DOI 10.1007/s00421-014-3023-6
ORIGINAL ARTICLE
Received: 21 May 2014 / Accepted: 10 October 2014 / Published online: 18 October 2014
© Springer-Verlag Berlin Heidelberg 2014
J. B. Coquart (*) F. Bart
Faculté des Sciences du Sport et de l’Education Physique, Department of Pneumology, Germon and Gauthier Hospital,
CETAPS, Boulevard Siegfried, 76821 Mont Saint Aignan Cedex, Béthune, France
France
e-mail: jeremy.coquart@voila.fr J.-M. Grosbois
Department of Effort Rehabilitation, Germon and Gauthier
R. G. Eston Hospital, Béthune, France
Sansom Institute for Health Research,
School of Health Sciences, University of South Australia, J.-M. Grosbois
Adelaide, Australia Formaction Santé, Perenchies, France
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Table 1 Anthropometric and spirometric data of the healthy participants and patients with chronic obstructive pulmonary disease (COPD)
Variable (units) Healthy Healthy Healthy Women Men with Patients with Women Men
women men participants with COPD COPD COPD (n = 8) (n = 25)
(n = 4) (n = 11) (n = 15) (n = 4) (n = 14) (n = 18)
Age (years) 46.5 ± 15.6 37.8 ± 13.5 39.9 ± 14.1 55.0 ± 6.5 58.7 ± 8.6 57.9 ± 8.1a 50.8 ± 12.0 49.4 ± 15.2
Height (m) 1.69 ± 0.09 1.79 ± 0.04 1.76 ± 0.07 1.59 ± 0.05 1.72 ± 0.07 1.69 ± 0.08a 1.64 ± 0.08 1.75 ± 0.07b
Body mass (kg) 71.0 ± 22.8 85.1 ± 20.5 81.3 ± 21.3 61.3 ± 19.9 83.7 ± 17.5 78.7 ± 19.9 66.1 ± 20.5 84.3 ± 18.5b
Body mass index (kg m−2) 25.0 ± 8.7 26.6 ± 6.4 26.1 ± 6.8 23.9 ± 6.3 28.3 ± 6.3 27.3 ± 6.4 24.5 ± 7.1 27.5 ± 6.3
FEV1 (L) 2.7 ± 0.4 4.1 ± 0.6 3.7 ± 0.8 1.3 ± 0.5 1.4 ± 0.5 1.4 ± 0.5a 2.0 ± 0.9 2.6 ± 1.4b
FEV1 (% predicted FEV1) 96.4 ± 13.7 99.2 ± 9.9 98.5 ± 10.6 56.1 ± 21.5 45.5 ± 15.4 47.9 ± 16.8a 76.3 ± 27.2 69.2 ± 30.1
FVC (L) 3.2 ± 0.5 4.9 ± 0.7 4.5 ± 1.0 2.1 ± 0.5 2.4 ± 0.7 2.4 ± 0.6a 2.7 ± 0.7 3.5 ± 1.4b
FVC (% predicted FVC) 95.8 ± 9.4 99.4 ± 12.9 98.4 ± 11.9 77.9 ± 14.0 60.1 ± 16.5 64.1 ± 17.3a 86.9 ± 14.6 77.4 ± 24.7
FEV1/FVC (%) 86.0 ± 7.5 82.7 ± 7.0 83.5 ± 7.0 59.7 ± 15.2 59.6 ± 14.0 59.6 ± 13.8a 72.8 ± 17.9 69.8 ± 16.2
FEV1 forced expiratory volume in one second, FVC forced vital capacity
a
Significant difference between the groups (P < 0.05)
b
Significant difference between the sexes (P < 0.05)
first second of maximal expiration (i.e., FEV1/FVC × 100) as possible, without thinking about what the actual physi-
was calculated. From FEV1, the severity of airflow limita- cal load is. Do not underestimate it, but do not overesti-
tion in COPD according to the Global initiative for chronic mate it neither. It is your own feeling of effort and exertion
Obstructive Lung Disease (2014) was determined. that is important, not how it compares to other people’s.
Prior to conducting the CPET, the RPE scale was pre- What other people think is not important neither. Look at
sented and explained to participants. This scale was used the scale and the expressions and then give a number. Any
because it is the most frequently used tool to assess effort question?”
perception in sport sciences (Eston 2012). The RPE scale Following a 3-min rest period, participants performed
measures effort perception, which may be defined as the a CPET on an electromagnetically braked cycle ergometer
intensity of subjective effort, stress, discomfort and/or (Ergometrics 800, Ergoline®, Blitz, Germany) in accord-
fatigue that is experienced during physical exercise (Noble ance with the American Thoracic Society (ATS)/American
and Robertson 1996). The scale is a 15-point equidistant College of Chest Physicians (ACCP) (2003). For healthy
interval tool, containing verbal descriptors of effort at RPE6 participants, power output in the first minute (0 and 50 W
(no exertion at all), between RPE7 and RPE8 (extremely in women and men, respectively) was followed by 1-min
light), RPE9 (very light), RPE11 (light), RPE13 (somewhat increments of 10 W (women) or 30 W (men). For the COPD
hard), RPE15 (hard), RPE17 (very hard), RPE19 (extremely group, initial power output was set at 10 W in women and
hard) and RPE20 (maximal exertion). 20 W in men, with increments of 10 and 15 W, respectively.
Prior to performing the CPET, the following instructions The initial and subsequent increments in power output were
were read: set to achieve an exercise duration of between 8 and 12 min.
“While exercising we want you to rate your perception A pedal rate of 60–70 rev min−1 was maintained through-
of exercise, i.e., how heavy and strenuous the exercise feels out CPET. The CPET ended at the point of volitional
to you. Look at this rating scale; we want you to use this exhaustion (i.e., the participant failed to maintain a pedal
scale from RPE6 to RPE20, where RPE6 below while means rate above 60 rev min−1 for more than 5 s, unless the test
‘no exertion at all’ and RPE20 means ‘maximal exertion’. was terminated for medical reasons). Expired air was con-
RPE9 corresponds to ‘very light’ exercise. For a normal, tinuously recorded via a breath-by-breath system (Medis-
healthy person it is like walking slowly at his or her own oft®, Sorinnes, Belgium), calibrated in accordance with
pace for some minutes. RPE13 on the scale is ‘‘somewhat the manufacturer’s guidelines and averaged during the last
hard’’ exercise, but it still feels OK to continue. RPE17 15 s of each stage. Overall RPE were collected during each
‘very hard’ is very strenuous. A healthy person can still go stage until RPE≥15. Only the RPE values inferior or equal
on, but he or she really has to push him- or herself. It feels to RPE15 were collected because our main aim was to test
very heavy, and the person is very tired. RPE19 on the scale the validity of the individual linear regression between V̇ O2
is an extremely strenuous exercise level. For most people and overall RPE≤15 to predict V̇ O2 peak. From RPE≥15, par-
this is the most strenuous exercise they have ever experi- ticipants were verbally encouraged until volitional exhaus-
enced. Try to appraise your feeling of exertion as honestly tion. As a plateau phenomenon in V̇ O2 is rarely observed
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Table 2 Percentage of peak oxygen uptake (% V̇ O2 peak) at different ratings of perceived exertion (RPE) in the healthy participants and patients
with chronic obstructive pulmonary disease (COPD)
Variable (units) Healthy Healthy Healthy Women with Men with Patients with Women Men
women men participants COPD COPD COPD (n = 8) (n = 25)
(n = 4) (n = 11) (n = 15) (n = 4) (n = 14) (n = 18)
V̇ O2 at RPE7 (%V̇ O2 peak) 33.4 ± 10.4 31.1 ± 14.9 31.7 ± 13.6 43.1 ± 19.2 41.5 ± 11.8 41.9 ± 13.1 38.2 ± 15.2 36.9 ± 14.0
V̇ O2 at RPE9 (%V̇ O2 peak) 45.8 ± 8.4 43.0 ± 13.2 43.7 ± 11.9 53.3 ± 15.1 52.6 ± 9.6 52.7 ± 10.5 49.5 ± 12.0 48.4 ± 12.1
V̇ O2 at RPE11 (%V̇ O2 peak) 58.1 ± 6.7 54.9 ± 11.6 55.7 ± 10.4 63.5 ± 11.2 63.6 ± 8.4 63.6 ± 8.7 60.8 ± 9.0 59.8 ± 10.7
V̇ O2 at RPE13 (%V̇ O2 peak) 70.5 ± 5.7 66.7 ± 10.4 67.7 ± 9.3 73.7 ± 7.9 74.7 ± 8.6 74.5 ± 8.2 72.1 ± 6.6 71.2 ± 10.1
V̇ O2 at RPE15 (%V̇ O2 peak) 82.8 ± 5.7 78.6 ± 9.6 79.8 ± 8.7 83.9 ± 6.2 85.7 ± 10.1 85.3 ± 9.3 83.4 ± 5.5 82.6 ± 10.3
Fig. 1 Left panel Association between actual and predicted peak Bland–Altman adapted by Ludbrook for the comparison between
oxygen uptake (V̇ O2 peak) in healthy participants. The dashed line is actual and predicted V̇ O2 peak in healthy participants. The dashed
the line of identity which corresponds to a perfect estimation of peak line is the bias. The thick lines are the 95 % limits of agreement
oxygen uptake. The thick line is the linear relationship. Right panel (LoA95 %)
contraindications to physical exercise), it is not neces- by several factors, including exercise intensity, modality
sary to regularly repeat CPET to exhaustion to readjust and habituation (Bolgar et al. 2010). It is not known how
the exercise intensity (i.e., percentage of V̇ O2 peak). The differentiated perceptual signals from dyspnea contribute to
advantage of this is to avoid negative affect and limitation the determination of overall RPE in patients with COPD,
of the risk of cardiovascular complications. Furthermore, in whom dyspnea is a major symptom (O’Donnell et al.
use of RPE≤15 (rather than RPE≤17) may be considered to 2009). The present study reveals that the extrapolation of
be more appropriate for sedentary and clinical populations the individual linear regression between V̇ O2 and overall
as it offers a compromise between the negative affect and RPE provided an acceptable estimate of V̇ O2 peak which
potentially greater risk of cardiovascular complications was slightly higher by 6.3 % (i.e., 1.0 mL kg−1 min−1),
associated with high exercise intensities during CPET, and although this was not statistically significant. It is possible
the gain of predictive accuracy using the large RPE range that the differentiated RPE arising from dyspnea, rather
(RPE≤17). Furthermore, in comparison to RPE≤17, the than overall RPE, may allow for an even more accurate
RPE≤15 reduces the duration and overall cost of using sub- estimation of V̇ O2 peak. Indeed, several abnormal physi-
maximal protocols. ological responses to CPET, including increased central
The overall RPE represents an integration of perceptual respiratory drive secondary to pulmonary gas exchange
signals from metabolic, physiological and thermal stimuli (e.g., high fixed physiological dead space secondary to
(Pandolf et al. 1975). These differentiated signals may not increased ventilation–perfusion abnormalities) and meta-
act equivalently on the overall RPE, i.e., each differentiated bolic (e.g., metabolic acidosis secondary to skeletal mus-
signal is assumed to carry a specific intensity weighting cle deconditioning which increases peripheral muscle
with the most intense signal dominating the sensory inte- metaboreceptor and mechanoreceptor activation) derange-
gration process that forms the overall RPE. The highest dif- ments, as well as some mechanical factors (e.g., static and
ferentiated RPE determined at a given moment during exer- dynamic pulmonary hyperinflation as a consequence of
cise, i.e., the “perceptual signal dominance”, is influenced expiratory flow limitation result in reduction of the resting
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Fig. 2 Left panel Association between actual and predicted peak line is the linear relationship. Right panel Bland–Altman adapted by
oxygen uptake (V̇ O2 peak) in patients with chronic obstructive pul- Ludbrook for the comparison between actual and predicted V̇ O2 peak
monary disease (COPD). The dashed line is the line of identity which in patients with COPD. The dashed line is the bias. The thick lines
corresponds to a perfect estimation of peak oxygen uptake. The thick are the 95 % limits of agreement (LoA95 %)
inspiratory capacity and inspiratory reserve volume such that participants will maintain a reserve capacity during
that as tidal volume increases during CPET, and a critically maximal exercise testing, presumably to prevent any cata-
minimal inspiratory reserve volume is reached early), are strophic failure of homeostasis (Swart et al. 2009).
frequently found in patients with COPD (O’Donnell et al. The current results reveal also that the accuracy of
2009). These common abnormal physiological responses to predicted V̇ O2 peak was better in healthy participants
CPET in patients with COPD increase the dyspnea inten- compared to patients with COPD. Indeed, although not
sity, and may limit exercise, leading to premature cessation statistically significant, predicted V̇ O2 peak was overes-
of CPET, specifically in patients who have a severe airflow timated by 3.7 and 6.3 % in healthy and COPD, respec-
limitation. Consequently, it is possible that using the indi- tively. Moreover, larger LoA95 % was noticed in patients
vidual linear regression between V̇ O2 and differentiated with COPD in comparison with healthy participants (4.0
RPE arising from dyspnea (which at least partially limits vs. 4.6 mL kg−1 min−1, respectively; Figs. 1, 2). The
exercise in patients with COPD), rather than an overall lower accuracy in patients with COPD may be explained
RPE, may allow for greater accuracy for predicting V̇ O2 by symptoms which will have limited the progression to
peak. However, further studies are necessary to confirm this maximal exercise as patients with COPD are often symp-
hypothesis. tom-limited, and may stop exercise before reaching physi-
In theory, as RPE20 is the theoretical maximal value on ological limits (American Thoracic Society (ATS)/Ameri-
the RPE scale, this value is generally expected at the CPET can College of Chest Physicians (ACCP) 2003). Indeed,
end. However, numerous studies (Demello et al. 1987; although dyspnea is a common symptom in patients with
Eston et al. 2007; Coquart et al. 2012) have shown that COPD, other symptoms including leg discomfort, chest
the theoretical maximal RPE (i.e., RPE 20) is infrequently pain, or fatigue will also limit the exercise response (Ham-
reported at volitional exhaustion during standard maximal ilton et al. 1995; Jones and Killian 2000). Additional stud-
exercise testing (Eston 2012). Consequently, to predict V̇ O2 ies are necessary to examine the influence of different
peak from the individual linear regression between overall symptoms limiting exercise on predicted V̇ O2 peak accord-
RPE and V̇ O2, several studies have shown that extrapola- ing to severity of airflow limitation in patients with COPD.
tion to RPE19 is accurate (Eston et al. 2012; Faulkner et The present study observed a larger LoA95 % in patients
al. 2007; Morris et al. 2010). Accordingly, we have used with COPD compared to healthy participants, suggesting
this generally tolerated maximal RPE value (i.e., RPE19) a lower accuracy for predicting V̇ O2 peak in this popula-
rather than RPE20 to predict V̇ O2 peak. Several reasons tion. Possible improvements in the prediction of V̇ O2 peak
may explain why many participants fail to achieve RPE20 at may be obtained from a second exercise test. Indeed, it is
the CPET end. Firstly, as reminded by Faulkner and Eston generally recognized that the accuracy of predicting V̇ O2
(2008) a high level of motivation is required to attain V̇ O2 peak from the individual relationship between V̇ O2 and
peak during CPET and consequently, a lack of motivation RPE is better following an initial exercise test in seden-
may lead to some participants prematurely stopping dur- tary subjects, suggesting a “practice” effect (Eston et al.
ing a CPET. Secondly, this “underestimation” of maximal 2008; Faulkner et al. 2007). Consequently, V̇ O2 peak may
effort perception may also be explained by the conserva- be predicted more accurately with repeated exercise test-
tion of a “reserve capacity”. Indeed, it has been suggested ing during a pulmonary rehabilitation program, which uses
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Eur J Appl Physiol (2015) 115:365–372 371
the individual relationship between RPE and V̇ O2. Further Eston R, Lambrick D, Sheppard K, Parfitt G (2008) Prediction of
studies are necessary to confirm this hypothesis. maximal oxygen uptake in sedentary males from a perceptu-
ally regulated, sub-maximal graded exercise test. J Sports Sci
26:131–139
Eston R, Evans H, Faulkner J, Lambrick D, Al-Rahamneh H, Parfitt
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the individual linear regression between V̇ O2 and overall ceived exertion during a graded exercise test to volitional exhaus-
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Conflict of interest No conflicts for all authors. Faulkner J, Parfitt G, Eston R (2007) Prediction of maximal oxygen
uptake from the ratings of perceived exertion and heart rate dur-
ing a perceptually-regulated sub-maximal exercise test in active
and sedentary participants. Eur J Appl Physiol 101:397–407
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