendall and spea man co ela ions. Psychome ika
2000,65, 23–28. [C ossRe ]
23. Koo, T.K.; Li, M.Y. A Guideline o Selec ing and Repo ing In aclass Co ela ion Coe icien s o Reliabili y Resea ch. J. Chi op .
Med. 2016,15, 155–163. [C ossRe ] [PubMed]
24. Fleiss, J.L. The Design and Analysis o Clinical Expe imen s; Wiley-In e science: New Yo k, NY, USA, 1986.
25.
Wei , J.P. Quan i ying es - e es eliabili y using he in aclass co ela ion coe icien and he SEM. J. S eng h Cond. Res.
2005
,19,
231–240. [C ossRe ] [PubMed]
26.
Huang, S.-L.; Hsieh, C.-L.; Lin, J.-H.; Chen, H.-M. Op imal sco ing me hods o hand-s eng h es s in pa ien s wi h s oke. In . J.
Rehabil. Res. 2011,34. [C ossRe ] [PubMed]
27.
Wo ld Heal h O ganiza ion. Die , Physical Ac i i y and Heal h: Repo by he Sec e a ia ; Wo ld Heal h O ganiza ion: Gene a,
Swi ze land, 2002.
28. Bogdanis, G.C. E ec s o physical ac i i y and inac i i y on muscle a igue. F on . Physiol. 2012,3, 142. [C ossRe ] [PubMed]
29.
Albouaini, K.; Eg ed, M.; Alahma , A.; W igh , D.J. Ca diopulmona y exe cise es ing and i s applica ion. Pos g ad. Med. J.
2007
,
83, 675–682. [C ossRe ]
30.
Goodwin, M.L.; Ha is, J.E.; He nández, A.; Gladden, L.B. Blood lac a e measu emen s and analysis du ing exe cise: A guide o
clinicians. J. Diabe es Sci. Technol. 2007,1, 558–569. [C ossRe ]
31.
Cos igan, P.A.; Deluzio, K.J.; Wyss, U.P. Knee and hip kine ics du ing no mal s ai climbing. Gai Pos u e
2002
,16, 31–37.
[C ossRe ]
32.
Todd, J.J. Lac a e: Valuable o physical pe o mance and main enance o b ain unc ion du ing exe cise. Biosci. Ho iz. In . J. S ud.
Res. 2014,7. [C ossRe ]
33.
Ishii, H.; Nishida, Y. E ec o Lac a e Accumula ion du ing Exe cise-induced Muscle Fa igue on he Senso imo o Co ex. J. Phys.
Sci. 2013,25, 1637–1642. [C ossRe ]
34.
Mille , G.P.; Vleck, V.E.; Ben ley, D.J. Physiological Di e ences Be ween Cycling and Running. Spo s Med.
2009
,39, 179–206.
[C ossRe ] [PubMed]