Safety and feasibility of a health-related fitness test battery for adults.

Evidence of the health-enhancing effects of

regular exercise and several recommendations for

the promotion of physical activity have been

published recently.[1,2] The justification for

increased physical activity is well documented, but

effective methods for the promotion of physical activity in the

general population are only now emerging.[3,4]

Assessment of fitness may have an important role in the

promotion of physical activity for health.[5] Increased

knowledge of the relationships among physical activity,

fitness, and health has generated a new concept:

health-related fitness (HRFI).[5-7] Health-related fitness refers to

those components of fitness that are related to health

and are affected by habitual physical activity. Based on

this new concept, test batteries of HRFI have been

proposed.[5,8,9] Before applying the test batteries to the

general public, evaluations of their accuracy, reliability,

and validity are needed.

Safety is a major concern in HRFI testing and exercise

prescription for adults. The potential health risks

include cardiovascular complications[10-12] and

musculoskeletal injuries.[13-15[ Sudden cardiac death due to

symptomatic or latent coronary heart disease[16] is the most

serious cardiovascular complication during exercise.

Habitually sedentary people have an increased risk for

complications, and regular physical activity provides

some protection against cardiovascular complications

related to physical exertion.[11] The intensity of exercise,

both absolute and relative, is likely the most important

characteristic influencing the risk.[16] A small number of

serious cardiovascular complications have occurred

during maximal exercise[10] and maximal strength testing,[12]

despite thorough medical screening and physician

supervision. The safety of fitness testing without a

physician's supervision among apparently healthy adults is

less well documented. In Canada, experiences involving

exercise testing outside of the medical domain have

been encouraging.[17,18] In a representative population

study in Finland, no cardiovascular complications

occurred during submaximal walk tests in field

conditions (ie, conducted outdoors on a flat asphalt-gravel

road).[19]

Only a few researchers have described the occurrence of

musculoskeletal injuries during fitness testing. Gordon

et al[12] found no orthopedic complications during

1-repetition maximum (1-RM) and maximal isokinetic

force testing with asymptomatic adults aged 20 to 69

years. In an earlier study of 57 elderly subjects, 19% were

injured during maximal leg extensor and chest press

tests, whereas no injuries occurred during treadmill

testing.[13] Based on these findings, the authors stated that

"1-RM strength testing is inappropriate for older men

and women who have had previous joint problems

specific to the muscle group being tested."[13]

In another study,[15] with a similar type of testing, one

elderly subject with no weight-training experience had a

back injury and another subject sustained a rib fracture.

Ito et al[20] recently reported on the safety of two simple

trunk muscle endurance tests in their study of

asymptomatic adults and subjects with chronic back pain. They

reported that none of the subjects with chronic back

pain experienced worsened low back pain.

Delayed-onset muscle soreness (DOMS) is usually a self-limiting

condition that typically occurs after unaccustomed or

strenuous exercise, particularly among persons using

eccentric contractions. There is recent evidence,

however, that impaired neuromuscular function may affect

the successful performance of certain motor tasks during

recovery from exercise-induced muscle damage.[21] The

delayed symptoms of soreness and pain, as well as high

perceived exertion during the testing, may also have

negative effects on exercise motivation and training

adherence, especially among inactive persons.[22,23] We

have not found any studies on the occurrence of

musculoskeletal injuries or the functional consequences of

DOMS in conjunction with adult HRFI testing.[5,18,24]

Pretest screening has been used as a means to ensure the

safety of testing or training.[19,25] A screening method

such as an interview or a self-administered health status

questionnaire is necessary to identify pertinent health

limitations. The Physical Activity Readiness

Questionnaire[26,27] has been successfully administered as a

screening instrument in conjunction with the Canadian Home

Fitness Test.[17,25] This screening method is sensitive in

identifying persons with potential health risks, but it

excludes a large number of subjects.[17,18,28] This method

may be counterproductive, because persons with chronic

diseases should be encouraged to participate regularly in

moderate-intensity exercise.[1,4]

Since 1991, the UKK Institute(*) has developed a field-based

HRFI test battery (ie, the tests do not require sophisticated

equipment, and they can be conducted under conditions

available in ordinary communities) for working-aged adults

with no major diseases.[8] The test battery consists of body

composition, cardiorespiratory, musculoskeletal, and

motor components (Appendix[8,29-39]), as suggested by Oja

and Tuxworth[5] and Bouchard and Shephard.[7] The

structure of the battery is based on the available evidence on the

relationships among different aspects of fitness and

health.[1,7] Cardiorespiratory fitness has consistently been

shown to influence health positively. It is associated with

decreased mortality from coronary heart disease[40] and with

decreased death due to all causes.[41] Motor fitness, as

assessed by balance tests, is proposed to have relevance to

falls among elderly persons[42] and possibly to back pain and

injury in middle-aged adults.[43] Musculoskeletal fitness

(flexibility, muscle force, and endurance) is known to be

associated with functional ability and musculoskeletal

symptoms. In older adults, mobility restriction can cause

limitations in daily activities.(42) Restricted spinal flexibility

has been proposed as a risk factor for low back

dysfunction,[44] but a protective role of mobility has not been

shown.[45] Endurance of the back muscles is the

best-documented fitness factor in the prevention of back

symptoms.[46] Lower-extremity force has been shown to correlate

with mobility functions such as stair climbing.[47] The

reliability of measurements obtained with the proposed

UKK Institute's HRFI test battery has been established

earlier.[8,29,30]

The aims of our study were (1) to evaluate the safety and

feasibility of the UKK Institute's HRFI test battery in an

adult population and (2) to present a practical health

screening procedure for non-physician fitness testing

personnel to use for safe and effective application of

HRFI testing.

Method

Subjects

The study sample was selected from specified age brackets

of the residents of Tampere, Finland, who had previously

attended preventive health examinations arranged by the

municipal primary health care center. On average, 80% of

the residents had annual examinations. About 80% of

those residents had given consent for their personal data to

be used for research purposes. Of these individuals, five

age groups -- subjects born in the years 1955 (age 37 years),

1950 (age 42 years), 1945 (age 47 years), 1940 (age 52

years), and 1935 (age 57 years) -- for each gender formed

our study population. A random sample of 437 men and

389 women, equal in size in each age cohort, were invited

to participate in the study. Fifty-six percent of the invited

men (n=246) and 65% of the invited women (n=254)

participated in the fitness testing. About 50 persons

(range=46-54) were included in each age group. The

age-specific participation rates, from youngest to oldest age

groups, were 57%, 58%, 52%, 59%, and 57% for the men

and 62%, 63%, 68%, 66%, and 68% for the women. All

subjects signed an informed consent statement, which

contained detailed information about the study and the

terms of participation.

Representativeness of the Sample

A questionnaire, administered in the municipal health

examinations and accessible to two age groups (47 and

52 years), was used to compare the participants (62%)

and the nonparticipants (38%) of the sample (Tab. 1).

Using a five-category scale ("very poor," "poor,"

"average," "good," and "very good"), the nonparticipants

rated their health status somewhat lower than the

participants did. In addition, more nonparticipants used

prescription medications and were smokers and fewer

nonparticipants exercised briskly compared with the

participants.

Table 1.

Comparison of Participants and Nonparticipants of the Study Sample (Expressed

as Percentages)

                              Participants   Nonparticipants

                              (62%, n=125)   (38%, n=76)



Living alone (single,

 divorced, or widowed)        13             25

Low Level of education

 (no vocational education)    13             22

Perceived health (good or

 very good)                   79             65

Using prescribed medication   29             35

Smoker                        13             40

Exercising briskly at least

twice a week                  55             43

Procedure

The subjects attended two measurement sessions at the

UKK Institute. During the first visit, the pretest health

screening was conducted by laboratory technicians and

fitness testing personnel.

During the second visit, individual

assessment of HRFI was conducted by three fitness

testers.

The laboratory personnel and fitness testers of the

institute work mainly for research purposes, and the

repeatability of their measurements can be assumed to

be good even though the reliability of the measurements

was not assessed in our study. All testers had master's

degrees in sport or health sciences and were trained to

perform standardized measurements during two

preliminary studies of 76 subjects. A test manual was prepared

to further enhance the quality of the measurements. In

case of emergency during fitness testing, a physician,

nurses, and equipment for cardiopulmonary

resuscitation were available.

Health-Related Fitness Assessment

The HRFI assessment consisted of a balance test for

motor fitness; three flexibility tests and five muscle force

and endurance tests for musculoskeletal fitness of the

upper body, trunk, and lower extremities; and a 2-km

walk test, developed at our institute,[29] for

cardiorespiratory fitness. Motor and musculoskeletal fitness was

assessed first in a standard order, followed by 10 minutes

of rest before the walk test. Brief descriptions of the

fitness tests and the specific contraindications for each

test are presented in the Appendix. More detailed

descriptions of the methods have been reported

elsewhere.[8,31] Only tests that provided relatively reliable

measurements, as reported elsewhere,[8,29,32,33] were

included in the battery (Appendix). In summary, the

interrater intraclass correlation coefficients (ICCs), based

on a one-way analysis-of-variance model, for one-leg

balance, trunk side-bending, push-up force, and

lower-extremity muscle tests ranged from .86 to 1.00, and the

test-retest coefficients of variation ranged from 0.6% to

12.1%.[8] The test-retest reliability, as measured with the

Pearson correlation coefficient (r), was reported to be

.89 for the Sorensen test of back muscular endurance[32]

and .99 for active range of motion in knee extension.[33]

In the walk test, the test-retest correlation coefficients (r)

for predicted maximal oxygen uptake (in milliliters per

minute per kilogram) were .98 and .94 for men and

women, respectively.[29]

Screening for Health Limitations

Pretesting health assessment included measures of body

mass and height to calculate body mass index (BMI) and

measures of systolic and diastolic blood pressure

(auscultation method with a mercury sphygmomanometer

after 5 minutes of rest in a sitting position). The

pretesting health assessment also included the modified

Physical Activity Readiness Questionnaire (MPAR-Q),[26,27] a

question on perceived health status, and an assessment

of current level of physical activity, including the

intensity of exercise (rated "none," "light," "moderate," and

"high") and a single-item self-assessment of leisure-time

physical activity (rated "vigorous activity twice or more a

week," "vigorous activity once a week and some

light-intensity activity," "some activity each week," and "no

regular weekly activity").[48] Descriptive results of the

health assessment are presented in Table 2. The

personnel conducting the testing used this information (1) to

refer subjects with severe diseases or symptoms (Tab. 3)

to a physician for a health examination or (2) to exclude

them from selected fitness tests according to

predetermined safety instructions generated by the three

physicians of the research group (Fig. 1).

[TABULAR DATA 2 NOT REPRODUCIBLE IN ASCII]

Table 3.

Diseases or Symptoms for Which the Subjects Were Referred to a

Physician for a Health Examination Before Fitness Testing

Disease or Symptom

Severe cardiovascular diseases or symptoms

Recent myocardial infarction (within 12 mo)

Coronary heart disease with chest pain

Moderate or severe valvular disease, cardiomyopathy, or other

cause of heart failure

Untreated or labile hypertension of [is greater than or equal to] 180/110

Severe anemia (hemoglobin level of [is less than] 110-100 g/L)

Severe symptoms during physical effort

Undiagnosed pain in the chest, shoulders, or upper extremities

in person over age 40 years

Susceptibility to arrhythmias during or after physical effort

Asthma

Dyspnea

Dizziness

Headache

Other severe chronic diseases of labile status

Juvenile diabetes

Hyperthyroid activity

Diseases of vertebral column or joints on active stage

Mental instability

Influenza or any generalized infection of the body

Recent major trauma

Recent surgery

Normal pregnancy in the third trimester

Complicated pregnancy in any trimester

Recent childbirth

Unusually severe tiredness or weakness

Intoxication (alcohol or drugs), hangover

[FIGURE 1, ILLUSTRATION OMITTED]

Subjects were allowed to participate in all fitness tests if

the following conditions Were met: (1) there were no

"yes" answers to questions in the MPAR-Q, (2) systolic

and diastolic blood pressure values were less than

160/100 mm Hg, and (3) the subjects were not obese

(BMI [is less than] 30). Individuals who had answered "yes" in

response to the questions concerning possible

cardiovascular diseases (questions 1, 2, and 3 of the MPAR-Q

[Tab. 2]) were referred to the physician if they reported

a severe disease or symptoms during physical effort, as

listed in Table 3. Individuals with less severe limitations

were excluded from upper-body (modified push-up)

and trunk (isometric back extension) muscle endurance

tests and were instructed to perform the UKK 2-km walk

test at a self-preferred pace instead of as fast as possible.

Physically active individuals with only mild hypertension

(ie, [is less than] 180/110 mm Hg) were allowed to participate in all

tests. Subjects reporting severe spells of fainting or

dizziness (question 4 of the MPAR-Q [Tab. 2]) were

referred to the physician and were excluded from the

balance test (standing on one leg) and and the

lower-extremity muscle tests jump and reach and one-leg

squat). Individuals with arthritis or other

musculoskeletal problems (question 5 of the MPAR-Q [Tab. 2]) were

interviewed about the joints and muscles that were

affected. Subjects with test-specific contraindications

(Appendix) were excluded. Subjects who indicated any

other hindrance to physical exercise (question 6 of the

MPAR-Q [Tab. 2]) were referred to the physician if they

reported having diseases or symptoms listed in Table 3.

Otherwise, they were treated according to the

procedures described. Individuals taking medications

affecting the heart rate (question 7 of the MPAR-Q [Tab. 2])

were identified by the physician and were excluded from

analyses including measures of heart rate. Subjects were

instructed to reschedule their fitness assessment if they

had fever, acute infections, or other acute symptoms.

Assessment of Safety

The testers recorded all acute musculoskeletal injuries

or symptoms and cardiovascular complications during

the fitness testing. Delayed-onset muscle soreness was

assessed with a questionnaire that was completed 4 to 6

days after testing. The questionnaire included questions

about (1) the experience and severity of DOMS, (2) the

location of the pain or soreness, (3) the possible test

performance that caused the DOMS, and (4) the

functional consequences of DOMS in usual daily activities.

Cardiovascular exertion was evaluated by recording the

heart rate immediately after each test, as indicated by

continuous heart rate monitoring.[dagger] The subjects without

medication that affects the heart rate were included

(n=435). Exertion was expressed as the percentage of

age-predicted maximum heart rate (%HRmax), which

was calculated according to Arstila et al,[49] as follows:

205 - 0.5 x age. In addition, the percentage of subjects

with heart rates higher than 85% of their age-predicted

maximum heart rate was calculated.

Assessment of Feasibility

The exclusion rate of the subjects from each fitness test on

the basis of health limitations was recorded. The reasons

for interrupting the tests and statements by the subjects

who were unwilling or unable to participate in a given test

also were recorded. The time required to prepare,

administer, and score each mot evaluated by three fitness testers

on a five-point scale (1=very poor, 2=poor, 3=average,

4=good, 5=excellent). Results are presented as the mean

value of the individual ratings. In addition, the average

time required to perform the complete test battery was

estimated.

Results

Safety

Acute health problems. No major complications

occurred during the testing. There were no symptoms

leading to interruptions in the balance or flexibility tests.

Two subjects interrupted the modified push-up test due

to back pain, and two subjects interrupted the test due to

arm pain. During the isometric back extension

endurance test, the tester interrupted the performance of two

subjects with a history of elevated blood pressure

because their heart rate increased dramatically during

the test. Three subjects interrupted the walk test because

of lower-extremity pain, and one subject interrupted the

test because of symptoms of influenza.

Delayed-onset muscle soreness. The response rate for

the DOMS questionnaire was 95%. Sixty percent of the

men and 78% of the women experienced some degree

of DOMS. Five percent of the men (n=12) and 10% of

the women (n=24) indicated that their DOMS was

severe. Eighty-three percent of the subjects reported

having severe pain in their thigh and gluteal muscles,

and most of them assumed the one-leg squat test to be

the cause. Few subjects reported having severe pain in

their upper-body (n=6) or back (n=5) muscles. For 7%

of the men and 12% of the women, DOMS caused

difficulties in daily activities, especially stair climbing,

squatting, and walking. Seventy-seven percent of the

subjects who did not participate in leisure-time exercise

or who exercised at a low intensity experienced DOMS

(Fig. 2). Sixty-five percent of the subjects who exercised

more vigorously experienced DOMS (Fig. 2).

Seventy-seven percent of the younger women and 67% of the

older women experienced DOMS. Severe DOMS was

experienced by 14% of the women in the low-intensity

exercise group and by 8% of the women in the

high-intensity exercise group. A different trend was found in

men: 9% of the men in the high-intensity exercise

reported having severe DOMS; the percentage of men

who experienced severe DOMS in the other groups

ranged from 2% to 4%.

[FIGURE 2, GRAPH OMITTED]

Cardiovascular exertion. The cardiovascular exertion of

the fitness tests assessed by the heart rate recordings is

presented in Table 4. In general, the range of heart rate

values after all tests was large. The mean %HRmax did

not differ more than 5% among the age groups. The

highest levels were recorded after the walk test. The

%HRmax after this cardiorespiratory fitness test was 84%

in men and 82% in women. The heart rate was higher

than 85% of the maximum level in 43% of the men and

37% of the women. Of the musculoskeletal fitness tests,

the highest heart rate levels were recorded after the

muscle endurance tests. The mean %HRmax after the

modified push-ups was 77% in men and 79% in women.

The heart rate was higher than 85% of the maximum

level in 19% of the men and 24% of the women. After

the isometric back extensor endurance test, the mean

%HRmax was 67% in both men and women, and the

heart rate values of few subjects (3%) exceeded 85% of

the maximum level. In the lower-extremity extensor

muscle tests, the mean %HRmax values were between

60% and 62%, and four women had heart rates that

exceeded 85% of the maximum level. In the balance,

flexibility, and handgrip tests, the mean %HRmax values

were lower than 60% and no subjects' heart rates

exceeded 85% of the maximum level.

[TABULAR DATA 4 NOT REPRODUCIBLE IN ASCII]

Feasibility

Subject exclusion and limitations to fitness testing. The

fitness testing personnel referred 8 subjects (2%) to the

physician prior to testing. One individual was excluded

from all tests because of multiple diseases and mental

instability. All other subjects participated in one or more

tests. Five of the 272 subjects who had not reported any

health problems (54%) on the MPAR-Q were excluded

due to a specific musculoskeletal problem that they

indicated during the fitness assessment. The overall

percentage of subjects who were excluded due to

interrupting or refusing to participate in one or more tests,

for each age group, is presented in Figure 3. The overall

exclusion rate increased with age, being less than 3% in

the youngest age group and 33% in the oldest age

group.

[FIGURE 3, GRAPH OMITTED]

The test-specific exclusion rates were variable, as shown

in Figure 4. Fewer than 5% of the subjects in any of the

five age groups were excluded from the balance,

flexibility, and handgrip tests. Severe dizziness (n=3) was the

main health limitation to balance testing. Three subjects

were excluded from one or more flexibility tests due to

musculoskeletal problems. No more than 10% of the

subjects in any age group were excluded from the

lower-extremity extensor muscle tests (jump and reach

and one-leg squat). Pain in the lower back or the

lower-extremity joints (n=8) and obesity (n=3) were

the main reasons for excluding subjects from the jump

and reach test. Nine subjects with pain in the lower back

or the lower-extremity joints and 6 subjects with severe

heart disease were excluded from the one-leg squat test.

A larger proportion of subjects over 50 years of age (up

to 27%) were excluded from the muscle endurance tests.

[FIGURE 4, GRAPH OMITTED]

The greatest number of subjects were excluded from the

modified push-up test (n=60). Heart disease (n=22)

and high blood pressure (n=20) were the main reasons

for exclusion. Seventeen subjects were excluded due to

musculoskeletal symptoms of the back or arms, and 1

subject was excluded due to incorrect performance

technique. Heart disease (n=15), high blood pressure

(n=18), and severe back problems (n=6) were the main

reasons that subjects were excluded from the isometric

back extension endurance test. Over 95% of the subjects

(n=481) completed the walk test. Nine subjects were

excluded due to musculoskeletal problems, 6 subjects

were excluded due to severe heart disease, and 2 subjects

were excluded due to severe dizziness. One subject was

not willing to participate after the warm-up. Maximal

oxygen uptake could not be predicted for 17% (n=83)

of the subjects who finished the walk test because they

were taking medications that affected their heart rate.

Practicality in terms of time requirements. The fitness

testers rated the jump and reach test as the most

practical test (mean=5.0 points). The mean scores for

the one-leg standing balance, shoulder-neck mobility,

handgrip, modified push-up, and isometric back

extension tests ranged from 4.3 to 4.7. The mean scores for

the trunk side-bending and one-leg squat tests were 4.0

and 3.7, respectively. The knee extension

range-of-motion test was rated as the least practical test

(mean=2.7 points). The average time to perform the

whole test battery was 80 minutes. This time included 40

to 45 minutes for the motor and musculoskeletal testing,

10 to 15 minutes for resting before the walk test, and 20

to 25 minutes for performing the walk test.

Discussion

Safety of Assessing Health-Related Fitness in an Adult Population

Health-related fitness assessment is indicated primarily

for middle-aged, often unfit and physically inactive,

person. In our study, 35% of the men and 30% of the

women were classified as inactive (Tab. 2). The health

risks of heavy physical exertion are increased among this

group.[11] Thus, the subjects' health status and physical

activity level, as well as their physiological exertion in

each fitness test and during the whole testing period, are

important factors affecting the safety of HRFI testing.

Extensive health examinations in large-scale fitness

programs or population surveys are often difficult to

conduct due to the time needed and financial costs. We

believe, however, that a standard health screening

procedure should be an integral part of any HRFI

assessment.[5,50] In our study, the fitness testing personnel used

a standard protocol to refer the subjects with potentially

consequential health problems to a physician and

standard instructions for themselves to exclude subjects with

minor health limitations from selected fitness tests. With

this procedure, the testers referred only 8 of the 500

subjects to a physician for further health examination,

yet no major health hazards occurred. The results

indicate that, among middle-aged adults, HRFI assessment

can be safely and effectively performed with minor

physician participation.

Most of the subjects experienced some

DOMS. Women experienced DOMS

more often than men did, and

physically inactive individuals experienced

DOMS more often than physically

active individuals did. Occurrence of

severe DOMS, with impaired function,

was our major concern. The one-leg

squat test seemed to cause severe

DOMS and difficulties in mobility

among a small number of subjects. The

finding that inactive women were the

most prone to severe DOMS is in

accordance with findings that training may

prevent or reduce muscle damage and

soreness.[51] Four subjects who reported

severe knee problems (arthrosis, pain,

surgery) during the health screening

were excluded from the squat test.

Their exclusion probably explains the

finding that there were no acute or

delayed experiences of pain in the

knee.

The one-leg squat test was developed to assess

restrictions in the lower-extremity extensors.[8] A maximum of

five squats for each lower extremity, with increasing

external load relative to the subject's body weight, were

performed (Appendix). Only 23% of the women were

able to perform the test with the highest load (40% of

their body weight) in contrast to 74% of the men. Thus,

for most of the women, the squat required substantial

effort, including a high amount of eccentric

contractions during the downward phase. To avoid or minimize

the DOMS in inactive women, we suggest that only loads up

to 20% or 30% of body weight be used. In addition,

subjects should be informed about the possibility of

DOMS. These precautions might minimize the possibility

of subjects developing negative attitudes toward fitness

testing and training.

Despite the risk of DOMS, inclusion of the lower-extremity

test in the HRFI test battery is warranted because it may be

an indicator of mobility and functional independence in

older adults.[47,52,53] There is a well-validated lower-extremity

performance test for elderly persons.[53] We developed the

squat test when we could not find any other easily

administered test of lower-extremity muscle force designed for

middle-aged adults. Suni et al[8] have established the

reliability of measurements obtained with the test (interrater

ICC=.86, coefficient of variation=12.1%). Further studies

are needed to ensure the safety of the test in terms of

DOMS.

Heart rate is a good indicator of cardiovascular exertion

in tests requesting movements of large muscles. The

mean %HRmax values after the 2-km walk test (84% in

men and 82% in women) were within the recommended

levels for submaximal aerobic fitness testing[50] and were

optimal for the walk test.[30] Forty-three percent of the

men and 37% of the women exceeded 85% of their

maximum heart rate. Similar heart rate levels during a

1.6-km (1-mile) walk test were reported by Porcari and

coworkers.[54] When pretest health screening has been

included in submaximal aerobic fitness tests, no

complications other than minor muscle injuries have been

reported,[18,19,50] despite the relatively high heart rate

levels. After the modified push-up test, mean heart rate

values were about 78% of the maximum level, and the

heart rates of about 20% of the subjects exceeded 85%

of the maximum level. Because the cardiac load in the

push-up test, as well as the isometric back extension test,

is predominantly of the "pressure" type as opposed to

"volume" type in the walk test, the cardiovascular health

risks are expected to be more substantial than in the

more dynamic walk test. The mean %HRmax values

were around 60% in the lower-extremity function tests

and were lower in all other tests, indicating a small risk

of cardiovascular complications. Heart rate alone may

not be an optimal indicator of cardiovascular stress

during isometric muscle contractions. Blood pressure

measurements during this type of testing would provide

further information about physiological exertion and

related cardiovascular risks.[55] Another, more accessible

possibility to assess physiological strain during field

testing would be the ratings of perceived exertion,

which indicate how close the subject is to maximal

exertion.[23,56]

Feasibility

Proportion of subjects qualified for the

tests. Ninety percent or more of the

subjects in each age group were

qualified to perform the balance, flexibility,

and short-term muscle tests. The low

exclusion rates are in accordance with

those reported in the Allied Dunbar

National Fitness Survey,[57] but they are

somewhat lower than in an earlier

population study in Finland.[58] A substantial

proportion of the subjects over 50 years

of age were not qualified for the

modified push-up test (22%) or the

isometric back extension muscle endurance

test (16%). The exclusion rates are

similar to those reported in surveys

assessing cardiorespiratory fitness of

adults by submaximal tests.[18,19,58]

Prevalence of the most important health

limitations (elevated blood pressure,

self-reported heart disease) to testing

was much higher in the two oldest age groups than in

the younger age groups (Tab. 2). Due to the isometric

contractions needed for the push-up and back extension

tests, a large number of subjects with coronary heart

disease or high blood pressure were excluded, although

most of them were allowed to perform the walk test.

Only 4% of the subjects were excluded from the walk

test. Thirty-eight percent of the subjects in the oldest age

group and 24% of the 52-year-olds were taking

medications that affected their heart rate, which limits the use

of the walk test for the prediction of maximal oxygen

uptake and caused the population estimates of maximal

oxygen uptake to be too high. To avoid this selection

bias, walk time could be a preferred population estimate

of aerobic fitness in adults over 50 years of age, because

only 6% of the 52-year-olds and 7% of 57-year-olds in our

study were not qualified to perform the test.

Time requirements for health-related fitness testing. The

only test we used that took a considerable amount of

time was the test of range of motion in knee extension,

which we measured with a Myrin inclinometer.[double dagger]

Standardization of subject positioning required careful

preparation and continuous surveillance during the test.

These characteristics may be overcome in individual

fitness or clinical-type test situations, but they limit the

use of the test in larger populations. Adding extra loads

during the one-leg squat test was somewhat time

consuming. We used a special weight belt[section] with additional

cuffs. The equipment helps to keep the extra load near

to the center of body mass. All other motor and

musculoskeletal fitness tests (one-leg balance, shoulder-neck

mobility, trunk side-bending, handgrip, modified

pushup, isometric back extension, jump and reach) were

quick and easy to administer. The average time needed

to perform the complete HRFI test battery was 80

minutes. The time needed for health screening is not

included in that estimate because health screening was

administered during a prior visit of the subjects. In

practice, health screening is typically administered

immediately prior to testing. The approximate time

required for the screening procedure described was 15

minutes, and additional time was required for subjects

needing further medical examination. To reduce the

time cost, a shorter test battery could be selected

according to the health of the subject group and the purpose of

the testing.

A Safety Model for Health-Related Fitness Assessment

A safety model for HRFI assessment conducted by

non-physician testing personnel was developed on the basis

of our results (Fig. 1). The model includes (1) standard

screening for health limitations, (2) standard

instructions to refer subjects with severe health limitations to a

physician for further examination, and (3) standard

instructions to exclude subjects with minor health

limitations from selected fitness tests. The model could serve

as an example of the elements needed in the safe and

effective assessment of HRFI in adults. Because medical

policies and regulations and practical needs vary greatly

from one country to another, no strict guidelines for

safety procedures can be given.[5]

General Applicability of the Test Battery

The test battery was designed to assess the HRFI of adults

with no known health problems. The study sample was

selected, to some extent, in the same manner that study

samples were selected in other fitness surveys.[9,53] The

participants had somewhat higher education and were

healthier and more physically active than the

nonparticipating part of the population (Tab. 1). This selection

bias may raise the question of whether the test battery is

safe and feasible for less healthy and more sedentary

middle-aged persons. Despite the method of selection of

subjects for our study, our study sample included

subjects with chronic diseases and physically inactive

lifestyles who were successfully screened to prevent severe

complications. The selection bias of the sample,

however, man, cause the population estimates of fitness, if

used as norm-referenced values, to be too high. The bias

will be larger in those tests and age groups from which a

large proportion of subjects are excluded. If this test

battery is applied to older subjects, or to some patient

groups, the context of health screening, the role of the

physician, and the criteria to exclude subjects need to be

reconsidered to ensure safety.

This HRFI test battery was designed to be used in the

context of health-related physical activity promotion. It

is a method for (1) assessing the status of HRFI of

individuals and populations in order to evaluate the

amount and type of physical activity needed to promote

health, (2) monitoring the changes in HRFI and

evaluating the effects of interventions, and (3) motivating

individuals for regular physical activity. Interpretation of

test results and exercise recommendations are important

parts of HRFI assessment. Currently, the HRFI test

battery provides an individual fitness profile based on

age- and gender-specific norm-referenced values derived

from the sample of the population described in this

report. Our general exercise recommendation is that

those components of fitness that are lower than the

average level should be enhanced. In addition, health

limitations to exercise, current physical activity, level,

existing knowledge of dose-response relationship of

different types of exercises to fitness and health, personal

resources, and the motivation and goals of the individual

are considered to ensure an effective and feasible

physical activity program, with good adherence.

Interpretation of the test scores according to the

health-related fitness concept[7] is aimed to give feedback to the

individual in terms of the adequacy of fitness with

respect to health criteria.[1] The health criteria relate to

disease prevention or functional adequacy and

retention.[57] More studies with representative samples are

needed to assess the relationships of different

components of fitness to health and functional ability. As a first

step toward this goal and to examine the validity of our

test battery, we have studied the associations of the

proposed tests with selected health outcomes

(cardiovascular risk factors, perceived health, mobility, and

back-related functioning and symptoms) in this particular

study population. These results will be published

elsewhere.

In addition to relevant assessment methods, we believe

that there is a need for training of testers to ensure

reliable, safe, and useful HRFI testing, with proper

interpretation and exercise recommendations for health

promotion. The fitness testers need to be well

acquainted with the testing procedures, appreciate the

strict standardization of procedures, and understand the

rationale for each test and for interpretation of the

results according to the HRFI concept. In addition, the;

have to be able to screen the health limitations of the

subjects and refer them to a physician when necessary.

According to our experience, professionals in health

care and physical education, including physical

therapists, have optimal qualifications to conduct HRFI

testing.

Summary and Conclusions

The proposed test battery offers a safe and feasible

method for HRFI assessment of adult populations, with

some reservations. In older subjects, coronary heart

disease and hypertension limit their participation in

isometric-type muscle endurance tests considerably, and

to some extent in lower-extremity muscle testing at a

near-maximal level. In addition, the high prevalence of

medication affecting the heart rate in older age brackets

hinders the prediction of maximal oxygen uptake in the

walk test. Inactive women are prone to DOMS during the

one-leg squat test at near-maximal levels. Most subjects

in all age groups are qualified for the balance, flexibility,

muscle force, and walk tests. Some musculoskeletal

symptoms may limit the participation in these tests

selectively. The results of our study highlight the

importance of a standard health screening procedure. Safe

testing is ensured, minor physician participation is

needed, and most individuals qualify for the majority of

tests.

(*) The President Urho Kaleva Kekkonen (UKK) Institute for Health Promotion

Research, Tampere, Finland.

([dagger]) Polar Sport Tester, Polar Electro A, Professorintie 5, 90440 Kempele,

Finland.

([double dagger]) Vinkelmatare Myrin, LIC, Rehab Vardrum, Solna, Sweden.

([sections]) SF-Sportfire Weight Belt, Urheiluareena, Tampereen Valtatic 19,

33100 Tampere, Finland.

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Appendix. Description of the Health-Related Fitness Assessment Method

MOTOR FITNESS

Balance:

Whole body. Test: Standing on one leg with eyes open for assessment of the

efficiency of static postural control while the area of support is

reduced.[34,35]

Outcome: duration of balance task up to 60 seconds, as measured with a

stopwatch.

Specific contraindications: dizziness, severe symptoms of the spine or lower

extremities that might be aggravated by the test movements.

MUSCULOSKELETAL FITNESS

Flexibility:

Upper body. Test: Shoulder-neck mobility for a rough estimate of functional

shoulder flexion range of motion (ROM).[8]

Outcome: visual estimation of the movement restriction in maximal

overhead flexion on a three-point scale based on the end-point position of the

arms.

Specific contraindications: severe symptoms of the neck or shoulder that might

be aggravated by the test movements.

Trunk. Side-bending to the right and left for the assessment of the total range

of movement of lateral flexion of the thoracic and lumbar spine and pelvis.[37]

Outcome: the distance (in millimeters) the fingertip moves down the lower

extremity during maximum lateral bending, as measured with a tape measure.

Specific contraindications: severe spinal symptoms that might be aggravated by

the test movements.

Legs. Active knee extension range of motion for hamstring muscle

extensibility.[33]

Outcome: end-point range-of-motion angle in knee extension, as measured with the

Myrin inclinometer.

Specific contraindications: severe symptoms of the lumbar spine or lower

extremities that hinder the subject from getting on or up from the floor or

that might be aggravated by the test movements.

Muscle performance:

Upper body. Handgrip for the maximal grip strength.

Outcome: maximal handgrip force (in kilograms), as measured with

a dynamometer.

Specific contraindications: severe symptoms of the forehand or the hand that

might be aggravated by the test.

Upper body. Modified push-ups for the short-time endurance capacity of the

upper-extremity extensors and the ability to stabilize the trunk.[8]

Outcome: number of push-up cycles completed in 40 seconds.

Specific contraindications: moderate to severe disease or symptoms of the

cardiovascular system (listed in Tab. 3) and severe symptoms of the lumbar

region or extremities that might be aggravated by the test movements.

Trunk. Back extension for the endurance capacity of the trunk extensor

muscles.[32,38]

Outcome: the endurance time (in seconds) of the task up to 4 minutes, as

measured with a stopwatch.

Specific contraindications: moderate to severe diseases or symptoms of the

cardiovascular system (listed in Tab. 3) and severe spinal symptoms that might

be aggravated by the test movements.

Lower extremities. Jump and reach for the lower-extremity extensor power.[39]

Outcome: the difference between the reach height and the jump height (in

centimeters), as measured with a jump-and-reach board and a tape measure.

Specific contraindications: severe obesity, dizziness, or severe symptoms of

the spine or the extremities that might be aggravated by the test movements.

Lower extremities. One-leg squat with increasing weights for the assessment of

functional strength restrictions of the leg extensors.[8]

Outcome: the load limit for successful squatting task measured as maximum weight

relative to the subject's body weight up to 140%. The test started with body

weight, and 10% increments of body weight were added at four successive steps

of 10%, 20%, 30%, and 40% using a weight belt.

Specific contraindications: severe symptoms of the spine and lower extremities

that might be aggravated by the test movements, as well as dizziness.

CARDIORESPIRATORY FITNESS

Test: 2-km walk test for the prediction of maximal oxygen uptake ([Vo.sub.2]max)

on the basis of walk time, heart rate at the end of the walk, body mass index,

and age.[29-31]

Outcome: walk time and the predicted [Vo.sub.2]max.

Specific contraindications: moderate to severe diseases or symptoms of the

cardiovascular system (listed in Tab. 3), severe dizziness, and severe

musculoskeletal symptoms that might be aggravated by walking.