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CHAPTER 3 Pre-Exercise Evaluations 59

13. Pellegrino R, Viegi G, Enright P, et al. Interpretive strategies for lung function tests. ATS/ERS Task
Force: standardisation of lung function testing. Eur Respir J. 2005;26:948–68.
14. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in
humans and experimental animals: Part 1: Blood pressure measurement in humans. Hypertension.
2005;45:142–61.
15. Smith Jr SC, Allen J, Blair SN, et al. AHA/ACC Guidelines. AHA/ACC guidelines for secondary
prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update.
Circulation. 2006;113:2363–72.
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> > > > > > > > > > > > >

4
C HAPTER

Health-Related Physical
Fitness Testing and
Interpretation

As evidence rapidly continues to evolve regarding the numerous health benefits of

physical activity and exercise, the focus on health-related physical fitness and phys-
iologic fitness appears to have superseded that of skill-related physical fitness (13).
The health-related components of physical fitness have a strong relationship with
good health, are characterized by an ability to perform daily activities with vigor,
and demonstrate the traits and capacities associated with low risk of premature
development of the hypokinetic diseases (e.g., those associated with physical inac-
tivity) (56). Both health-related and physiologic fitness measures are closely allied
with disease prevention and health promotion and can be modified through regular
physical activity and exercise. A fundamental goal of primary and secondary inter-
vention programs is promotion of health; therefore, such programs should focus on
enhancement of health-related and physiologic components of physical fitness.

PURPOSES OF HEALTH-RELATED FITNESS TESTING

Measurement of physical fitness is a common and appropriate practice in pre-

ventive and rehabilitative exercise programs. The purposes of health-related fit-
ness testing in such programs include the following:
• Educating participants about their present health-related fitness status rela-
tive to health-related standards and age- and sex-matched norms
• Providing data that are helpful in development of exercise prescriptions to
address all fitness components
• Collecting baseline and follow-up data that allow evaluation of progress by
exercise program participants
• Motivating participants by establishing reasonable and attainable fitness goals
• Stratifying cardiovascular risk

BASIC PRINCIPLES AND GUIDELINES

The information obtained from health-related physical fitness testing, in combi-

nation with the individual’s health and medical information, is used by the health
60
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 61

and fitness professional to help an individual achieve specific fitness goals. An

ideal health-related physical fitness test is reliable, valid, relatively inexpensive,
and easy to administer. The test should yield results that are indicative of the cur-
rent state of fitness, reflect change from physical activity or exercise intervention,
and be directly comparable to normative data.

PRETEST INSTRUCTIONS
All pretest instructions should be provided and adhered to before arrival at the
testing facility. Certain steps should be taken to ensure client safety and comfort
before administering a health-related fitness test. A minimal recommendation is
that individuals complete a questionnaire such as the Physical Activity Readiness
Questionnaire (PAR-Q; see Fig. 2.1) or the ACSM/AHA form (see Fig. 2.2). A
listing of preliminary instructions for all clients can be found in Chapter 3 under
Participant Instructions, page 57. These instructions may be modified to meet
specific needs and circumstances.

TEST ORDER
The following should be accomplished before the participant arrives at the test
site:
• Assure all forms, score sheets, tables, graphs, and other testing documents are
organized and available for the test’s administration
• Calibrate all equipment a minimum of once each month to ensure accuracy
(e.g., metronome, cycle ergometer, treadmill, sphygmomanometer, skinfold
calipers)
• Organize equipment so that tests can follow in sequence without stressing the
same muscle group repeatedly
• Provide informed consent form (see Fig. 3.1)
• Maintain room temperature of 68!F to 72!F (20!C–22!C) and humidity of
"60%
When multiple tests are to be administered, the organization of the testing
session can be very important, depending on what physical fitness components
are to be evaluated. Resting measurements such as heart rate (HR), blood pres-
sure (BP), height, weight, and body composition should be obtained first. Rest-
ing measurements should be followed (in order) by tests of cardiorespiratory
(CR) endurance, muscular fitness, and flexibility when all fitness components
are assessed in a single session. Testing CR endurance after assessing muscular
fitness (which elevates HR) can produce inaccurate results about an individual’s
CR endurance status, particularly when tests using HR to predict aerobic fitness
are used. Likewise, dehydration resulting from CR endurance tests might influ-
ence body composition values if measured by bioelectrical impedance analysis
(BIA). Because certain medications, such as #-blockers, which lower HR, will
affect some fitness test results, use of these medications should be noted.
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TEST ENVIRONMENT
The test environment is important for test validity and reliability. Test anxiety,
emotional problems, food in the stomach, bladder distention, room temperature,
and ventilation should be controlled as much as possible. To minimize anxiety,
the test procedures should be explained adequately, and the test environment
should be quiet and private. The room should be equipped with a comfortable
seat and/or examination table to be used for resting BP and HR and/or electro-
cardiographic (ECG) recordings. The demeanor of personnel should be one of
relaxed confidence to put the subject at ease. Testing procedures should not be
rushed, and all procedures must be explained clearly before initiating the
process. These seemingly minor tasks are accomplished easily and are important
in achieving valid and reliable test results.

BODY COMPOSITION

It is well established that excess body fat, particularly when located centrally
around the abdomen, is associated with hypertension, the metabolic syndrome,
type 2 diabetes, stroke, coronary artery disease, and hyperlipidemia (49). Approx-
imately two thirds of American adults are classified as overweight (body mass
index [BMI] $25), and about 32% are classified as obese (BMI $30) (51). In the
years 1960 to 1962, 1971 to 1974, 1976 to 1980, 1988 to 1994, 1999 to 2000, and
2003 to 2004, the prevalence of obesity in the United States was 13.4%, 14.5%,
15%, 23.3%, 30.9%, and 32.2%, respectively (19,51). The more than twofold
increase in adult obesity between 1980 and 2004 coincides with an alarming trend
in the prevalence of overweight children in the United States and other developed
nations, who displayed an increase from !4% in 1970 to 15% in 2000 to 17% in
2004 (51,52,68). This more than fourfold increase in the past three decades shows
no signs of abatement (51,52) Moreover, in 2003 to 2004, significant differences
in obesity prevalence remained by race/ethnicity. Approximately 30% of non-
Hispanic white adults were obese as were 45% of non-Hispanic black adults and
36.8% of Mexican Americans (51). Consequently, efforts to address health dispar-
ities related to obesity and its comorbidities should be emphasized.
Basic body composition can be expressed as the relative percentage of body
mass that is fat and fat-free tissue using a two-compartment model. Body com-
position can be estimated with both laboratory and field techniques that vary in
terms of complexity, cost, and accuracy. Different assessment techniques are
briefly reviewed in this section; however, the detail associated with obtaining
measurements and calculating estimates of body fat for all of these techniques is
beyond the scope of this text. More detailed descriptions of each technique are
available in Chapter 12 of the ACSM Resource Manual for Guidelines for Exercise
Testing and Prescription, 6th ed. and elsewhere (28,37,62). Before collecting data
for body composition assessment, the technician must be trained, be routinely
practiced in the techniques, and already have demonstrated reliability in his or
her measurements, independent of the technique being used. Experience can be
accrued under the direct supervision of a highly qualified mentor in a controlled
testing environment.
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 63

ANTHROPOMETRIC METHODS
Measurements of height, weight, circumferences, and skinfolds are used to esti-
mate body composition. Although skinfold measurements are more difficult than
other anthropometric procedures, they provide a better estimate of body fatness
than those based only on height, weight, and circumferences (43).

Body Mass Index

The BMI, or Quetelet index, is used to assess weight relative to height and is cal-
culated by dividing body weight in kilograms by height in meters squared
(kg%m&2). For most people, obesity-related health problems increase beyond a
BMI of 25, and the Expert Panel on the Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults (54) lists a BMI of 25.0 to 29.9 kg%m&2 for over-
weight and a BMI of $30.0 kg%m&2 for obesity. Although BMI fails to distinguish
between body fat, muscle mass, or bone, an increased risk of hypertension, total
cholesterol/high-density lipoprotein (HDL) cholesterol ratio, coronary disease,
and mortality are associated with a BMI '30 kg %m&2 (Table 4.1) (59). A BMI of
"18.5 kg%m&2 also increases the risk of cardiovascular disease and is responsi-
ble for the lower portion of the J-shaped curve of BMI versus cardiovascular risk.
The use of specific BMI values to predict percentage body fat and health risk can
be found in Table 4.2 (22). Because of the relatively large standard error of esti-
mating percent fat from BMI ((5% fat) (43), other methods of body composition
assessment should be used to predict body fatness during a fitness assessment.

Circumferences
The pattern of body fat distribution is recognized as an important predictor of
the health risks of obesity (69). Android obesity, which is characterized by more

TABLE 4.1. CLASSIFICATION OF DISEASE RISK BASED ON BODY MASS

INDEX (BMI) AND WAIST CIRCUMFERENCE
DISEASE RISKa RELATIVE TO NORMAL
WEIGHT AND WAIST CIRCUMFERENCE
MEN, )102 cm MEN, '102 cm
BMI (kg % m&2) WOMEN, )88 cm WOMEN, '88 cm

Underweight "18.5 — —
Normal 18.5–24.9 — —
Overweight 25.0–29.9 Increased High
Obesity, class
I 30.0–34.9 High Very high
II 35.0–39.9 Very high Very high
III $40 Extremely high Extremely high
a
Disease risk for type 2 diabetes, hypertension, and cardiovascular disease. Dashes (—) indicate that no additional risk
at these levels of BMI was assigned. Increased waist circumference can also be a marker for increased risk even in per-
sons of normal weight.

Modified from Expert Panel. Executive summary of the clinical guidelines on the identification, evaluation, and treat-
ment of overweight and obesity in adults. Arch Intern Med. 1998;158:1855–67.
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TABLE 4.2. PREDICTED BODY FAT PERCENTAGE BASED ON BODY

MASS INDEX (BMI) FOR AFRICAN-AMERICAN AND WHITE ADULTSa
BMI (kg % m–2) HEALTH RISK 20–39 Yr 40–59 Yr 60–79 Yr
Men
"18.5 Elevated "8% "11% "13%
18.6–24.9 Average 8%–19% 11%–21% 13%–24%
25.0–29.9 Elevated 20%–24% 22%–27% 25%–29%
'30 High $25% $28% $30%
Women
"18.5 Elevated "21% "23% "24%
18.6–24.9 Average 21%–32% 23%–33% 24%–35%
25.0–29.9 Elevated 33%–38% 34%–39% 36%–41%
'30 High $39% $40% $42%
a
Note: Standard error of estimate is (5% for predicting percent body fat from BMI (based on a four-compartment esti-
mate of body fat percentage).

From Gallagher D, Heymsfield SB, Heo M, et al. Healthy percentage body fat ranges: an approach for developing guide-
lines based on body mass index. Am J Clin Nutr. 2000;72:694–701.

fat on the trunk (abdominal fat), provides an increased risk of hypertension,

metabolic syndrome, type 2 diabetes, dyslipidemia, coronary artery disease, and
premature death compared with individuals who demonstrate gynoid or
gynecoid obesity (fat distributed in the hip and thigh) (20).
Girth measurements may be used to predict body composition, and equations
are available for both sexes and a range of age groups (66,67). The accuracy may
be within 2.5% to 4% of the actual body composition if the subject possesses sim-
ilar characteristics of the original validation population and the girth measure-
ments are precise. A cloth tape measure with a spring-loaded handle (e.g., Gulick
tape measure) reduces skin compression and improves consistency of measure-
ment. Duplicate measurements are recommended at each site and should be
obtained in a rotational instead of a consecutive order. The average of the two
measures is used provided each measure is within 5 mm. Box 4.1 contains a
description of the common sites.
The waist-to-hip ratio (WHR) is the circumference of the waist divided by the
circumference of the hips (Box 4.1, buttocks/hips measure) and has been used as
a simple method for determining body fat distribution (8). Health risk increases
with WHR, and standards for risk vary with age and sex. For example, health risk
is very high for young men when WHR is more than 0.95 and for young women
when WHR is more than 0.86. For people 60 to 69 years old, the WHR values
are greater than 1.03 for men and greater than 0.90 for women for the same risk
classification (20,28).
The waist circumference can be used alone as an indicator of health risk
because abdominal obesity is the primary issue. The Expert Panel on the Identi-
fication, Evaluation and Treatment of Overweight and Obesity in Adults pro-
vided a classification of disease risk based on both BMI and waist circumference
as shown in Table 4.1 (54). Furthermore, a newer risk stratification scheme for
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 65

Standardized Description of Circumference Sites

BOX 4.1 and Procedures

Abdomen: With the subject standing upright and relaxed, a horizon-

tal measure is taken at the greatest anterior extension of
the abdomen, usually at the level of the umbilicus.
Arm: With the subject standing erect and arms hanging freely
at the sides with hands facing the thigh, a horizontal
measure is taken midway between the acromion and
olecranon processes.
Buttocks/hips: With the subject standing erect and feet together, a
horizontal measure is taken at the maximal circumfer-
ence of buttocks. This measure is used for the hip
measure in a waist/hip measure.
Calf: With the subject standing erect (feet apart !20 cm), a
horizontal measure is taken at the level of the maximum
circumference between the knee and the ankle, perpen-
dicular to the long axis.
Forearm: With the subject standing, arms hanging downward but
slightly away from the trunk and palms facing
anteriorly, a measure perpendicular to the long axis at
the maximal circumference.
Hips/thigh: With the subject standing, legs slightly apart (!10 cm), a
horizontal measure is taken at the maximal circumference
of the hip/proximal thigh, just below the gluteal fold.
Midthigh With the subject standing and one foot on a bench so
the knee is flexed at 90 degrees, a measure is taken mid-
way between the inguinal crease and the proximal bor-
der of the patella, perpendicular to the long axis.
Waist: With the subject standing, arms at the sides, feet
together, and abdomen relaxed, a horizontal measure is
taken at the narrowest part of the torso (above the
umbilicus and below the xiphoid process). The National
Obesity Task Force (NOTF) suggests obtaining a horizon-
tal measure directly above the iliac crest as a method to
enhance standardization. Unfortunately, current formu-
lae are not predicated on the NOTF suggested site.

PROCEDURES
• All measurements should be made with a flexible yet inelastic tape
measure.
• The tape should be placed on the skin surface without compressing
the subcutaneous adipose tissue. >
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> Box 4.1. continued

• If a Gulick spring-loaded handle is used, the handle should be
extended to the same marking with each trial.
• Take duplicate measures at each site, and retest if duplicate measure-
ments are not within 5 mm.
• Rotate through measurement sites or allow time for skin to regain
normal texture.
Modified from Callaway CW, Chumlea WC, Bouchard C. Circumferences. In: Lohman TG,
Roche AF, Martorell R, editors. Anthropometric Standardization Reference Manual. Champaign (IL):
Human Kinetics; 1988;39–54.

adults based on waist circumference has been proposed (Table 4.3) (7). This
can be used alone or in conjunction with BMI to evaluate chronic disease risk
(Table 4.1). All assessments should include a minimum of either waist circum-
ference or BMI, but preferably both, for risk stratification.

Skinfold Measurements
Body composition determined from skinfold measurements correlates well (r *
0.70–0.90) with body composition determined by hydrodensitometry (62). The
principle behind this technique is that the amount of subcutaneous fat is pro-
portional to the total amount of body fat. It is assumed that close to one third of
the total fat is located subcutaneously. The exact proportion of subcutaneous-to-
total fat varies with sex, age, and ethnicity (61). Therefore, regression equations
used to convert sum of skinfolds to percent body fat must consider these vari-
ables for greatest accuracy. Box 4.2 presents a standardized description of skin-
fold sites and procedures. Refer to the ACSM Resource Manual, 6th ed. for addi-
tional descriptions of the skinfold sites. To improve the accuracy of the
measurement, it is recommended that one train with a skilled technician, use
video media that demonstrate proper technique, participate in workshops, and
accrue experience in a supervised practical environment. The accuracy of pre-
dicting percent fat from skinfolds is approximately (3.5% assuming that appro-
priate techniques and equations have been used (28).
Factors that may contribute to measurement error within skinfold assessment
include poor technique and/or an inexperienced evaluator, an extremely obese or

TABLE 4.3. CRITERIA FOR WAIST CIRCUMFERENCE IN ADULTS

WAIST CIRCUMFERENCE cm (IN)
RISK CATEGORY WOMEN MEN

Very low "70 cm (27.5 in) "80 cm (31.5 in)

Low 70–89 (28.5–35.0) 80–99 (31.5–39.0)
High 90–109 (35.5–43.0) 100–120 (39.5–47.0)
Very high '110 (43.5) '120 (47.0)
From Bray GA. Don’t throw the baby out with the bath water. Am J Clin Nutr. 2004;70(3):347–9.
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 67

Standardized Description of Skinfold Sites and

BOX 4.2 Procedures

SKINFOLD SITE
Abdominal Vertical fold; 2 cm to the right side of the umbilicus
Triceps Vertical fold; on the posterior midline of the upper arm,
halfway between the acromion and olecranon processes,
with the arm held freely to the side of the body
Biceps Vertical fold; on the anterior aspect of the arm over the
belly of the biceps muscle, 1 cm above the level used to
mark the triceps site
Chest/pectoral Diagonal fold; one half the distance between the ante-
rior axillary line and the nipple (men), or one third of
the distance between the anterior axillary line and the
nipple (women)
Medial calf Vertical fold; at the maximum circumference of the calf
on the midline of its medial border
Midaxillary Vertical fold; on the midaxillary line at the level of the
xiphoid process of the sternum (An alternate method is
a horizontal fold taken at the level of the xiphoid/
sternal border in the midaxillary line.)
Subscapular Diagonal fold (at a 45-degree angle); 1 to 2 cm below
the inferior angle of the scapula
Suprailiac Diagonal fold; in line with the natural angle of the iliac
crest taken in the anterior axillary line immediately
superior to the iliac crest
Thigh Vertical fold; on the anterior midline of the thigh, mid-
way between the proximal border of the patella and the
inguinal crease (hip)

PROCEDURES
• All measurements should be made on the right side of the body with
the subject standing upright.
• The caliper should be placed directly on the skin surface, 1 cm away
from the thumb and finger, perpendicular to the skinfold, and halfway
between the crest and the base of the fold.
• A pinch should be maintained while reading the caliper.
• Wait 1 to 2 seconds (not longer) before reading caliper.
• Take duplicate measures at each site, and retest if duplicate measure-
ments are not within 1 to 2 mm.
• Rotate through measurement sites, or allow time for skin to regain
normal texture and thickness.
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extremely lean subject, and an improperly calibrated caliper (tension should be

set at !12 g %mm&2) (27). Various regression equations have been developed to
predict body density or percent body fat from skinfold measurements. For exam-
ple, Box 4.3 lists generalized equations that allow calculation of body density
without a loss in prediction accuracy for a wide range of individuals (27,33).
However, if a population-specific equation is needed, Heyward and Stolarczyk
provide a quick reference guide to match the client to the correct equation based
on sex, age, ethnicity, fatness, and sport (28).

BOX 4.3 Generalized Skinfold Equations

MEN
• Seven-Site Formula (chest, midaxillary, triceps, subscapular,
abdomen, suprailiac, thigh)
Body density * 1.112 & 0.00043499 (sum of seven skinfolds)
+ 0.00000055 (sum of seven skinfolds)2
& 0.00028826 (age) [SEE 0.008 or !3.5% fat]
• Three-Site Formula (chest, abdomen, thigh)
Body density * 1.10938 & 0.0008267 (sum of three skinfolds)
+ 0.0000016 (sum of three skinfolds)2
& 0.0002574 (age) [SEE 0.008 or !3.4% fat]
• Three-Site Formula (chest, triceps, subscapular)
Body density * 1.1125025 & 0.0013125 (sum of three skinfolds)
+ 0.0000055 (sum of three skinfolds)2
& 0.000244 (age) [SEE 0.008 or !3.6% fat]
WOMEN
• Seven-Site Formula (chest, midaxillary, triceps, subscapular,
abdomen, suprailiac, thigh)
Body density * 1.097 & 0.00046971 (sum of seven skinfolds)
+ 0.00000056 (sum of seven skinfolds)2
& 0.00012828 (age) [SEE 0.008 or !3.8% fat]
• Three-Site Formula (triceps, suprailiac, thigh)
Body density * 1.099421 & 0.0009929 (sum of three skinfolds)
+ 0.0000023 (sum of three skinfolds)2
& 0.0001392 (age) [SEE 0.009 or !3.9% fat]
• Three-Site Formula (triceps, suprailiac, abdominal)
Body density * 1.089733 & 0.0009245 (sum of three skinfolds)
+ 0.0000025 (sum of three skinfolds)2
& 0.0000979 (age) [SEE 0.009 or !3.9% fat]
Adapted from Jackson AS, Pollock ML. Practical assessment of body composition. Phys Sport
Med. 1985;13:76–90. Pollock ML, Schmidt DH, Jackson AS. Measurement of cardiorespiratory
fitness and body composition in the clinical setting. Comp Ther. 1980;6:12–7.
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 69

DENSITOMETRY
Body composition can be estimated from a measurement of whole-body density,
using the ratio of body mass to body volume. In this technique, which has been
used as a reference or criterion standard for assessing body composition, the
body is divided into two components: the fat mass (FM) and the fat-free mass
(FFM). The limiting factor in the measurement of body density is the accuracy
of the body volume measurement because body mass is measured simply as body
weight. Body volume can be measured by hydrodensitometry (underwater)
weighing and by plethysmography.

Hydrodensitometry (Underwater) Weighing

This technique of measuring body composition is based on Archimedes’ principle,
which states that when a body is immersed in water, it is buoyed by a counterforce
equal to the weight of the water displaced. This loss of weight in water allows cal-
culation of body volume. Bone and muscle tissue are denser than water, whereas
fat tissue is less dense. Therefore, a person with more FFM for the same total body
mass weighs more in water and has a higher body density and lower percentage of
body fat. Although hydrostatic weighing is a standard method for measuring body
volume and hence, body composition, it requires special equipment, the accurate
measurement of residual volume, and significant cooperation by the subject (23).
For a more detailed explanation of the technique, see Chapter 17 of ACSM’s
Resource Manual for Guidelines for Exercise Testing and Prescription.

Plethysmography
Body volume also can be measured by air rather than water displacement. One
commercial system uses a dual-chamber plethysmograph that measures body vol-
ume by changes in pressure in a closed chamber. This technology shows promise
and generally reduces the anxiety associated with the technique of hydrodensit-
ometry (16,23,43). For a more detailed explanation of the technique, see Chapter
17 of ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription.

Conversion of Body Density to Body Composition

Percent body fat can be estimated once body density has been determined. Two of
the most common prediction equations used to estimate percent body fat from body
density are derived from the two-component model of body composition (9,65):
457
% fat ! ## " 414.2
Body Density
495
% fat ! ## " 450
Body Density
Each method assumes a slightly different density of both fat and FFM. Ongo-
ing research using the three- and four-component models of body composition
provides a variety of newer equations that should increase the accuracy of the
estimate of percent fat when applied to different populations. These equations
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TABLE 4.4. POPULATION-SPECIFIC FORMULAS FOR CONVERSION OF

BODY DENSITY (Db) TO PERCENT BODY FAT
POPULATION AGE SEX % BODY FAT a
Race
American Indian 18–60 Female (4.81/Db)–4.34
Black 18–32 Male (4.37/Db)–3.93
24–79 Female (4.85/Db)–4.39
Hispanic 20–40 Female (4.87/Db)–4.41
Japanese Native 18–48 Male (4.97/Db)–4.52
Female (4.76/Db)–4.28
61–78 Male (4.87/Db)–4.41
Female (4.95/Db)–4.50
White 7–12 Male (5.30/Db)–4.89
Female (5.35/Db)–4.95
13–16 Male (5.07/Db)–4.64
Female (5.10/Db)–4.66
17–19 Male (4.99/Db)–4.55
Female (5.05/Db)–4.62
20–80 Male (4.95/Db)–4.50
Female (5.01/Db)–4.57
Levels of body fatness
Anorexia 15–30 Female (5.26/Db)–4.83
Obese 17–62 Male (5.00/Db)–4.56
a
Percent body fat is obtained by multiplying the value calculated from the equation by 100.

Adapted from Heyward VH, Stolarczyk LM. Applied Body Composition Assessment. Champaign (IL): Human Kinetics; 1996. p. 12.

(Table 4.4) are likely to improve over time as additional studies are done on
larger samples within each population group (28).

OTHER TECHNIQUES
Additional assessment techniques of dual energy x-ray absorptiometry (DEXA)
and total body electrical conductivity (TOBEC) are reliable and accurate measures
of body composition, but these techniques are not popular for general health fit-
ness testing because of cost and the need for highly trained personnel (62). Tech-
niques of BIA and near-infrared intercadence are used for general health fitness
testing. Generally, the accuracy of BIA is similar to skinfolds, as long as a stringent
protocol is followed and the equations programmed into the analyzer are valid and
accurate for the populations being tested (26). Near-infrared intercadence requires
additional research to substantiate the validity and accuracy for body composition
assessment (46). Detailed explanations of these techniques are found in Chapter 12
of ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription.

BODY COMPOSITION NORMS

There are no universally accepted norms for body composition; however, Tables
4.5 and 4.6, which are based on selected populations, provide percentile values
for percent body fat in men and women, respectively. A consensus opinion for an
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 71

TABLE 4.5. BODY COMPOSITION (% BODY FAT) FOR MEN

AGE
% 20–29 30–39 40–49 50–59 60–69 70–79

99 4.2 7.0 9.2 10.9 11.5 13.6

95 6.3 9.9 12.8 14.4 15.5 15.2 VLa
90 7.9 11.9 14.9 16.7 17.6 17.8
85 9.2 13.3 16.3 18.0 18.8 19.2
80 10.5 14.5 17.4 19.1 19.7 20.4 E
75 11.5 15.5 18.4 19.9 20.6 21.1
70 12.7 16.5 19.1 20.7 21.3 21.6
65 13.9 17.4 19.9 21.3 22.0 22.5
60 14.8 18.2 20.6 22.1 22.6 23.1 G
55 15.8 19.0 21.3 22.7 23.2 23.7
50 16.6 19.7 21.9 23.2 23.7 24.1
45 17.4 20.4 22.6 23.9 24.4 24.4
40 18.6 21.3 23.4 24.6 25.2 24.8 F
35 19.6 22.1 24.1 25.3 26.0 25.4
30 20.6 23.0 24.8 26.0 26.7 26.0
25 21.9 23.9 25.7 26.8 27.5 26.7
20 23.1 24.9 26.6 27.8 28.4 27.6 P
15 24.6 26.2 27.7 28.9 29.4 28.9
10 26.3 27.8 29.2 30.3 30.9 30.4
5 28.9 30.2 31.2 32.5 32.9 32.4
1 33.3 34.3 35.0 36.4 36.8 35.5 VP
n* 1826 8373 10442 6079 1836 301
Total n * 28,857
Norms are based on Cooper Clinic patients.
a
Very Lean—No less than 3% body fat is recommended for males.

VL, very lean; E, excellent; G, good; F, fair; P, poor; VP, very poor.

Reprinted with permission from the Cooper Institute, Dallas, Texas. For more information: www.cooperinstitute.org.

exact percentage body-fat value associated with optimal health risk has yet to be
defined; however, a range 10% to 22% and 20% to 32% for men and women,
respectively, is considered satisfactory for health (42).

CARDIORESPIRATORY FITNESS

Cardiorespiratory fitness is related to the ability to perform large muscle,

dynamic, moderate-to-high intensity exercise for prolonged periods. Perfor-
mance of such exercise depends on the functional state of the respiratory, car-
diovascular, and skeletal muscle systems. Cardiorespiratory fitness is considered
health-related because (a) low levels of CR fitness have been associated with a
markedly increased risk of premature death from all causes and specifically from
cardiovascular disease, (b) increases in CR fitness are associated with a reduction
in death from all causes, and (c) high levels of CR fitness are associated with
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72 GUIDELINES FOR EXERCISE TESTING • www.acsm.org

TABLE 4.6. BODY COMPOSITION (% BODY FAT) FOR WOMEN

AGE
% 20–29 30–39 40–49 50–59 60–69 70–79

99 9.8 11.0 12.6 14.6 13.9 14.6

95 13.6 14.0 15.6 17.2 17.7 16.6 VLa
90 14.8 15.6 17.2 19.4 19.8 20.3
85 15.8 16.6 18.6 20.9 21.4 23.0
80 16.5 17.4 19.8 22.5 23.2 24.0 E
75 17.3 18.2 20.8 23.8 24.8 25.0
70 18.0 19.1 21.9 25.1 25.9 26.2
65 18.7 20.0 22.8 26.0 27.0 27.7
60 19.4 20.8 23.8 27.0 27.9 28.6 G
55 20.1 21.7 24.8 27.9 28.7 29.7
50 21.0 22.6 25.6 28.8 29.8 30.4
45 21.9 23.5 26.5 29.7 30.6 31.3
40 22.7 24.6 27.6 30.4 31.3 31.8 F
35 23.6 25.6 28.5 31.4 32.5 32.7
30 24.5 26.7 29.6 32.5 33.3 33.9
25 25.9 27.7 30.7 33.4 34.3 35.3
20 27.1 29.1 31.9 34.5 35.4 36.0 P
15 28.9 30.9 33.5 35.6 36.2 37.4
10 31.4 33.0 35.4 36.7 37.3 38.2
5 35.2 35.8 37.4 38.3 39.0 39.3
1 38.9 39.4 39.8 40.4 40.8 40.5 VP
n* 1360 3597 3808 2366 849 136
Total n * 12,116
Norms are based on Cooper Clinic patients.
a
Very Lean—No less than 10–13% body fat is recommended for females.

VL, very lean; E, excellent; G, good; F, fair; P, poor; VP, very poor.

Reprinted with permission from the Cooper Institute, Dallas, Texas. For more information: www.cooperinstitute.org.

higher levels of habitual physical activity, which in turn are associated with many
health benefits (5,6,63). The assessment of CR fitness is an important part of a
primary or secondary prevention program.

THE CONCEPT OF MAXIMAL OXYGEN UPTAKE

.
Maximal oxygen uptake (VO2max) is accepted as the criterion measure of CR fit-
ness. Maximal oxygen uptake is the product of the maximal cardiac output
(L blood % min&1) and arterial-venous
. oxygen difference (mL O2 per L blood).
Significant variation in VO2max across populations and fitness levels
. results pri-
marily from differences in maximal cardiac output; therefore, VO2max is closely
related to the functional capacity of the heart. .
Open-circuit spirometry is used to measure VO2max. In this procedure, the sub-
ject breathes through a low-resistance valve with his/her nose occluded (or
through a nonlatex foam mask) while pulmonary ventilation and expired fractions
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 73

of oxygen (O2) and carbon dioxide (CO2) are measured. Modern automated sys-
tems provide ease of use and a detailed printout of test results that save time and
effort (15). However, attention to detail relative to calibration is still essential to
obtain accurate results. Administration of the test and interpretation of results
should be reserved for professional personnel with a thorough understanding of
exercise science. Because of the costs associated with the equipment,
. space, and
personnel needed to carry out these tests, direct measurement of VO2max generally
is reserved for research or clinical. settings.
When direct measurement of VO2max is not feasible or desirable,
. a variety of sub-
maximal and maximal exercise tests can be used to estimate VO2max. These tests
have
. been validated
. by examining (a) the correlation between directly measured
VO2max and the VO2max estimated from physiologic responses to submaximal exer-
cise (e.g., HR
. at a specified power output); or (b) the correlation between directly
measured VO2max and test performance (e.g., time to run 1 or 1.5 miles [1.6 or 2.4
km] or time to volitional fatigue using a standard graded exercise test protocol).

MAXIMAL VERSUS SUBMAXIMAL EXERCISE TESTING

The decision to use a maximal or submaximal exercise test depends largely on
the reasons
. for the test and the availability of appropriate equipment and per-
sonnel. VO2max can be estimated using conventional exercise test protocols, by
considering test duration at a given workload on an ergometer, and by using the
prediction equations found in Chapter 7. The user would need to consider the
population being tested and the standard error of the associated equation. Max-
imal tests have the disadvantage of requiring participants to exercise to the point
of volitional fatigue and might require medical supervision (Chapter 2) and
emergency equipment. However, maximal exercise testing offers increased sensi-
tivity in the diagnosis of coronary
. artery disease in asymptomatic individuals and
provides a better estimate of VO2max (Chapter 5). Additionally, the use of open
circuit spirometry during maximal exercise testing allows . for the accurate assess-
ment of anaerobic threshold and the measurement of VO2max.
Practitioners commonly rely on submaximal exercise tests to assess CR fitness
because maximal exercise testing is not always feasible in the health and fitness set-
ting. The basic aim of submaximal exercise testing is to determine the HR response
.
to one or more submaximal work rates and uses the results to predict V.O2max.
Although the primary purpose of the test has traditionally been to predict VO2max
from the HR-workload relationship, it is important to obtain additional indices of
the client’s response to exercise. The practitioner should use the various submaxi-
mal measures of HR, BP, workload, rating of perceived exertion (RPE), and other
subjective indices as valuable information regarding one’s functional response to
exercise. This information can be used to evaluate submaximal exercise responses
over time in a controlled environment
. and to fine-tune an exercise prescription.
The most accurate estimate of VO2max is achieved if all of the following assump-
tions are met. Subjects with diabetes may have a blunted HR response . to exercise
and may not have an age-normal maximal HR (32). Estimates of VO2max from the
HR response to submaximal exercise tests are based on these assumptions:
• A steady-state HR is obtained for each exercise work rate and is consistent
each day.
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74 GUIDELINES FOR EXERCISE TESTING • www.acsm.org

• A linear relationship exists between HR and .work rate.

• The maximal work load is indicative of the VO2max.
• The maximal HR for a given. age is uniform.
• Mechanical efficiency (i.e., VO2 at a given work rate) is the same for every-
one.
• The subject is not on medications that alter HR.

MODES OF TESTING
Commonly used modes for exercise testing include field tests, treadmill tests,
cycle ergometry tests, and step tests. Medical supervision may be required for
moderate or high-risk individuals for each of these modes. Refer to Figure 2.4 for
exercise testing and supervision guidelines. There are advantages and disadvan-
tages of each mode:
• Field tests consist of walking or running a certain distance in a given time
(i.e., 12-minute and 1.5-mile [2.4-km] run tests, and the 1- and 6-minute
walk test). The advantages of field tests are that they are easy to administer to
large numbers of individuals at one time and little equipment (e.g., a stop-
watch) is needed. The disadvantages are that they all potentially could be
maximal tests, and by their nature, are unmonitored for BP and HR. An indi-
vidual’s level of motivation and pacing ability also can have a profound impact
on test results. These all-out run tests may be inappropriate for sedentary
individuals or individuals at increased
. risk for cardiovascular and muscu-
loskeletal complications. However, VO2max can be estimated from test results.
• Motor driven treadmills can be used for submaximal and maximal testing and
often are used for diagnostic testing. They provide a common form of exercise
(i.e., walking) and can accommodate the least fit to the fittest individuals
across the continuum of walking to running speeds. Nevertheless, a practice
session might be necessary in some cases to permit habituation and reduce
anxiety. On the other hand, treadmills usually are expensive, not easily trans-
portable, and make some measurements (e.g., BP) more difficult. Treadmills
must be calibrated to ensure the accuracy of the test. In addition, holding on
to the support rail should not be permitted to ensure accuracy of the metabolic
work.
• Mechanically braked cycle ergometers are excellent test modalities for sub-
maximal and maximal testing. They are relatively inexpensive, easily trans-
portable, and allow BP and the ECG (if appropriate) to be measured easily.
The main disadvantage is that cycling is a less familiar mode of exercise, often
resulting in limiting localized muscle fatigue. Cycle ergometers provide a
non–weight-bearing test modality in which work rates are easily adjusted in
small work-rate increments, and subjects tend to be least anxious using this
device. The cycle ergometer must be calibrated and the subject must maintain
the proper pedal rate because most tests require that HR be measured at spe-
cific work rates. Electronic cycle ergometers can deliver the same work rate
across a range of pedal rates, but calibration might require special equipment
not available in most laboratories. Some electronic fitness cycles cannot be
calibrated and should not be used for testing.
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 75

• Step testing is an inexpensive modality for predicting CR fitness by measur-

ing the HR response to stepping at a fixed rate and/or a fixed step height or
by measuring postexercise recovery HR. Step tests require little or no equip-
ment; steps are easily transportable; stepping skill requires little practice; the
test usually is of short duration; and stepping is advantageous for mass test-
ing (45). Postexercise (recovery) HR decreases with improved CR fitness,
and test results are easy to explain to participants (36). Special precautions
might be needed for those who have balance problems or are extremely
deconditioned. Some single-stage step tests require an energy cost of seven
to nine metabolic equivalents (METs), which may exceed the maximal
capacity of the participant (2). The workload must be appropriate to the fit-
ness level of the client. In addition, inadequate compliance to the step
cadence and excessive fatigue in the lead limb may diminish the value of a
step test. Most tests are unmonitored because of the difficulty of measuring
HR and BP during a step test.

Field Tests
Two of the most widely used running tests for assessing CR fitness are the
Cooper 12-minute test and the 1.5-mile (2.4-km) test for time. The objec-
tive in the 12-minute test is to cover the greatest distance in the allotted
time period; for the 1.5-mile. (2.4-km) test, it is to run the distance in the
shortest period of time. V O2max can be estimated from the equations in
Chapter 7.
The Rockport One-Mile Fitness Walking Test has gained wide popularity as an
effective means for estimating CR fitness. In this test, an individual walks 1 mile
(1.6 km) as fast as possible, preferably on a track or a level surface, and HR is
obtained in the final minute. An alternative is to measure a 10-second HR imme-
diately
. on completion of the 1-mile (1.6 km) walk, but this may overestimate
. the
VO2max compared with when HR is measured during the walk. VO2max is esti-
mated from a regression equation (found in Chapter 7) based on weight, age, sex,
walk time, and HR (38). In addition to independently predicting morbidity and
mortality (4), the 6-minute walk test has been used to evaluate CR fitness within
some clinical patient populations (e.g., persons with chronic heart failure or pul-
monary disease). Even though the test is considered submaximal, it may result in
near maximal performance for those with low fitness levels or disease. Patients
completing "300 meters during the 6-minute walk demonstrate a limited short-
term
. survival (10). Several multivariate equations are available to predict peak
VO2 from the 6-minute walk; however, the following equation requires minimal
clinical information (10):
. .
• Peak VO2 * VO2 mL %kg&1 %min&1 * [0.02 , distance (m)]
& [0.191 , age (yr)] & [0.07 , weight (kg)]
+ [0.09 , height (cm)] + [0.26 , RPP (, 10&3)] + 2.45
Where m * distance in meters; y * year; kg * kilogram; cm * centimeter;
RPP * rate pressure product (HR , systolic BP in mm Hg)
• R2 * 0.65 SEE * 2.68
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76 GUIDELINES FOR EXERCISE TESTING • www.acsm.org

Submaximal Exercise Tests

Both single-stage
. and multistage submaximal exercise tests are available to esti-
mate VO2max from simple HR measurements. Accurate measurement of HR is crit-
ical for valid testing. Although HR obtained by palpation is used commonly, the
accuracy of this method depends on the experience and technique of the evalua-
tor. It is recommended that an ECG, HR monitor, or a stethoscope be used to
determine HR. The use of a relatively inexpensive HR monitor can reduce a sig-
nificant source of error in the test. The submaximal HR response is easily altered
by several environmental (e.g., heat and/or humidity, Chapter 7), dietary (e.g.,
caffeine, time since last meal), and behavioral (e.g., anxiety, smoking, previous
activity) factors. These variables must be controlled to have a valid estimate that
can be used as a reference point in a person’s fitness program. In addition, the test
mode (e.g., cycle, treadmill, or step) should be consistent with the primary activ-
ity used by the participant to address specificity of training issues. Standardized
procedures for submaximal testing are presented in Box 4.4. Although there are
no specific submaximal protocols for treadmill testing, several stages from any of
the treadmill protocols found in Chapter 5 can be used to assess submaximal exer-
cise responses. Pre-exercise test instructions were presented in Chapter 3.
Cycle Ergometer Tests
The Astrand-Rhyming cycle ergometer test is a single-stage test lasting 6 minutes
(3).
. For the population studied, these researchers observed that at 50% of
VO2max the average HR was 128 and 138. beats % min&1 for men and women,
respectively. If a woman was. working at a VO2 of 1.5 L%min&1 and her HR was
138 beats %min&1, then her VO2max was estimated to be 3.0 L %min&1. The sug-
gested work rate is based on sex and an individual’s fitness status as follows:
men, unconditioned: 300 or 600 kg %m%min&1 (50 or 100 watts)
men, conditioned: 600 or 900 kg%m%min&1 (100 or 150 watts)
women, unconditioned: 300 or 450 kg%m%min&1 (50 or 75 watts)
women, conditioned: 450 or 600 kg %m%min&1 (75 or 100 watts)
The pedal rate is set at 50 rpm. The goal is to obtain HR values between 125 and
170 beats%min&1, and HR is measured during the fifth and.sixth minute of work. The
average of the two heart rates is then used to estimate VO2max from a nomogram
(Fig. 4.1). This value must then. be adjusted for age (because maximal HR decreases
with age) by multiplying the VO2max value by the following correction factors (2):

AGE CORRECTION FACTOR

15 1.10
25 1.00
35 0.87
40 0.83
45 0.78
50 0.75
55 0.71
60 0.68
65 0.65
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 77

VO2, L

Work load
(kg/min)
Women Men
0.8
Step test 0.9 300
33 cm 40 cm
Women Men 300
(weight, kg) 1.0
Pulse rate
Men Women 40 1.1

170 VO2max, L 1.2 450

450
1.6 40
166 1.3
50
162 1.8 1.4
172
2.0 600
158 168 1.5
60 600
2.2 50
154 164 1.6
2.4
150 160 1.7
2.6
70 750
146 156 2.8 1.8
60 750
3.0 1.9
142 152
3.2
138 148 3.4 2.0
80
3.6 900
134 144 3.8 2.1
70 900
4.0
130 140 4.2 2.2
4.4 90
126 4.6 2.3
136 4.8
5.0
122 132 5.2 2.4
5.4 80
5.6 1.050
128 5.8 6.0 2.5

124 2.6

120 90 2.7
2.8 1.200
2.9
100 3.0

3.1

3.2

3.3

3.4

3.5
1.500

FIGURE 4.1. Modified Astrand-Ryhming nomogram. (Used with permission from

Astrand PO, Ryhming I. A nomogram for calculation of aerobic capacity [physical fitness]
from pulse rate during submaximal work. J Appl Physiol. 1954;7:218–21.)
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78 GUIDELINES FOR EXERCISE TESTING • www.acsm.org

1st 150 kgm/min

stage (0.5 kg)

HR: <80 HR: 80–89 HR: 90–100 HR: >100

2nd 750 kgm/min 600 kgm/min 450 kgm/min 300 kgm/min

stage (2.5 kg)* (2.0 kg) (1.5 kg) (1.0 kg)

3rd 900 kgm/min 750 kgm/min 600 kgm/min 450 kgm/min

stage (3.0 kg) (2.5 kg) (2.0 kg) (1.5 kg)

4th 1050 kgm/min 900 kgm/min 750 kgm/min 600 kgm/min

stage (3.5 kg) (3.0 kg) (2.5 kg) (2.0 kg)

Directions:
1 Set the 1st work rate at 150 kgm/min (0.5 kg at 50 rpm)
2 If the HR in the third minute of the stage is:
<80, set the 2nd stage at 750 kgm/min (2.5 kg at 50 rpm)
80-89, set the 2nd stage at 600 kgm/min (2.0 kg at 50 rpm)
90-100, set the 2nd stage at 450 kgm/min (1.5 kg at 50 rpm)
>100, set the 2nd stage at 300 kgm/min (1.0 kg at 50 rpm)
3 Set the 3rd and 4th (if required) according to the work rates in
the columns below the 2nd loads
FIGURE 4.2. YMCA cycle ergometry protocol. Resistance settings shown here are appro-
priate for an ergometer with a flywheel of 6 m%rev&1.

In contrast to the single-stage test, Maritz et al. (44) measured HR at a series of

submaximal work rates and extrapolated the response to the subject’s age-
predicted maximal HR.. This has become one of the most popular assessment
techniques to estimate VO2max, and the YMCA test is a good example (24). The
YMCA protocol uses two to four 3-minute stages of continuous exercise (Fig. 4.2).
The test is designed to raise the steady-state HR of the subject to between
110 beats%min&1 and 70% HRR (85% of the age-predicted maximal HR) for at least
two consecutive stages. It is important to remember that two consecutive
. HR meas-
urements must be obtained within this HR range to predict VO2max. In the YMCA
protocol, each work rate is performed for at least 3 minutes, and HRs are recorded
during the final 15 to 30 seconds of the second and third minutes. The work rate
should be maintained for an additional minute if the two HRs vary by more than
5 beats%min&1. The test administrator should recognize the error associated with
age-predicted maximal HR and monitor the subject throughout the test to ensure
the test remains submaximal. The HR measured during the last minute of each
steady-state stage is plotted against work rate. The line generated from the plotted
points is then extrapolated to the age-predicted maximal HR (e.g., 220 – age), and
a perpendicular line is dropped to the x-axis to estimate the work rate .that would
have been achieved if the person had worked to maximum (Fig. 4.3). VO2max can
be estimated from the work rate using the formula in Chapter 7. These equations
are valid to estimate oxygen consumption at submaximal steady-state workloads
from 300 to 1,200 kg%m%min&1; therefore, caution must be used if extrapolating
to workloads outside of this range. The two lines noted as (1 SD in Figure 4.3
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 79

200

190 +1SD

180

170

160
-1SD

150

140

130

120

110
150 300 450 600 750 900 1050 1200

FIGURE 4.3. Heart rate responses to three submaximal work rates for a 40-year-old, seden-
.
tary woman weighing 64 kg. VO2max was estimated by extrapolating the heart rate (HR)
response to the age-predicted maximal HR of 180 beats %min&1 (based on 220 & age). The
work rate that would have been. achieved at that HR was determined by dropping a line from
that HR value to the x-axis. VO2max is estimated using the formula in Chapter 7. and
expressed in L%min–1, was 2.2 L%min–1. The other two lines estimate what the VO2max would
have been if the subject’s true maximal HR was (1 SD from the 180 beats%min–1 value.

.
show what the estimated VO2max would be if the subject’s true maximal HR were
&1
168 or 192 beats%min
. , rather than 180 beats%min&1. Part of the error involved
in estimating VO2max from submaximal HR responses occurs because the formula
(220 – age) can provide only an estimate of maximal HR (standard deviation of for-
mula * 12 to 15 beats%min&1) (70). In addition, errors can be attributed to inac-
curate pedaling cadence (workload) and imprecise steady-state heart rates.

Treadmill Tests
The primary exercise modality for submaximal exercise testing traditionally has
been the cycle ergometer, although treadmills have been used in many settings.
The same endpoint (70% HRR or 85% of age-predicted maximal HR) is used, and
the stages of the test should be 3 minutes or longer to ensure a steady-state HR
response at
. each stage. The HR values are extrapolated to age-predicted maximal
HR, and VO2max is estimated using the formula in Chapter 7 from the highest
speed and/or grade that would have been achieved if the person had worked to
maximum. Most common treadmill protocols (Chapter 5) can be used, but the
duration of each stage should be at least 3 minutes.
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80 GUIDELINES FOR EXERCISE TESTING • www.acsm.org

Step Tests
.
Step tests have also been used to estimate VO2max. Astrand and Ryhming (3) used
a single-step height of 33 cm (13 in) for women and 40 cm (15.7 in) for men at
a rate of 22.5 steps %min&1. These tests require oxygen uptakes of about 25.8 and
29.5 mL%kg&1 %min .
&1
, respectively. Heart rate is measured as described for the
cycle test, and VO2max is estimated from the nomogram (Fig. 4.1). In contrast,
Maritz et al. (44) used a single-step height of 12 inches (30.5 cm) and four-step
rates to systematically increase the work rate. A steady-state HR was measured
for each step rate, and a line formed from these HR values was extrapolated to
age-predicted maximal HR; . the maximal work rate was determined as described
for the YMCA cycle test. VO2max can be estimated from the formula for stepping
in Chapter 7. Such step tests should be modified to suit the population being
tested. The Canadian Home Fitness Test has demonstrated that such testing can
be performed on a large scale
. and at low cost (2,3,24,36,38,44,64).
Instead of estimating VO2max from HR responses to several submaximal work
rates, a wide variety of step tests have been developed to categorize cardiovascu-
lar fitness on the basis of a person’s recovery HR following a standardized step
test. The 3-Minute YMCA Step Test is a good example of such a test. This test
uses a 12-inch (30.5 cm) bench, with a stepping rate of 24 steps %min&1 (esti-
mated oxygen cost of 25.8 mL %kg&1 % min&1). After exercise is completed, the
subject immediately sits down and HR is counted for 1 minute. Counting must
start within 5 seconds at the end of exercise. Heart rate values are used to obtain
a qualitative rating of fitness from published normative tables (24).

CARDIORESPIRATORY TEST SEQUENCE AND MEASURES

A minimum of HR, BP, and RPE should be measured during exercise tests. After
the initial screening process, selected baseline measurements should be obtained
before the start of the exercise test. Taking a resting ECG before exercise testing
assumes that trained personnel are available to interpret the ECG and provide
medical guidance. An ECG is not necessary when diagnostic testing is not being
done and when apparently healthy individuals are being tested with submaximal
tests. The sequence of measures is listed in Box 4.4.
Heart rate can be determined using several techniques, including radial or
carotid pulse palpation, auscultation with a stethoscope, or the use of HR moni-
tors. The pulse palpation technique involves “feeling” the pulse by placing the
first and second fingers over an artery (usually the radial artery located near the
thumb side of the wrist or the carotid artery located in the neck near the larynx).
The pulse is typically counted for 15 seconds, and then multiplied by four, to
determine the per-minute HR. Although the carotid pulse might be easier to
obtain, one should not press too hard with the palpating fingers because this
could produce a marked bradycardia in the presence of a hypersensitive carotid
sinus reflex. For the auscultation method, the bell of the stethoscope should be
placed to the left of the sternum just above the level of the nipple. This method
is most accurate when the heart sounds are clearly audible and the subject’s torso
is relatively stable. Heart rate telemetry monitors (heart rate watches) with chest
electrodes have proved to be accurate and reliable, provided there is no outside
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 81

General Procedures for Submaximal Testing of

BOX 4.4 Cardiorespiratory Fitness

1. Obtain resting heart rate and BP immediately before exercise in the

exercise posture.
2. The client should be familiarized with the ergometer. If using a cycle
ergometer, properly position the client on the ergometer (i.e., upright
posture, five-degree bend in the knee at maximal leg extension, hands
in proper position on handlebars).
3. The exercise test should begin with a two- to three-minute warm-up
to acquaint the client with the cycle ergometer and prepare him or
her for the exercise intensity in the first stage of the test.
4. A specific protocol should consist of 2- or 3-minute stages with
appropriate increments in work rate.
5. Heart rate should be monitored at least two times during each stage,
near the end of the second and third minutes of each stage. If heart
rate '110 beats%min&1, steady-state heart rate (i.e., two heart rates
within 5 beats%min&1) should be reached before the workload is
increased.
6. Blood pressure should be monitored in the last minute of each stage
and repeated (verified) in the event of a hypotensive or hypertensive
response.
7. Perceived exertion and additional rating scales should be monitored
near the end of the last minute of each stage using either the 6–20 or
0–10 scale (Table 4.8).
8. Client appearance and symptoms should be monitored and recorded
regularly.
9. The test should be terminated when the subject reaches 70% heart
rate reserve (85% of age-predicted maximal heart rate), fails to con-
form to the exercise test protocol, experiences adverse signs or symp-
toms, requests to stop, or experiences an emergency situation.
10. An appropriate cool-down/recovery period should be initiated con-
sisting of either:
a. Continued exercise at a work rate equivalent to that of the first
stage of the exercise test protocol or lower; or
b. A passive cool-down if the subject experiences signs of discomfort
or an emergency situation occurs
11. All physiologic observations (e.g., heart rate, BP, signs and
symptoms) should be continued for at least 5 minutes of recovery
unless abnormal responses occur, which would warrant a longer
posttest surveillance period. Continue low-level exercise until heart
rate and BP stabilize, but not necessarily until they reach pre-exercise
levels.
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82 GUIDELINES FOR EXERCISE TESTING • www.acsm.org

electrical interference (e.g., emissions from the display consoles of computerized

exercise equipment) (39). Many electronic cycles and treadmills have embedded
this HR technology into the equipment.
Blood pressure should be measured at heart level with the subject’s arm
relaxed and not grasping a handrail (treadmill) or handlebar (cycle ergometer).
To help ensure accurate readings, the use of an appropriate-sized BP cuff is
important. The rubber bladder of the BP cuff should encircle at least 80% of the
subject’s upper arm. If the subject’s arm is large, a normal-size adult cuff will be
too small, thus resulting in an erroneous elevated reading (the converse is also
true). Blood pressure measurements should be taken with a mercury sphygmo-
manometer adjusted to eye level or a recently calibrated aneroid manometer. Sys-
tolic and diastolic BP measurements can be used as indicators for stopping an
exercise test (see next section). To obtain accurate BP measures during exercise,
follow the guidelines in Chapter 3 (Box 3.4) for resting BP; however, obtain BP
in the exercise position. In addition, if the fourth Korotkoff sound can not be dis-
cerned, the fifth Korotkoff sound should be obtained. During exercise, it is advis-
able to obtain the first, fourth, and fifth Korotkoff sounds.
RPE can be a valuable indicator for monitoring an individual’s exercise toler-
ance. Although perceived exertion ratings correlate with exercise HRs and work
rates, large interindividual variability in RPE with both healthy as well as cardiac
patients mandates caution in the universal application of the scales (71). Borg’s
RPE scale was developed to allow the exerciser to subjectively rate his or her feel-
ings during exercise, taking into account personal fitness level, environmental
conditions, and general fatigue levels (50). Ratings can be influenced by psycho-
logical factors, mood states, environmental conditions, exercise modes, and age,
which reduce its utility (60). Currently, two RPE scales are widely used: the orig-
inal or category scale, which rates exercise intensity on a scale of 6 to 20, and the
category-ratio scale of 0 to 10. Both RPE scales are shown in Table 4.7. Either
scale is appropriate as a subjective tool.
During exercise testing, the RPE can be used as an indication of impending
fatigue. Most apparently healthy subjects reach their subjective limit of fatigue at
an RPE of 18 to 19 (very, very hard) on the category Borg scale or 9 to 10 (very,
very strong) on the category-ratio scale; therefore, RPE can be used to monitor
progress toward maximal exertion during exercise testing (48).

TEST TERMINATION CRITERIA

Graded exercise testing, whether maximal or submaximal, is a safe procedure
when subject screening and testing guidelines (Chapter 2) are adhered to. Occa-
sionally, for safety reasons,
. the test may have to be terminated before the subject
reaches a measured VO2max, volitional fatigue, or a predetermined endpoint (i.e.,
50% to 70% HRR or 70% to 85% age-predicted maximal HR). Because of the indi-
vidual variation in maximal HR, the upper limit of 85% of an estimated maximal
HR may result in a maximal effort for some individuals. General indications—
those that do not rely on physician involvement or ECG monitoring—for stop-
ping an exercise test are outlined in Box 4.5. More specific termination criteria
for clinical or diagnostic testing are provided in Chapter 5.
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 83

TABLE 4.7. CATEGORY AND CATEGORY-RATIO SCALES FOR RATINGS

OF PERCEIVED EXERTION
CATEGORY SCALE CATEGORY-RATIO SCALE

6 No exertion at all 0 Nothing at all

7 Extremely light 0.3
8 0.5 Extremely weak Just noticeable
9 Very light 0.7
10 1 Very weak
11 Light 1.5
12 2 Weak Light
13 Somewhat hard 2.5
14 3 Moderate
15 Hard (heavy) 4
16 5 Strong Heavy
17 Very hard 6
18 7 Very strong
19 Extremely hard 8
20 Maximal exertion 9
10 Extremely strong “Maximal”
11

● Absolute maximum Highest possible

Copyright Gunnar Borg. Reproduced with permission. For correct use of the Borg scales, it is necessary to follow the
administration and instructions given in Borg G. Borg’s Perceived Exertion and Pain Scales. Champaign (IL): Human Kinetics;
1998.

General Indications for Stopping an Exercise Test in

BOX 4.5 Low-Risk Adultsa

• Onset of angina or anginalike symptoms

• Drop in systolic BP of '10 mm Hg from baseline BP despite an
increase in workload
• Excessive rise in BP: systolic pressure '250 mm Hg or diastolic pres-
sure '115 mm Hg
• Shortness of breath, wheezing, leg cramps, or claudication
• Signs of poor perfusion: light-headedness, confusion, ataxia, pallor,
cyanosis, nausea, or cold and clammy skin
• Failure of heart rate to increase with increased exercise intensity
• Noticeable change in heart rhythm
• Subject requests to stop
• Physical or verbal manifestations of severe fatigue
• Failure of the testing equipment
a
Assumes that testing is nondiagnostic and is being performed without direct physician involvement or ECG
monitoring. For clinical testing, Box 5–2 provides more definitive and specific termination criteria.
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84 GUIDELINES FOR EXERCISE TESTING • www.acsm.org

INTERPRETATION OF RESULTS
. "1
Table 4.8 provides normative values for VO2max (mL!kg. !min"1), with specific
reference to age and sex. Research suggests that a VO2max below the twentieth per-
centile for age and sex, which is often indicative of a sedentary lifestyle, is associ-
ated with an increased risk of death from all causes (5). In a comparison of the fit-
ness status of any one individual to published norms, the accuracy of the
classification is dependent on the similarities
. between the populations and method-
ology (estimated versus measured VO2max; maximal versus submaximal, etc.).
Although submaximal exercise testing is not as precise as maximal exercise testing,
it provides a reasonably accurate reflection of an individual’s fitness at a lower cost
and reduced risk, and requires less time and effort on the part of the subject.
Some of the assumptions inherent in a submaximal test are more easily met
(e.g., steady-state HR can be verified), whereas others . (e.g., estimated maximal
HR) introduce unknown errors into the prediction of VO2max. When an individual

TABLE 4.8. PERCENTILE VALUES FOR MAXIMAL AEROBIC POWER

MALES
AGE 20–29 AGE 30–39
. .
Balke Max V O2 12 min 1.5 Mile Balke Max V O2 12 min 1.5 Mile
Treadmill (mL/kg/ Run Run Treadmill (mL/kg/ Run Run
% (time) min) (miles) (time) (time) min) (miles) (time)

99 32:00 61.2 2.02 8:22 30:00 58.3 1.94 8:49

95 28:31 56.2 1.88 9:10 27:11 54.3 1.82 9:31 S
90 27:00 54.0 1.81 9:34 26:00 52.5 1.77 9:52
85 26:00 52.5 1.77 9:52 24:45 50.7 1.72 10:14
80 25:00 51.1 1.73 10:08 23:30 47.5 1.67 10:38 E
75 23:40 49.2 1.68 10:34 22:30 47.5 1.63 10:59
70 23:00 48.2 1.65 10:49 22:00 46.8 1.61 11.09
65 22:00 46.8 1.61 11:09 21:00 45.3 1.57 11:34
60 21:15 45.7 1.58 11:27 20:20 44.4 1.55 11:49 G
55 21:00 45.3 1.57 11:34 20:00 43.9 1.53 11 :58
50 20:00 43.9 1.53 11:58 19:00 42.4 1:49 12:25
45 19:26 43.1 1.51 12:11 18:15 41.4 1.46 12:44
40 18:50 42.2 1.49 12:29 18:00 41.0 1.45 12:53 F
35 18:00 41.0 1.45 12:53 17:00 39.5 1.41 13:25
30 17:30 40.3 1.43 13:08 16:15 38.5 1.38 13:48
25 17:00 39.5 1.41 13:25 15:40 37.6 1.36 14:10
20 16:00 38.1 1.37 13:58 15:00 36.7 1.33 14:33 P
15 15:00 36.7 1.33 14:33 14:00 35.2 1.29 15:14
10 14:00 35.2 1.29 15:14 13:00 33.8 1.25 15:56
5 12:00 32.3 1.21 16:46 11:10 31.1 1.18 17:30
1 8:00 26:6 1.05 20:55 8:00 26.6 1.05 20:55 VP
n # 2,606 n # 13,158
Total n # 15,764
S, Superior; E, excellent; G, good; F, fair; P, poor; VP, very poor.

Reprinted with permission from the Cooper Institute, Dallas, TX. For more information: www.cooperinstitute.org.
LWBK119-3920G_CH04_60-104.qxd 20/10/2008 09:33 PM Page 85 Aptara (PPG-Quark)

CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 85

TABLE 4.8. PERCENTILE VALUES FOR MAXIMAL

AEROBIC POWER (Continued)
MALES
AGE 40–49 AGE 50–59
. .
Balke Max V O2 12 min 1.5 Mile Balke Max V O2 12 min 1.5 Mile
Treadmill (mL/kg/ Run Run Treadmill (mL/kg/ Run Run
% (time) min) (miles) (time) (time) min) (miles) (time)

99 29:06 57.0 1.90 9:02 27:15 54.3 1.82 9:31

95 26:16 52.9 1.79 9:47 24:00 49.7 1.69 10:27 S
90 25:00 51.1 1.73 10:09 22:00 46.8 1.61 11:09
85 23:14 48.5 1.66 10:44 20:31 44.6 1.55 11:45
80 22:00 46.8 1.61 11:09 19:35 43.3 1.52 12:08 E
75 21:02 45.4 1.58 11:32 18:32 41.8 1.47 12:37
70 20:15 44.2 1.54 11:52 18:00 41.0 1.45 12:53
65 20:00 43.9 1.53 11:58 17:00 39.5 1.41 13:25
60 19:00 42.4 1.49 12:25 16:10 38:3 1.38 13.53 G
55 18:02 41.0 1.45 12:53 16:00 38.1 1.37 13:58
50 17:34 40.4 1.44 13:05 15:02 36.7 1.33 14:33
45 17:00 39.5 1.41 13:25 14:56 36.6 1.33 14:35
40 16:12 38.4 1.38 13:50 14:00 35.2 1.29 15:14 F
35 15:38 37.6 1.36 14:10 13:05 33.9 1.26 15:53
30 15:00 36.7 1.33 14:33 12:38 33.2 1.24 16:16
25 14:20 35.7 1.31 15:00 12:00 32.3 1.21 16:46
20 13:35 34.6 1.28 15:32 11:10 31.1 1.18 17:30 P
15 12:45 33.4 1.24 16:09 10:15 29.8 1.14 18:22
10 11:40 31.8 1.20 17:04 9:15 28.4 1.10 19:24
5 10:00 29.4 1.13 18:39 7:30 25.8 1.03 21:40
1 7:00 25.1 1.01 22.22 4:20 21.3 0.90 27:08 VP
n ! 16,534 n ! 9,102
Total n ! 25,636
S, Superior; E, excellent; G, good; F, fair; P, poor; VP, very poor.

Reprinted with permission from the Cooper Institute, Dallas, TX. For more information: www.cooperinstitute.org.

is given repeated submaximal exercise tests over a period of weeks or months

and the HR response to a fixed work rate decreases over time, it is likely that
. the
individual’s CR fitness has improved, independent of the accuracy of the VO2max
prediction. Despite differences in test accuracy and methodology, virtually all
evaluations can establish a baseline and be used to track relative progress.

MUSCULAR STRENGTH AND MUSCULAR ENDURANCE

Muscular strength and endurance are health-related fitness components that may
improve or maintain the following:
• Bone mass, which is related to osteoporosis
• Glucose tolerance, which is related to type 2 diabetes
• Musculotendinous integrity, which is related to a lower risk of injury, includ-
ing low-back pain
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86 GUIDELINES FOR EXERCISE TESTING • www.acsm.org

TABLE 4.8. PERCENTILE VALUES FOR MAXIMAL

AEROBIC POWER (Continued)
MALES
AGE 60–69 AGE 70–79
. .
Balke Max V O2 12 min 1.5 Mile Balke Max V O2 12 min 1.5 Mile
Treadmill (mL/kg/ Run Run Treadmill (mL/kg/ Run Run
% (time) min) (miles) (time) (time) min) (miles) (time)

99 25:02 51.1 1.74 10:09 24:00 49.7 1.69 10:27

95 21:33 46.1 1.60 11:20 19:00 42.4 1.49 12:25 S
90 19:30 43.2 1.51 12:10 17:00 39.5 1.41 13:25
85 18:00 41.0 1.45 12:53 16:00 38.1 1.37 13:57
80 17:00 39.5 1.41 13:25 14:34 36.0 1.32 14:52 E
75 16:00 38.1 1.37 13:58 13:25 34.4 1.27 15:38
70 15:00 36.7 1.33 14:33 12:27 33.0 1.23 16:22
65 14:30 35.9 1.31 14:55 12:00 32.3 1.21 16:46
60 13:51 35.0 1.29 15:20 11:00 30.9 1.17 17:37 G
55 13:04 33.9 1.26 15:53 10:30 30.2 1.15 18:05
50 12:30 33.1 1.23 16:19 10:00 29.4 1.13 18:39
45 12:00 32.3 1.21 16:46 9:20 28.5 1.11 19:19
40 11:21 31.4 1.19 17:19 9:00 28.0 1.09 19:43 F
35 10:49 30.6 1.17 17:49 8:21 27.1 1.07 20:28
30 10:00 29.4 1.13 18:39 7:38 26.0 1.04 21:28
25 9:29 28.7 1.11 19:10 7:00 25.1 1.01 22:22
20 8:37 27.4 1.08 20:13 6:00 23.7 0.97 23:55 P
15 7:33 25.9 1.03 21:34 5:00 22.2 0.93 25:49
10 6:20 24.1 0.99 23:27 4:00 20.8 0.89 27:55
5 4:55 22.1 0.93 25:58 3:00 19.3 0.85 30:34
1 2:29 18.6 0.83 31:59 2:00 17.9 0.81 33:30 VP
n # 2,682 n # 467
Total n # 3,149
S, Superior; E, excellent; G, good; F, fair; P, poor; VP, very poor.

Reprinted with permission from the Cooper Institute, Dallas, TX. For more information: www.cooperinstitute.org.

• The ability to carry out the activities of daily living, which is related to self-esteem
• The FFM and resting metabolic rate, which are related to weight management
The ACSM has melded the terms muscular strength and muscular endurance
into a category termed muscular fitness and included it as an integral portion of
total health-related fitness in a position stand on the quantity and quality of exer-
cise to achieve and maintain fitness (1). Muscular strength refers to the ability of
the muscle to exert force (56). Muscular endurance is the muscle’s ability to continue
to perform for successive exertions or many repetitions (56). Traditionally, tests
allowing few (!3) repetitions of a task before reaching momentary muscular
fatigue have been considered strength measures, whereas those in which numer-
ous repetitions ("12) are performed before momentary muscular fatigue were
considered measures of muscular endurance. However, the performance of a
maximal repetition range (i.e., 4, 6, 8) also can be used to assess strength.
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 87

TABLE 4.8. PERCENTILE VALUES FOR MAXIMAL

AEROBIC POWER (Continued)
FEMALES
AGE 20–29 AGE 30–39
. .
Balke Max V O2 12 min 1.5 Mile Balke Max V O2 12 min 1.5 Mile
Treadmill (mL/kg/ Run Run Treadmill (mL/kg/ Run Run
% (time) min) (miles) (time) (time) min) (miles) (time)

99 27:43 55.0 1.84 9:23 26:00 52.5 1.77 9:52

95 24:24 50.2 1.71 10:20 22:06 46.9 1.62 11:08 S
90 22:30 47.5 1.63 10:59 20:34 44.7 1.56 11:43
85 21:00 45.3 1.57 11:34 19:03 42.5 1.50 12:23
80 20:04 44.0 1.54 11:56 18:00 41.0 1.45 12:53 E
75 19:42 43.4 1.52 12:07 17:30 40.3 1.43 13:08
70 18:06 41.1 1.46 12:51 16:30 38.8 1.39 13:41
65 17:45 40.6 1.44 13:01 16:00 38.1 1.37 13.58
60 17:00 39.5 1.41 13:25 15:02 36.7 1.33 14:33 G
55 16:00 38.1 1.37 13:58 15:00 36.7 1.33 14:33
50 15:30 37.4 1.35 14:15 14:00 35.2 1.29 15:14
45 15:00 36.7 1.33 14:33 13:30 34.5 1.27 15:35
40 14:11 35.5 1.30 15:05 13:00 33.8 1.25 15:56 F
35 13:36 34.6 1.27 15:32 12:03 32.4 1.21 16:43
30 13:00 33.8 1.25 15:56 12:00 32.3 1.21 16:46
25 12:04 32.4 1.22 16:43 11:00 30.9 1.17 17:38
20 11:30 31.6 1.19 17:11 10:20 29.9 1.15 18:18 P
15 10:42 30.5 1.16 17:53 9:39 28.9 1.12 19:01
10 10:00 29.4 1.13 18:39 8:36 27.4 1.08 20:13
5 7:54 26.4 1.05 21:05 7:16 25.5 1.02 21:57
1 5:14 22.6 0.94 25:17 5:20 22.7 0.94 25:10 VP
n ! 1,350 n ! 4,394
Total n ! 5,744
S, Superior; E, excellent; G, good; F, fair; P, poor; VP, very poor.

Reprinted with permission from the Cooper Institute, Dallas, TX. For more information: www.cooperinstitute.org.

RATIONALE
Performing fitness tests to assess muscular strength and muscular endurance
before commencing exercise training or as part of a fitness screening evaluation
can provide valuable information on a client’s baseline fitness level. For exam-
ple, muscular fitness test results can be compared with established standards
and can be helpful in identifying weaknesses in certain muscle groups or mus-
cle imbalances that could be targeted in exercise training programs. The infor-
mation obtained during baseline muscular fitness assessments can also serve as
a basis for designing individualized exercise training programs. An equally use-
ful application of fitness testing is to show a client’s progressive improvements
over time as a result of the training program and thus provide feedback that is
often beneficial in promoting long-term exercise adherence.
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88 GUIDELINES FOR EXERCISE TESTING • www.acsm.org

TABLE 4.8. PERCENTILE VALUES FOR MAXIMAL

AEROBIC POWER (Continued)
FEMALES
AGE 40–49 AGE 50–59
. .
Balke Max V O2 12 min 1.5 Mile Balke Max V O2 12 min 1.5 Mile
Treadmill (mL/kg/ Run Run Treadmill (mL/kg/ Run Run
% (time) min) (miles) (time) (time) min) (miles) (time)

99 25:00 51.1 1.74 10:09 21:00 45.3 1.57 11:34

95 20:56 45.2 1.57 11:35 17:16 39.9 1.42 13:16 S
90 19:00 42.4 1.49 12:25 16:00 38.1 1.37 13:58
85 17:20 40.0 1.43 13:14 15:00 36.7 1.33 14:33
80 16:34 38.9 1.40 13:38 14:00 35.2 1.29 15:14 E
75 16:00 38.1 1.37 13:58 13:15 34.1 1.26 15:47
70 15:00 36.7 1.33 14:33 12:23 32.9 1.23 16:26
65 14:14 35.6 1.30 15:03 12:00 32.3 1.21 16:46
60 13:56 35.1 1.29 15:17 11:23 31.4 1.19 17:19 G
55 13:02 33.8 1.25 15:56 11:00 30.9 1.17 17:38
50 12:39 33.3 1.24 16:13 10:30 30.2 1.15 18:05
45 12:00 32.3 1.21 16:46 10:00 29.4 1.13 18:39
40 11:30 31.6 1.19 17:11 9:30 28.7 1.11 19:10 F
35 11:00 30.9 1.17 17:38 9:00 28.0 1.09 19:43
30 10:10 29.7 1.14 18:26 8:30 27.3 1.07 20:17
25 10:00 29.4 1.13 18:39 8:00 26.6 1.05 20:55
20 9:00 28.0 1.09 19:43 7:15 25.5 1.02 21:57 P
15 8:07 26.7 1.06 20:49 6:40 24.6 1.00 22:53
10 7:21 25.6 1.03 21:52 6:00 23.7 0.97 23:55
5 6:17 24.1 0.98 23:27 4:48 21.9 0.92 26:15
1 4:00 20.8 0.89 27:55 3:00 19.3 0.85 30:34 VP
n * 4,834 n * 3,103
Total n * 7,937
S, Superior; E, excellent; G, good; F, fair; P, poor; VP, very poor.

Reprinted with permission from the Cooper Institute, Dallas, TX. For more information: www.cooperinstitute.org.

PRINCIPLES
Muscle function tests are very specific to the muscle group tested, the type of con-
traction, the velocity of muscle movement, the type of equipment, and the joint
range of motion. Results of any one test are specific to the procedures used, and no
single test exists for evaluating total body muscular endurance or muscular strength.
Unfortunately, few muscle endurance or strength tests control for repetition duration
(speed of movement) or range of motion, thus results are difficult to interpret. Indi-
viduals should participate in familiarization/practice sessions with the equipment
and adhere to a specific protocol (including a predetermined repetition duration and
range of motion) to obtain a reliable score that can be used to track true physiologic
adaptations over time. Moreover, proper warm-up consisting of 5 to 10 minutes of
brief cardiovascular exercise, light stretching, and several light repetitions of the
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 89

TABLE 4.8. PERCENTILE VALUES FOR MAXIMAL

AEROBIC POWER (Continued)
FEMALES
AGE 60–69 AGE 70–79
. .
Balke Max V O2 12 min 1.5 Mile Balke Max V O2 12 min 1.5 Mile
Treadmill (mL/kg/ Run Run Treadmill (mL/kg/ Run Run
% (time) min) (miles) (time) (time) min) (miles) (time)

99 19:00 42.4 1.49 12:25 19:00 42.4 1.49 12:25

95 15:09 36.9 1.34 14:28 15:00 36.7 1.33 14:33 S
90 13:33 34.6 1.27 15:32 12:50 33.5 1.25 16:06
85 12:28 33.0 1.23 16:22 11:46 32.0 1.20 16:57
80 12:00 32.3 1.21 16:46 10:30 30.2 1.15 18:05 E
75 11:04 31.0 1.18 17:34 10:00 29.4 1.13 18:39
70 10:30 30.2 1.15 18:05 9:15 28.4 1.10 19:24
65 10:00 29.4 1.13 18:39 8:43 27.6 1.08 20:02
60 9:44 29.1 1.12 18:52 8:00 26.6 1.05 20:54 G
55 9:11 28.3 1.10 19:29 7:37 26.0 1.04 21:45
50 8:40 27.5 1.08 20:08 7:00 25.1 1.01 22:22
45 8:15 26.9 1.06 20:38 6:39 24.6 1.00 22:54
40 8:00 26.6 1.05 20:55 6:05 23.8 0.98 23:47 F
35 7:14 25.4 1.02 22:03 5:28 22.9 0.95 24:54
30 6:52 24.9 1.01 22:34 5:00 22.2 0.93 25:49
25 6:21 24.2 0.99 23:20 4:45 21.9 0.92 26:15
20 6:00 23.7 0.97 23:55 4:16 21.2 0.90 27:17 P
15 5:25 22.8 0.95 25:02 4:00 20.8 0.89 27:55
10 4:40 21.7 0.92 26:32 3:00 19.3 0.85 30:34
5 3:30 20.1 0.87 29:06 2:00 17.9 0.81 33:32
1 2:10 18.1 0.82 33:05 1:00 16.4 0.77 37:26 VP

n * 1,088 n * 209
Total n * 1,297
S, superior; E, excellent; G, good; F, fair; P, poor; VP, very poor.

Reprinted with permission from the Cooper Institute, Dallas, Texas. For more information:www.cooperinstitute.org

specific testing exercise should precede muscular fitness testing. This increases mus-
cle temperature and localized blood flow as well as promotes appropriate cardiovas-
cular responses to exercise. A summary of standardized conditions include:
• Strict posture
• Consistent repetition duration (movement speed)
• Full range of motion
• Use of spotters (when necessary)
• Equipment familiarization
• Proper warm-up
A change in one’s muscular fitness over time can be based on the absolute
value of the external load or resistance (e.g., newtons, kilograms [kg], or pounds
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[lb]), but when comparisons are made between individuals, the values should be
expressed as relative values (per kilogram of body weight [kg/kg]). In both cases,
caution must be used in the interpretation of the scores because the norms may
not include a representative sample of the individual being measured, a stan-
dardized protocol may be absent, or the exact test being used (free weight versus
machine weight) may differ.

MUSCULAR STRENGTH
Although muscular strength refers to the external force (properly expressed in
newtons, although kilograms and pounds are commonly used as well) that can be
generated by a specific muscle or muscle group, it is commonly expressed in terms
of resistance lifted. Strength can be assessed either statically (no overt muscular
movement or limb movement) or dynamically (movement of an external load or
body part, in which the muscle changes length). Static or isometric strength can be
measured conveniently using a variety of devices, including cable tensiometers and
handgrip dynamometers. Unfortunately, measures of static strength are specific to
both the muscle group and joint angle involved in testing; therefore, their utility in
describing overall muscular strength is limited. Peak force development in such
tests is commonly referred to as the maximum voluntary contraction (MVC).
Traditionally, the one-repetition maximum (1-RM), the greatest resistance
that can be moved through the full range of motion in a controlled manner with
good posture, has been the standard for dynamic strength assessment. However,
a multiple RM can be used, such as 4- or 8-RM, as a measure of muscular
strength, which may allow the participant to integrate evaluation into their train-
ing program. For example, if one were training with 6- to 8-RM, the performance
of a 6-RM to momentary muscular fatigue would provide an index of strength
changes over time, independent of the true 1-RM. Estimating a 1-RM from such
tests is problematic and generally not necessary. The number of lifts one can per-
form at a fixed percent of a 1-RM for different muscle groups (e.g., leg press ver-
sus bench press) varies tremendously, thus rendering an estimate of 1-RM
impractical (29,31). However, the true 1-RM is still a popular measure (41).
Valid measures of general upper-body strength include the 1-RM values for
bench press or military press. Corresponding indices of lower-body strength
include 1-RM values for leg press or leg extension. Norms, based on resistance
lifted divided by body mass for the bench press and leg press are provided in
Tables 4.9 and 4.10, respectively. The following represents the basic steps in
1-RM (or any multiple RM) testing following familiarization/practice sessions (41):
1. The subject should warm up by completing several submaximal repetitions.
2. Determine the 1-RM (or any multiple RM) within four trials with rest periods
of 3 to 5 minutes between trials.
3. Select an initial weight that is within the subject’s perceived capacity
(!50%–70% of capacity).
4. Resistance is progressively increased by 2.5 to 20 kg until the subject cannot com-
plete the selected repetition(s); all repetitions should be performed at the same
speed of movement and range of motion to instill consistency between trials.
5. The final weight lifted successfully is recorded as the absolute 1-RM or mul-
tiple RM.
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 91

TABLE 4.9. UPPER BODY STRENGTHa

MALES

weight pushed in Ibs

Bench Press Weight Ratio * ---
body weight in Ibs
AGE

% "20 20–29 30–39 40–49 50–59 60+

99 '1.76 '1.63 '1.35 '1.20 '1.05 '.94

95 1.76 1.63 1.35 1.20 1.05 .94 S
90 1.46 1.48 1.24 1.10 .97 .89
85 1.38 1.37 1.17 1.04 .93 .84
80 1.34 1.32 1.12 1.00 .90 .82 E
75 1.29 1.26 1.08 .96 .87 .79
70 1.24 1.22 1.04 .93 .84 .77
65 1.23 1.18 1.01 .90 .81 .74
60 1.19 1.14 .98 .88 .79 .72 G
55 1.16 1.10 .96 .86 .77 .70
50 1.13 1.06 .93 .84 .75 .68
45 1.10 1.03 .90 .82 .73 .67
40 1.06 .99 .88 .80 .71 .66 F
35 1.01 .96 .86 .78 .70 .65
30 .96 .93 .83 .76 .68 .63
25 .93 .90 .81 .74 .66 .60
20 .89 .88 .78 .72 .63 .57 P
15 .86 .84 .75 .69 .60 .56
10 .81 .80 .71 .65 .57 .53
5 .76 .72 .65 .59 .53 .49
1 ".76 ".72 ".65 ".59 ".53 ".49 VP
n 60 425 1,909 2,090 1,279 343
Total n * 6,106
FEMALES
AGE
% "20 20–29 30–39 40–49 50–59 60+

99 '.88 '1.01 '.82 '.77 '.68 '.72

95 .88 1.01 .82 .77 .68 .72 S
90 .83 .90 .76 .71 .61 .64
85 .81 .83 .72 .66 .57 .59
80 .77 .80 .70 .62 .55 .54 E
75 .76 .77 .65 .60 .53 .53
70 .74 .74 .63 .57 .52 .51
65 .70 .72 .62 .55 .50 .48
60 .65 .70 .60 .54 .48 .47 G
55 .64 .68 .58 .53 .47 .46
50 .63 .65 .57 .52 .46 .45
45 .60 .63 .55 .51 .45 .44
40 .58 .59 .53 .50 .44 .43 F
(Continued)
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TABLE 4.9. UPPER BODY STRENGTHa (Continued)

FEMALES AGE

35 .57 .58 .52 .48 .43 .41

30 .56 .56 .51 .47 .42 .40
25 .55 .53 .49 .45 .41 .39
20 .53 .51 .47 .43 .39 .38 P
15 .52 .50 .45 .42 .38 .36
10 .50 .48 .42 .38 .37 .33
5 .41 .44 .39 .35 .31 .26
1 ".41 ".44 ".39 ".35 ".31 ".26 VP
n 20 191 379 333 189 42
Total n * 1,154
S, superior; E, excellent; G, good; F, fair; P, poor; VP, very poor.
a
One repetition maximum bench press, with bench press weight ratio * weight pushed in pounds/body weight in pounds.

Reprinted with permission from The Cooper Institute, Dallas, Texas. For more information: www.cooperinstitute.org.

TABLE 4.10. LEG STRENGTHa

AGE
PERCENTILE 20–29 30–39 40–49 50–59 60+
Men
90 2.27 2.07 1.92 1.80 1.73
80 2.13 1.93 1.82 1.71 1.62
70 2.05 1.85 1.74 1.64 1.56
60 1.97 1.77 1.68 1.58 1.49
50 1.91 1.71 1.62 1.52 1.43
40 1.83 1.65 1.57 1.46 1.38
30 1.74 1.59 1.51 1.39 1.30
20 1.63 1.52 1.44 1.32 1.25
10 1.51 1.43 1.35 1.22 1.16
Women
90 1.82 1.61 1.48 1.37 1.32
80 1.68 1.47 1.37 1.25 1.18
70 1.58 1.39 1.29 1.17 1.13
60 1.50 1.33 1.23 1.10 1.04
50 1.44 1.27 1.18 1.05 0.99
40 1.37 1.21 1.13 0.99 0.93
30 1.27 1.15 1.08 0.95 0.88
20 1.22 1.09 1.02 0.88 0.85
10 1.14 1.00 0.94 0.78 0.72
a
One repetition maximum leg press with leg press weight ratio * weight pushed/body weight.

Adapted from Institute for Aerobics Research, Dallas, 1994. Study population for the data set was predominantly white
and college educated. A Universal DVR machine was used to measure the 1-RM. The following may be used as descrip-
tors for the percentile rankings: well above average (90), above average (70), average (50), below average (30), and well
below average (10).
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 93

Isokinetic testing involves the assessment of maximal muscle tension through-

out a range of joint motion set at a constant angular velocity (e.g., 60 angles/sec).
Equipment that allows control of the speed of joint rotation (degrees/sec) as well
as the ability to test movement around various joints (e.g., knee, hip, shoulder,
elbow) is available from commercial sources. Such devices measure peak rota-
tional force or torque, but an important drawback is that this equipment is
extremely expensive compared with other strength-testing modalities (25).

MUSCULAR ENDURANCE
Muscular endurance is the ability of a muscle group to execute repeated con-
tractions over a period of time sufficient to cause muscular fatigue, or to main-
tain a specific percentage of the MVC for a prolonged period of time. If the total
number of repetitions at a given amount of resistance is measured, the result is
termed absolute muscular endurance. If the number of repetitions performed at a
percentage of the 1-RM (e.g., 70%) is used both pre- and posttesting, the result
is termed relative muscular endurance. Simple field tests such as a curl-up
(crunch) test (12,25) or the maximum number of push-ups that can be per-
formed without rest (12) may be used to evaluate the endurance of the abdomi-
nal muscle groups and upper-body muscles, respectively. Although scientific data
to support a cause-effect relationship between abdominal strength and low back
pain are lacking, poor abdominal strength or endurance is commonly thought to
contribute to muscular low back pain (17,18). Procedures for conducting the
push-up and curl-up (crunch) muscular endurance tests are given in Box 4.6,
and fitness categories are provided in Tables 4.11 and 4.12, respectively.
Resistance-training equipment also can be adapted to measure muscular
endurance by selecting an appropriate submaximal level of resistance and measur-
ing the number of repetitions or the duration of static contraction before fatigue.
For example, the YMCA bench-press test involves performing standardized

Push-up and Curl-up (Crunch) Test Procedures

BOX 4.6 for Measurement of Muscular Endurance

PUSH-UP
1. The push-up test is administered with male subjects starting in the stan-
dard “down” position (hands pointing forward and under the shoulder,
back straight, head up, using the toes as the pivotal point) and female
subjects in the modified “knee push-up” position (legs together, lower
leg in contact with mat with ankles plantar-flexed, back straight, hands
shoulder width apart, head up, using the knees as the pivotal point).
2. The subject must raise the body by straightening the elbows and
return to the “down” position, until the chin touches the mat. The
stomach should not touch the mat.
3. For both men and women, the subject’s back must be straight at all
times and the subject must push up to a straight arm position. >
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> Box 4.6. continued

4. The maximal number of push-ups performed consecutively without
rest is counted as the score.
5. The test is stopped when the client strains forcibly or is unable to
maintain the appropriate technique within two repetitions.
CURL-UP (CRUNCH)
1. The individual assumes a supine position on a mat with the knees at
90 degrees. The arms are at the side, palms facing down with the mid-
dle fingers touching a piece of masking tape. A second piece of mask-
ing tape is placed 10 cm apart.a Shoes remain on during the test.
2. A metronome is set to 50 beats%min&1 and the individual does slow,
controlled curl-ups to lift the shoulder blades off the mat (trunk
makes a 30-degree angle with the mat) in time with the metronome at
a rate of 25 per minute. The test is done for 1 minute. The low back
should be flattened before curling up.
3. Individual performs as many curl-ups as possible without pausing, to
a maximum of 25.b
a
Alternatives include (a) having the hands held across the chest, with the head activating a
counter when the trunk reaches a 30-degree position (17) and placing the hands on the thighs
and curling up until the hands reach the knee caps (18). Elevation of the trunk to 30 degrees
is the important aspect of the movement.
b
An alternative includes doing as many curl-ups as possible in 1 minute.
From Canadian Society for Exercise Physiology. Canadian Physical Activity, Fitness & Lifestyle
Approach: CSEP-Health & Fitness Program’s Appraisal & Counseling Strategy. 3rd ed. Ottawa (ON):
Canadian Society for Exercise Physiology; 2003, with permission.

TABLE 4.11. FITNESS CATEGORIES BY AGE GROUPS AND

SEX FOR PUSH-UPS
AGE
CATEGORY 20–29 30–39 40–49 50–59 60–69
SEX M F M F M F M F M F

Excellent 36 30 30 27 25 24 21 21 18 17
Very good 35 29 29 26 24 23 20 20 17 16
29 21 22 20 17 15 13 11 11 12
Good 28 20 21 19 16 14 12 10 10 11
22 15 17 13 13 11 10 7 8 5
Fair 21 14 16 12 12 10 9 6 7 4
17 10 12 8 10 5 7 2 5 2
Needs improvement 16 9 11 7 9 4 6 1 4 1
M, male; F, female.

Source: Canadian Physical Activity, Fitness & Lifestyle Approach: CSEP-Health & Fitness Program’s Appraisal & Counsel-
ing Strategy, 3rd ed, ©2003. Used with permission from the Canadian Society for Exercise Physiology.
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 95

TABLE 4.12. FITNESS CATEGORIES BY AGE GROUPS AND SEX FOR

PARTIAL CURL-UP
AGE
CATEGORY 20–29 30–39 40–49 50–59 60–69
SEX M F M F M F M F M F

Excellent 25 25 25 25 25 25 25 25 25 25
Very good 24 24 24 24 24 24 24 24 24 24
21 18 18 19 18 19 17 19 16 17
Good 20 17 17 18 17 18 16 18 15 16
16 14 15 10 13 11 11 10 11 8
Fair 15 13 14 9 12 10 10 9 10 7
11 5 11 6 6 4 8 6 6 3
Needs improvement 10 4 10 5 5 3 7 5 5 2
M, male; F, female.

Source: Canadian Physical Activity, Fitness & Lifestyle Approach: CSEP-Health & Fitness Program’s Appraisal & Counsel-
ing Strategy, 3rd ed, ©2003. Used with permission from the Canadian Society for Exercise Physiology.

repetitions at a rate of 30 lifts or reps%min&1. Men are tested using an 80-pound

(36.3-kg) barbell and women using a 35-pound (15.9-kg) barbell. Subjects are
scored by the number of successful repetitions completed (24). The YMCA test is
an excellent example of a test that attempts to control for repetition duration and
posture alignment, thus possessing high reliability. Normative data for the YMCA
bench press test are presented in Table 4.13.

TABLE 4.13. YMCA BENCH PRESS TEST: TOTAL LIFTS

AGE
CATEGORY 18–25 26–35 36–45 46–55 56–65 '65
SEX M F M F M F M F M F M F

Excellent 64 66 61 62 55 57 47 50 41 42 36 30
44 42 41 40 36 33 28 29 24 24 20 18
Good 41 38 37 34 32 30 25 24 21 21 16 16
34 30 30 29 26 26 21 20 17 17 12 12
Above average 33 28 29 28 25 24 20 18 14 14 10 10
29 25 26 24 22 21 16 14 12 12 9 8
Average 28 22 24 22 21 20 14 13 11 10 8 7
24 20 21 18 18 16 12 10 9 8 7 5
Below average 22 18 20 17 17 14 11 9 8 6 6 4
20 16 17 14 14 12 9 7 5 5 4 3
Poor 17 13 16 13 12 10 8 6 4 4 3 2
13 9 12 9 9 6 5 2 2 2 2 0
Very poor "10 6 9 6 6 4 2 1 1 1 1 0
M, male. F, female.

Reprinted with permission from Golding LA, editor. YMCA Fitness Testing and Assessment Manual, 4th ed. Champaign (IL):
Human Kinetics; 2000.
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SPECIAL CONSIDERATIONS
Older Adults
The number of older adults in the United States is expected to increase expo-
nentially over the next several decades. As people are living longer, it is becom-
ing increasingly more important to find ways to extend active, healthy lifestyles
and reduce physical frailty in later years. Assessing muscular strength, muscular
endurance, and other aspects of health-related physical fitness in older adults can
aid in detecting physical weaknesses and yield important information used to
design exercise programs that improve strength before serious functional limita-
tions occur. The Senior Fitness Test (SFT) was developed in response to a need
for improved assessment tools for older persons (58). The test was designed to
assess the key physiologic parameters (e.g., strength, endurance, agility, and bal-
ance) needed to perform common everyday physical activities that are often dif-
ficult in later years. One aspect of the SFT is the 30-second chair-stand test. This
test, and others of the SFT, meets scientific standards for reliability and validity,
is simple and easy to administer in the “field” setting, and has accompanying per-
formance norms for older men and women ages 60 to 94 years based on a study
of more than 7,000 older Americans (58). This test has been shown to correlate
well with other muscular fitness tests, such as the 1-RM. Two specific tests
included in the SFT, the 30-second chair stand and the single arm curl, can be
used by the health/fitness professional to safely and effectively assess muscular
strength and muscular endurance in most older adults.

Coronary-Prone Clients
Moderate-intensity resistance training performed 2 to 3 days per week has been
shown to be effective for improving muscular fitness, preventing and managing
a variety of chronic medical conditions, modifying coronary risk factors, and
enhancing psychosocial well-being for persons with and without cardiovascular
disease. Consequently, authoritative professional health organizations, including
the American Heart Association and ACSM, support the inclusion of resistance
training as an adjunct to endurance-type exercise in their current recommenda-
tions and guidelines on exercise for individuals with cardiovascular disease (55).
The absence of anginal symptoms, ischemic ST-segment changes on the ECG,
abnormal hemodynamics, and complex ventricular dysrhythmias suggests that
both moderate-to-high intensity (e.g., 40%–80% 1-RM) resistance testing and
training can be performed safely by cardiac patients deemed low risk (e.g., per-
sons without resting or exercise-induced evidence of myocardial ischemia, severe
left ventricular dysfunction, or complex ventricular dysrhythmias, and with nor-
mal or near-normal CR fitness; see Box 2.3). Moreover, despite concerns that
resistance exercise elicits abnormal cardiovascular “pressor responses” in
patients with coronary artery disease and/or controlled hypertension, studies
have found that strength testing and resistance training in these patients elicit HR
and BP responses that appear to fall within clinically acceptable limits. Specific
data on the safety of muscular fitness testing in moderate-to-high–risk cardiac
patients, especially those with poor left ventricular function, are limited and
require additional investigation (55).
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 97

Contemporary exercise guidelines suggest that contraindications to muscular

strength and muscular endurance testing should include unstable angina, uncon-
trolled hypertension (systolic BP $160 mm Hg and/or diastolic BP $100 mm Hg),
uncontrolled dysrhythmias, a recent history of heart failure that has not been eval-
uated and effectively treated, severe stenotic or regurgitant valvular disease, and
hypertrophic cardiomyopathy. Because patients with myocardial ischemia or poor
left ventricular function may develop wall-motion abnormalities or serious ven-
tricular arrhythmias during resistance-related exertion, moderate to good left ven-
tricular function and CR fitness ('5 or 6 METs) without anginal symptoms or
ischemic ST-segment changes have been suggested as additional prerequisites for
participation in traditional resistance-training programs and, thus, for testing of
muscular strength and muscular endurance (21,55). As with graded exercise test-
ing, the risk of a serious cardiac event during muscular strength and muscular
endurance testing can be minimized by proper preparticipation screening and
close supervision by health/fitness instructors.

Children and Adolescents

Along with CR fitness, flexibility, and body composition, muscular fitness is rec-
ognized as an important component of health-related fitness in children and ado-
lescents. The benefits of enhancing muscular strength and muscular endurance in
youth include developing proper posture, reducing the risk of injury, improving
body composition, and enhancing motor performance skills such as sprinting and
jumping. Assessing muscular strength and muscular endurance with the push-up
and abdominal curl-up is common practice in most physical education programs,
YMCA/YWCA recreation programs, and youth sport centers. Standardized testing
procedures have been developed for youth, and normative data for children and
teenagers are available in most physical education text books.
When properly administered, different muscular fitness measures can be used to
assess a child’s strengths and weaknesses, develop a personalized fitness program,
track progress, and motivate participants. Conversely, unsupervised or poorly
administered muscular fitness assessments may not only discourage youth from par-
ticipating in fitness activities, but may also result in injury. Qualified fitness profes-
sionals should demonstrate the proper performance of each skill, provide an oppor-
tunity for each child to practice a few repetitions of each skill, and offer guidance
and instruction when necessary. In addition, it is important and usually required to
obtain informed consent from the parent or legal guardian before initiating muscu-
lar fitness testing. The informed consent includes information on potential benefits
and risks, the right to withdraw at any time, and issues regarding confidentiality.
When assessing muscular fitness in youth, it is important to avoid the “pass-
fail” mentality that may discourage some boys and girls from participating.
Instead, consider referring to the assessment as a “challenge” in which all partic-
ipants can feel good about their performance and get excited about monitoring
their progress. Fitness professionals should also understand that children are not
simply “miniature” adults. Because children are physically and psychologically
less mature than adults, the assessment of any physical fitness measure requires
special considerations. Fitness professionals should develop a friendly rapport
with each child, and the exercise area should be nonthreatening. Because most
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children have limited experience performing maximum exertion, fitness profes-

sionals should reassure children that they can safely perform exercise at a high
level of exertion. Moreover, positive encouragement serves as a useful motiva-
tional tool to help ensure a valid test outcome.

FLEXIBILITY

Flexibility is the ability to move a joint through its complete range of motion. It
is important in athletic performance (e.g., ballet, gymnastics) and in the ability
to carry out the activities of daily living. Consequently, maintaining flexibility of
all joints facilitates movement; in contrast, when an activity moves the structures
of a joint beyond a joint’s shortened range of motion, tissue damage can occur.
Flexibility depends on several specific variables, including distensibility of the
joint capsule, adequate warm-up, and muscle viscosity. Additionally, compliance
(“tightness”) of various other tissues, such as ligaments and tendons, affects the
range of motion. Just as muscular strength is specific to the muscles involved,
flexibility is joint specific; therefore, no single flexibility test can be used to eval-
uate total body flexibility. Laboratory tests usually quantify flexibility in terms of
range of motion, expressed in degrees. Common devices for this purpose include
various goniometers, electrogoniometers, the Leighton flexometer, inclinometers,
and tape measures. Comprehensive instructions are available for the evaluation of
flexibility of most anatomic joints (14,53). Visual estimates of range of motion can
be useful in fitness screening but are inaccurate relative to directly measured range
of motion. These estimates can include neck and trunk flexibility, hip flexibility,
lower-extremity flexibility, shoulder flexibility, and postural assessment. A more
precise measurement of joint range of motion can be assessed at most anatomic
joints following strict procedures (14,53) and the proper use of a goniometer.
Accurate measurements require in-depth knowledge of bone, muscle, and joint
anatomy, as well as experience in administering the evaluation. Table 4.14 pro-
vides normative range of motion values for select anatomic joints. Additional
information can be found in the ACSM Resource Manual.
The sit-and-reach test has been used commonly to assess low-back and hip-
joint flexibility; however, its relationship to predict the incidence of low-back pain
is limited (35). The sit-and-reach test is suggested to be a better measure of ham-
string flexibility than low-back flexibility (34). However, the relative importance
of hamstring flexibility to activities of daily living and sports performance requires
the inclusion of the sit-and-reach test for health-related fitness testing until a cri-
terion measure evaluation of low-back flexibility is available. Although limb- and
torso-length disparity may affect the sit-and-reach scoring, modified testing that
establishes an individual zero point for each participant has not enhanced the
predictive index for low-back flexibility or low-back pain (11,30,47).
Poor lower-back and hip flexibility may, in conjunction with poor abdominal
strength/endurance or other causative factors, contribute to development of
muscular low-back pain; however, this hypothesis remains to be substantiated
(57). Methods for administering the sit-and-reach test are presented in Box 4.7.
Normative data for two sit-and-reach tests are presented in Tables 4.15 and 4.16.
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CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 99

TABLE 4.14. RANGE OF MOTION OF SELECT SINGLE JOINT

MOVEMENTS (DEGREES)
SHOULDER GIRDLE

Flexion 90–120 Extension 20–60

Abduction 80–100
Horizontal abduction 30–45 Horizontal adduction 90–135
Medial rotation 70–90 Lateral rotation 70–90
ELBOW

Flexion 135–160
Supination 75–90 Pronation 75–90
TRUNK

Flexion 120–150 Extension 20–45

Lateral flexion 10–35 Rotation 20–40
HIP

Flexion 90–135 Extension 10–30

Abduction 30–50 Adduction 10–30
Medial rotation 30–45 Lateral rotation 45–60
KNEE

Flexion 130–140 Extension 5–10

ANKLE

Dorsiflexion 15–20 Plantarflexion 30–50

Inversion 10–30 Eversion 10–20
Adapted from Norkin C, Levangie P. Joint Structure and Function: A Comprehensive Approach. 2nd ed. Philadelphia (PA):
Davis FA; 1992.

BOX 4.7 Trunk Flexion (Sit-and-Reach) Test Procedures

Pretest: Participant should perform a short warm-up before this test and
include some stretches (e.g., modified hurdler’s stretch). It is also recom-
mended that the participant refrain from fast, jerky movements, which may
increase the possibility of an injury. The participant’s shoes should be
removed.
1. For the Canadian Trunk Forward Flexion test, the client sits without
shoes and the soles of the feet flat against the flexometer (sit-and-
reach box) at the 26-cm mark. Inner edges of the soles are placed
within 2 cm of the measuring scale. For the YMCA sit-and-reach test,
a yardstick is placed on the floor and tape is placed across it at a
right angle to the 15-inch mark. The participant sits with the yardstick
between the legs, with legs extended at right angles to the taped line
on the floor. Heels of the feet should touch the edge of the taped
line and be about 10 to 12 inches apart. (Note the zero point at the
foot/box interface and use the appropriate norms.) >