RESEARCH REPORT

Reliability of Physiological Cost Index

Measurements in Walking Normal Subjects
Using Steady-state, Non-steady-state and
Post-exercise Heart Rate Recording
expenditure haa traditionally been calculated by
measuring oxygen consumption, but this method
involves the use of expensive and cumbersome
equipment. Such apparatus may adversely
affect the measurement itself, and it is particularly unsuitable for use with children and
disabled patients (Davies, 1977;Stallard et al,
1978;Butler et al, 1984).

Introduction
In the current climate of health care, where
assessment of cost and quality are paramount,
outcome measures used in clinical audit and
reeearcb assume considerable importance. Those
which have both ease of application and objectivity, and which are ale0 related to client function,
are of particular value.
Assessment of energy eqxmditure during walking
isanimportant parameterwhich eanbe d to
determine clinical and hnctional improvements
in patients with locomotor probleme. Energy

Studies have shown that heart rate (HR)is linearly related to oxygen consumption a t submaximal levels (Andrewe, 1967;h t r a n d and
Rodahl, 1986;Bradfieid et al, 1971;Waters et al,
1983).Waters et a1 (1983)have shown that HR
during walking ie significantly higher in children
compared with adolescents, which probably
reflects children's increased resting rate; and in
females compared with males.
Speed of walking can also be a useful indicator
and Waters et al(1988)have demonstrated that,
in normal subjects, s p e d increases from childhood to young adulthood, then declines with age.
With each age group, the rate of oxygen uptake
increases with gait velocity. The relationship has
been found to be linear in normal children and
adults up to a speed of 100 metres per minute
(Pearce et a2,1983;Waters et al, 19881,also in
cerebral palsied children (Roseet d,1989,1990).
Maximum efficiency, hence minimal energy
expenditure, occurs at the individual's optimal
or 'preferred' speed of walking (Wton, 1960).
Both speed and HR have been used as indicators
of efficiency and energy cost of locomotion (Stallard e# al,1978;Stallard and Rose, 1980),but
their combined use was first reported by MacGregor in 1979,who highlighted the problems of
factors other than workload which may cause HR
variability. Maffiregor (1979)p r o p o d the use of
a physiologicalcoat index (PCI). He suggested that
the effect of an activity was better represented
by the net HR (working HR resting HR)divided
by speed of walking, this yielding a PCI in net
beats per metre. He demonetsated that, for a variety of n o d and handicapped subjecte, PCI was
minimal at self-selected or preferred speeds of
walking, and that the relationship was reproducible. Nene and Jennings (1992)found a
Werence in PCI that waa l e a than 10% between

test and retest on a group of four paraplegic subjects, a very small sample. Rose et a1 (1991)also
combined HR and speed of walking in children
and adolescents to calculate their energy expenditure index, which like PCI also yields beats per
metre. They found that this index and oxygen
uptake were linearly related, thus demonstrating
validity of the measure, and, by implication,validity of PCI. Researchers at the Orthotic Research
and Locomotor Assessment Unit (ORLAU),
Oswestry, Shropshire, have routinely used PCI as
a measure since 1984 (ORLAU, 1992),and have
expressed considerable confidence in its use as a
clinicaltoo for monitoring changes in patient performance. PCI is calculated thus:

In specialist or resear& centrea,there is a c c e ~

to~
telemetry equipment for the continuous monitoring of HR. In the average physiotherapy
department, however, such expensive and spe-

PCI = Walking HR (beatdmin)- Resting HR (beatdmin)

A same-subject correlational design waa chosen,

and all measurements were repeated on a separate occasion. Informed consent was obtained
ftom the subjecta 15 female physiotherapy students. Exclusion criteria included smokers and
any subjects with known medicalhespiratory
conditions. Ages ranged from 19-29years (x 21.67,
SD 2.84).None had any locomotor problems and
all were in good health.

Walking speed (metredmin)

Guidelines from ORLAU (1992)for the measurement of PCI emphasise that for maximum efficacy:
1. Resting HR must be carefully measured to
reflect a true value.

2.Steady-state conditions should obtain.

Steady state implies a situation where oxygen
uptake equals the oxygen requirements of the
tissues (Mattsson, 1989).Steady-state conditions
mean that HR has stabilised for a particular activity (Kamath et ul, 1991).True resting HR can be
measured as the average HR taken over a twominute period after subjects have been sitting
quietly for five minutes (Rose et ul, 1991).Measuring the walking HR under steady-state
conditions is more problematical. Such conditions
have been found to take between three and seven
minutes to achieve in normal subjects Waters et
al, 1983;Zingrafet al, 1983;Rose et al, 1985;Nene
and Patrick, 1990;Kamath et al, 19911,with the
majority of authors suggesting a time of three or
four minutes. Walking for this length of time is
not always possible for patients with locomotor
disability. Non-steady-stateconditionsmay therefore be the only practicable alternative, and have
been previously used (Nene and Jennings, 1992).
Average preferred walking speed can be assessed
more accurately if the walkway used avoids the
patients having to stop and turn.

cialised equipment is rarely available, and either

simple portable HR monitors to measure exercise

HR,or manual pulse readings to measure postexercise HR,may have to be used. The purpose
of this experiment is to establish whether PCI
remains a reliable measure under steady-state
and non-steady state conditions, and also when
post-exercise HR readings are used to calculate
PCI.

Methods and Materials

An electronic Powejog treadmill (Sports Engineering, model MEDL) was used,and a horizontal
walkway setting chosen. Speeds from 0-18
kmhour were available via the touch sensor control box. HR was monitored using a Tunturi
digital pulsemeter (model TPM 400). Marcelino
and Harms (1992)have previously demonstrated
instrument reliability for this monitor.
Before starting the protocol, each subject was
f d a r i s e d with tmadmili walking for a few minutes while the speed of the treadmill was slowly
increased and the subject waa asked to state when
the speed had reached her perceived comfortable
or preferred walking speed,which wa8 noted and
used for the subject during the experiment and
the repeat trial. Subjects were then allowed to
rest for five minutes, after which time they were
attached to the pulse meter u i a the ear-clip sensor
and, after allowing 30 seconds for the readings
to stabilise, HR was recorded every ten seconds for
two minutes, and the average calculated to give
resting HR.

Individually, subjeds then returned to the treadmill, still connected to the puhe meter, and the
speed was gradually increased until it reached
PCI can be used either to measure changes in 1motor efficiency over time, or changes as a result their previously chosen preferred speed.This was
of the use of different orthotic or prosthetic maintained for a total time of four minutes. All
devices, or as an indicator of handicap when com- subjects wore gym shoes. After the first 30 secpared with matched normative data (MacGregor, onds,to allow the pulse meter to a t a b i i , HR was
1979;Butler et al, 1984,Nene and Patrick, 1989; recorded every ten seconds for one minute and
Rose et al, 1989,1990;Nene and Jennings, 1992). averaged to give the non-steady-state HR reading.
In general, whatever the cause of disability, a After three minutes walking, steady-state was
assumed to have been reached (Kamath et al.
pathological gait yields a higher value for PCI.

19911,and H R was recorded as before to give a

steady-state H R reading. At four minutes the
treadmill was slowed to a stop and the subject
remained standing. Post-exercise H R was then
recorded every two seconds for ten seconds, and
the average calculated to give post-exercise HR.
This time was chosen in an attempt to minimise
error, on the one hand from too short a period of
recording,and on the other to best reflect exercise
HR.HR was always calculated in beats per minute
(bpm). Speed of walking for each subject was
calculated using treadmill speed in km/h. This
was computed in metredmin achieved over the
four-minute walk period.

mean HR was 94 bpm (SD9.49)for week 1 and

92bpm (SD 8.39)for week 2.For post-exercise HR
the mean was 85 bpm (SD 8.89)for week 1and
83 bpm (SD10.43)for week 2. It is apparent that
little difference exists between non-steady-state
and steady-state group H R values, and hence
these respective values for PCI although postexercise HR values - and hence PCI values are lower, as might be expected. The mean
walking speed for the group was 54.9 d m i n
(range 38.3-8.17; SD 15.12). Mean resting HR
was 66 bpm (range 53-83;SD 10.72).

For the non-steady-state conditions test-retest,

the mean difference in PCI was 0.134,maximum
The entire procedure was repeated for each of the difference for any one subject was 0.4;four sub15 subjects one week later, by the same experi- jects showed a test-retest PCI difference > 0.2,
eight subjects a difference of < 0.1.For the steadymenter, under the same conditions.
state condition,mean test-retest difference in PCI
Data sets from each of the two sets of readings
was 0.08,maximum 0.3;only two subjects had a
was analysed using Pearson's product moment
difference greater than 0.2,and 11 subjects had
correlation coefficient to test for significant relaa PCI test-retest difference of less than 0.1.For
tionships (p < 0.01)between test and retest for
post-exercise HR calculation for PCI mean testeach of the three conditions.
retest the difference was 0.108, maximum 0.29;
two subjects had differences greater than 0.2 and
ReSllltS
Results shown in the table indicate significant nine subjects less than 0.1.This demonstrates
positive correlation between PCI values obtained lowest test-retest differences under steady-state
conditions. Figures 1-3show test-retest PCI valin weeks one and two of the experiment.
ues for each of the 15 subjects under
PCI (aatJm)for 15 subjects
non-steady-state, steady-state and post-exercise
HR conditions respectively.
week 7
Week 2
r'
Subjects 1,3,7,11,13and 15 walked at speeds
tum&mdy-staboondibbns
of
between 65 and 81 ndmin, which reflects preX
0.55
0.52
0.773
viously reported normal adult walking speeds of
0.2-1.1 3
0.28-0.85
Ranse
SD
0.25
around 70 d m i n (MacGregor, 1979,1981;Rose et
al,
1991;Waters et al, 19831,and results show
staady-state conaWons
that, in general, their PCI values were closer to
x
0.55
0.52
0.868
0.090.99
0.29-1.03
the expected value of around 0.4 bpm.

0.23

0.22

Discussion

~ ~ + X W C & L ~ H R

These results indicate that X I is a reliable measure when calculated on a test-retest basis, using
SD
non-steady-state, steady-state and 10-second
post-exercise HR values, on this group of healthy
'SlgniRCant at p < 0.01, tfcrit) 0.76,dl 13. two-tailed
young women. It must be emphasised that these
PCI values calculated under non-steady-state convalues are relative and therefore whichever
ditions give a test-retest correlation of r = 773
method is used, the protocol should be strictly
(p < 0.01).PCI values calculated under steadyadhered to on subsequent occasions. Also, if PCI
state conditions give a test-retest correlation
values are required for research purposes, when
coefficient of r = 868 (p < 0.01),and PCI values
comparisons may be made with data from other
calculated using poet-exercise H R give a correlexperimenters, then steady-state conditions
ation coefficient of r = 796 (p < 0.01).
should be obtained where possible, and accurate
This demonstrates reliability of the measure, continuous HR monitoring during exercise should
whether H R is measured in steady-state or non- ideally be used. For best results, such conditions
steady-state conditions, and when post-exercise should also be adhered to for clinical measurement.
measurements are used in the calculation.

Ranas

0.38
0.2-0.86
0.25

0.34
0.1-0.78
0.18

0.796

Group mean HR for non-steady-state conditions However, on the level of individual clinical meawas 94 bpm (SD 7.96)for week 1 and 93 bpm (SD surement as opposed t o group monitoring of
12.7) for week 2. For steady-state conditions, patients, in a physiotherapy department for

,-

oaokr 1-

v d 81. no 10

lol n

Average values found here for PCI of around 0.6

beatdm are higher than those previously maxded
(ORLAU,19921,where values between 0.3 and 0.4
beatdm were recorded across all age groups and
both sexes. However, MacGregor (1981) stated
resulta rangingfrom 0.11to 0.6beatdm in normal
subjecta.

12

2
0

sub)eds 1-15

0 week1

a week2

Fig 1: p c i weak 1 and mW8t week 2 mlng noMtUdy h e

nR In bcuttrlmatm

l2

'Oi

rl

v)

!?6

2
0

S u m 1-15

0 SSWkl

rn s s W 2

Flg 2 PCI weak 1 and ratest rnsk 2 wlng s b d y - t t . 1 , HR

In beatdImtN

B
7

05
:4

3
2
1

The h t u r i pulse meter can be w i l y read only if

the subject remains in a relatively constant p i tion while walking. If a treadmill were not uwd,
the experimenter would have to walk dongside
the subject to take reafrom the pulse meter.
"his would undoubtedly affect the subject's nab
ural preferred speed of walking. For thie reason,
a treadmill method was chosen, rather than a circular or figure-of-eight track, because continuous
telemetered HR recording apparatus necessary
to obtain pulse measures with ease when the subject is walking along such a track was not
available. The pulse meter is relatively cheap and
easy to use. and is more l i e l y to be available in
a physiotherapy department. Studies comparing
floor and treadmill walking found no difference in
walking speeds for normal children and young
adults (Greig et af, 1993; Rose et al, 19901,
although conflicting results exist regarding comparisons of energy cost of floor and treadmill
walking. Pearce et af (1983)and Bassett et a1
(1985)both showed that level walking requires
more energy than treadmill walking. Ralston
(1960) found no significant difference. Such
results contrast with this study which found a
slightly higher PCI than might be expecki. MacGregor (1981)demonstrated that PCI is at a
maximum a t a subject's self-selected or preferred
speed, whereas PCI rises a t speeds either faster
or slower than this optimum speed.Average speed
in this study was 64.9 d m i n , considerably slower
than mean speed of normal children (Roseet af,
1990)of 74.8 d m i n or Waters et a1 (1983)who
reported 73.3 d m i n for normal teenagers:It is
therefore probable that subjecta in this study had
not had sufficient time, during their familiarisation with the treadmill, to identify accurately
their preferred natural speed of wallung, and had
perceived it as being lower than it actually was.

This slower speed would lead to reduced economy

example, then a repeat test will reflect a change

of performance even if steady-state is not reached
or post-exercise HR is used, provided t h a t the
same criteria are used on initial and subsequent
occasions.

of walking and increased energy requirements,

reflected in the higher than expected PCI values
obtained in many cases. Indeed, one subject
walked at a speed of only 28.3 d m i n with a correspondingly high X I greater than unity. This
value approaches values achieved by patients
with locomotor disability. Further study is needed
to assess how much treadmill familiarisation time
is necessary for subjects accurately to identify
their preferred walking apeed. If PE values of HR
were used in the PCI calculation, then use of a

treadmill,with the attendant problems discussed

here, would not be necBBBBTy.
Butler et a1 (1984) showed good repeatability of
PCI in ten normal children, demonetrating that
only one exceeded a difference of 0.2 beatdm in
PCI on retest. Results fmm this study are broadly
similar. Butler et al's study (1984) did not use a
treadmill and Rose et al(1990) who did use a
treadmill did not repeat the PCI measure. Thus
theae resulte are not strictly comparable.

In clinical situations, disabled patients are likely

to have greater HR increasesduring walking, and
have reduced walking speed, and thus much
higher values for XI. For example, Nene and Jenninge (1992)found a PCI value of 4.76 beatehn in
one of their paraplegic subjects. Therefore, the
a n d l discrepancies on repeated measures found
in this study would have a relatively insigiticant
effect on measurement of patienta with locomotor
dieorders. When tranecribing reaulta from a pulse
meter, as opposed to hard copy recording, there
are always possibilities of experimenter error
which may be a coneideration in explaining some
of the larger Werences in calculated PCI values
on repeated measures.
Further study is needed to evaluate reliability of
PCI measures when a treadmill is used. Clearly,
the etaady-etate HR conditions for PCI calculation

give the moat reliable repeat measure, aa would

be expeded. During non-steady-state and immediately postexerciee, HR is not stabilised and is
therefore likely to show greater variability.
The mean resting HR recorded here, of 66 bpm,
is cloae to that found by others (Blanksby and
Reidy, 1988,Kamath et d,1991). Resting HR was
measured before walking test began. It may be
preferable to meaeure resting HR at the conclusion of the experiment, during the recovery
period, a~ done by Nene and Jenninge (19921, to
minim;oP potentially a t r e d i d effects i n d u d by
the imminent experimental procedure. Resting
HR ahodd be repeated each time a PCI is calculated. PCI values calculated using post-exercise
HR as a reflection of exercise HR are lower, as
expected,due to the rapid decrease in HR on cessation of exercise. In the first 3-5 seconds after
exercise, HR is said to fall between 7-10 bpm on
average (Burger, 1969). Nevertheless, 80 long as
strict measurement protocol is adhered to on
repeated measures, postexercise HR appears to
yield reliable results for the PCI calculation.
Indeed, it may be the only method available in
a physiotherapy department. In such a case,
the pulee could be measured manually and no
equipment, except a stopwatch, would then
be neawaary,particularly if a circular or figureof-eight walkway of measured length was used

instead of a treadmill. Use of a treadmill might

preclude assessment of patients with severe
locomotor disability, who may not have the
capacity to walk and balance on such apparatus at constant speed.
ORLAU (1992)has shown that PCI is a very stable
measure across age ranges from 4 to 60 years,
with an average decrease of only 0.06 beatdm.

Similarly, it found very small differences in

average X I between males and females which,
although tending to increase with age, showed a
maximum difference of only 0.09 beatdm. Such
stability enhances the value of PCI as an indicator
of energy cost of wallring, 88 both HR and walking
speed may alter significantly with age and in
malea compared with females.

Conclusion
This study demonstrates reliability of PCI measurement in a test-retest situation, in normal
women walking at preferred speed on a treadmill,
whether HR is measured in non-steady-state,
steady-state or 10 seconds post-exercise condition~.Ae XI is an easy-to-uee, valid and reliable
measure of ansrgy expenditure, it may be a useful
tool for physiotherapists in the assessment and
evaluation of locomotor disability, functional
performance,and effectivenessof orthotic or p m thetic devices. This study shows that, for best
repeatability, steady-state conditions should id*
ally be achieved for the walking HR measure. It is
suggested that more accurate resting HR may be
recorded during the recovery period rather than
at the beghing of the walk test. If a treadmill is
to be used, the subjects ebould be fully familiarised with the apparatus in order to assess
accurately their own preferred speed of walking.
If only a stopwatch ia available, a flat circular or
flgumof-eight walkway of known distance could
be used and past-exercise (10 seconds)HR taken
manually. A flat walkway test would also remove
some of the difficulties experienced with a
treadmill. The poet-exercise HR method, as
demonstrated here, gives lower repeatability
values for X I . However, such relatively small
testretestdifferencesmay be of little consequence
in relation to the large PCI values seen in patients
with locomotor disability. Further study is needed
to assess the reliability of such a minimal cost
field method, particularly if steady-state conditions are not achievable. Teabredeat repeatability
of the measure also requires further investigation
related to patients with locomotor disability. For
purposes of research, and to calculate accurate
absolute values of PCI which can be compared
with data from other workers, continuous telemetered HR monitoring would be needed and
steady-state heart rate conditions should be
attained by subjecte.

623

Authors
Maggie Bailey MSc &4 MCSP DipTP is a lecturer in the Department of Physiotherapy Studies at the University of K W .
Claire RatcliffeBSc MCSPis a physiotherapist at Dewsbury District Hospital, West Yorkshire.
This article was received on October 5,
March 3.1995.

and accepted on

Address for ComsponMrs M J Bailey BA M S c MCSP DipTP, Departmentof Physiotherapy Studies, Universityof Keele, Staffordshire, ST5 586.
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