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Safety and Feasibility of a Health-Related Fitness Test Battery for Adults

Article  in  Physical Therapy · March 1998

DOI: 10.1093/ptj/78.2.134 · Source: PubMed

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 Safety and Feasibility of a Health-
Related Fitness Test Battery for Adults
Background and Purpose. Health-related fitness (HRFI) assessment may be
useful in promoting physical activity. Health-related fitness refers to those
components of fitness that are related to health status. The safety and
feasibility of a test battery designed for the assessment of HFWI were
evaluated. Subjects and Methods. Middle-aged men (n=246) and women
(n=254), evenly selected from five age cohorts of a random sample
(N=826), were tested. The subjects had a mean age of 47.0 years
(SD=7.9, range=37-57). Screening to i d e n w subjects with health limi-
tations was conducted by fitness testers who had master's degrees in sport
or health sciences. Safety was assessed in terms of acute complications,
delayed-onset muscle soreness (DOMS), and heart rate after each test.
Subject exclusion and time costs were evaluated for feasibility. Results. No
acute complications occurred. The leg function test caused severe DOMS
among inactive women. The overall exclusion rate increased with age. Up
to 27% of subjects aged 52 and 57 years were excluded from muscle
endurance tests, mainly due to self-reported heart disease or elevated
blood pressures. Over 90% of the subjects, however, qualified for balance,
flexibility, muscle force, and walk tests. Conclusion and Discussion. The
test battery offers a safe and feasible method for the assessment of HRFI
in working-aged adults, with the limitation that the one-leg squat function
test may cause DOMS, particularly in inactive women. [Suni JH, Miilun-
palo SI, Asikainen T-M, et al. Safety and feasibility of a health-related
fitness test battery for adults. Phys Ther. 1998;78:134-148.1

Key Words: Exercise promotion, Exertion, Field testing, Health-related fitness, Safety.
Jaana H Suni
S@o I Miilunpalo
Tuula-MariaAsikainen

Matti E Pasanen
Klaus Bos
IlMa M Vuori

Physical Therapy. Volume 78 . Number 2 . February 1998

 vidence of the health-enhancing effects of regu-
lar exercise and several recommendations for
the promotion of physical activity have been
published recently.l,Vhe justification for
increased physical activity is well documented, but effec-
tive methods for the promotion of physical activity in the
general population are only now emerging.X4 Assess-
ment 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)."- 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
propo~eci.~."~ 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 complication^^^-^^ and musculo-
skeletal injuries.lSl5 Sudden cardiac death due to symp-
tomatic or latent coronary heart disease16 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." 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 dur-
ing maximal exerciselo and maximal strength testing,"
despite thorough medical screening and physician
supervision. The safety of fitness testing without a physi-
cian's supervision among apparently healthy adults is
less well documented. In Canada, experiences involving

JH Suni, PT, is Researcher, The President Urho Kaleva Kekkonen Institute for Health Promotion Research (UKKInstitute),PO Box 30, FIN-33501,
Tampere, Finland (lojasu&uta.fi). Address all correspondence to Ms Suni.

SI Miilunpalo, MD, DMed, Specialist in Public Health Medicine, is Senior Researcher, UKK Institute.

T-M Asikainen, MD, is Researcher, UKK Institute.

RT Laukkanen, PhD, is Research Director, Polar Electro Oy, Kempele, Finland.

P Oja, PhD, Docent, is Scientific Director, UKK Institute.

ME Pasanen is ADP Manager, UKK Institute.

K Biis, PhT), is Professor, Sports Research Institute, University of Frankfurt, Frankfurt am Main, Germany.

IM Vuori, MD, is Professor and Director, UKK Institute.

The ethical committee of UKK Institute approved the study.

The Finnish Ministry of Education granted financial support for the study.

This article was submitltd Seplenrber 4, 1996, and was accepted ~rplekbrr3, 1997.

Physical Therapy . Volume 7 8 . Number 2 . February 1998 Suni et al . 135

exercise testing outside of the medical domain have
been e n c o ~ r a g i n g . In
~ ~a. ~representative
~ populationHRFI test battery (ie, the tests do not require sophisticated
study in Finland, no cardiovascular complications
occurred during submaximal walk tests in field condi-
tions (ie, conducted outdoors on a flat asphalt-gravel
road) .Ig
Only a few researchers have described the occurrence of
musculoskeletal injuries during fitness testing. Gordon
et a112 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 decreased mortality from coronary heart disease40and with
injured during maximal leg extensor and chest press
tests, whereas no injuries occurred during treadmill
testing.13Based 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(~~11gu-11gg)
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 a120 recently reported on the safety of two simple
trunk muscle endurance tests in their study of asymp-
tomatic 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, how-
ever, 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 per~ons.22.~~ We
have not found any studies on the occurrence of mus-
culoskeletal injuries or the functional consequences of
DOMS in conjunction with adult HREI t e ~ t i n g . ~ , ~ ~ Subjects
Pretest screening has been used as a means to ensure the
safety of testing or ~ a i n i n g . l A
~ .screening
~~ method attended preventive health examinations arranged by the
such as an interview or a self-administered health status
questionnaire is necessary to identify pertinent health
limitations. The Physical Activity Readiness Question-
naire26,27 has been successfully administered as a screen-
ing instrument in conjunction with the Canadian Home
Fitness Te~t.l~,~"his screening method is sensitive in
identifying persons with potential health risks, but it
excludes a large number of s ~ b j e c t s . 1 This
~ ~ 1 method
~~~~
may be counterproductive, because persons with chronic
diseases should be encouraged to participate regularly in
moderate-in tensity exercise.1.4
136 . Suni et al
Since 1991, the UKK Institute* has developed a field-based
equipment, and they can be conducted under conditions
available in ordinary communities) for working-aged adults
with no major disea~es.~ The test battery consists of body
composition, cardiorespiratoq, musculoskeletal, and
motor components ( A p p e n d i ~ ~ , ~ as
" ~suggested
~), by Oja
and TuxworthQnd Bouchard and S h e ~ h a r dThe . ~ struc-
ture of the battery is based on the available evidence on the
relationships among different aspects of fitness and
health.ls7 Cardiorespiratory fitness has consistently been
shown to influence health positively. It is associated with
decreased death due to all causes.41 Motor fitness, as
assessed by balance tests, is proposed to have relevance to
falls among elderly persons42and 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 a~tivities.~~Restricted spinal flexibility
has been proposed as a risk factor for low back dysfunc-
t i ~ n 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 symp
toms.46Lowerextremity 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.H.2Y~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
HREI testing.
Method
,~~
The study sample was selected from specified age brackets
of the residents of Tampere, Finland, who had previously
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
The President Urho Kaleva Kekkonen (UKK) Institute for Health Promotion
Research, Tampere, Finland.
Physical Therapy. Volume 78 . Number 2 . February 1998
Table 1.
Comparison of Participants and Nonparticipants of the Study Sample (Expressed as Percentages)
Living alone (single, divorced, or widowed)
Low level of education [no vocational education)
Perceived health (good or very good)
Using prescribed medication
Smoker
Exercisir~gbriskly at least twice a week
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," "aver-
age," "good," and "very good"), the nonparticipants
rated their health status somewhat lower than the par-
ticipants did. In addition, more nonparticipants used
prescription medications and were smokers and fewer
nonparticipants exercised briskly compared with the
participants.
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 (see "Screening for Health
Limitations" section). During the second visit, individual
assessment of HRFI was conducted by three fitness
testers (see "Health-Related Fitness Assessment" sec-
tion). 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 prelim-
inary 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,
Physical Therapy . Volume 7 8 . Number 2 . February 1998
Age Groups 47 and 52 Years
Participants Nonparticipants
(62%, n= 125) (38%,n=76)
13 25
13 22
79 65
29 35
13 40
55 43
nurses, and equipment for cardiopulmonary resuscita-
tion 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 i n s t i t ~ t efor
, ~ ~cardiorespira-
tory 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 else-
here.^.^^ Only tests that provided relatively reliable
measurements, as reported e l s e ~ h e r e , ~ . " ~ were ~*,~~
included in the battery (Appendix). In summary, the
interrater intraclass correlation coe!Ticients (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 The test-retest reliability, as measured with the
Pearson correlation coefficient (r), was reported to be
.89 for the Sorensen test of back muscular endurance3'
and .99 for active range of motion in knee e~tension.~"
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, respecti~ely.'~
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 (aus-
cultation method with a mercury sphygmomanometer
after 5 minutes of rest in a sitting position). The pretest-
ing health assessment also included the modified Physi-
cal Activity Readiness Questionnaire (MPAR-Q,2"27 a
question on perceived health status, and an assessment
of current level of physical activity, including the inten-
Suni et al . 137
-
0
Table 2.
Descriptive Results of the Health Assessment: Percentage of Subiects With High Body Mass Index, Elevated Blood Pressure, Poor Health, Low Physical Activity Level, or Diseases and Symptoms
Reported in the Modified Physical Activity Questionnaire (MPAR-Q)26,27
Y
2. L

LP Age Groups (in Years) for Men Age Groups (in Years) for Women
(1
N for N for All
All Age
37 42 47 52 57 Grou r 37 42 47 52 57 ;$us
Health Status Measure (n=50) (n=46) (n=50) (n=50) (n=50) (n=2g6) (n=53) (n=50) (n=54) (n=47) ("=SO) (n=204)

Body moss index 230 (moss/height2] 8 11 20 24 12 37 6 10 15 19 30 40

Blood pressure (BP)

Diastolic BP 2 100 mm Hg 2 7 14 20 16 29 0 4 2 9 12 13
Systolic BP 2 160 mm Hg 0 0 6 6 12 12 0 0 0 9 2 5

Perceived health compared with agematched

peers (much worse or worse) 12 2 14 26 26 40" 6 18 13 25 26 44

Leisure-time hysical activity PA) level (no

weekly ~ B o some
r ~i ht P no more
A
than two times a weel] 38 41 30 33 34 86" 21 30 35 32 32 76

Leisuretime exercise intensity (no exercise or

light exercise only] 32 39 26 39 42 87" 29 32 39 43 42 93

MPAR-Q questions
1. Has your physician ever said that you
hove heart trouble? 2 2 8 12 16 20 2 4 2 6 16 15
2. Do ou frequently hove pains in your heart
andYchest? 2 4 4 6 4 10 4 2 7 13 16 21
3. Has a physician ever said that your blood
pressure wos too high? 4 9 10 20 34 38 2 8 13 13 32 34
4. Do you often feel faint or have spells of
severe dizziness? 2 0 2 6 6 8 13 10 19 9 16 34
5. Has your physician ever told you that you
have a bone or ioint problem such as
arthritis that has been or might be
aggravoted by exercise? 10 2 8 20 26 33 6 14 11 32 38 50
6. Is there a ood physical reason not
mentioned9here why you should not follow
an act~vityprogram? 0 0 0 0 10 5 0 0 2 0 6 4
7. Are you taking medications? 8 11 14 28 54 57 15 12 22 60 66 87
z " Number of missing cases: 1
3,
4
sity 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 a c t i ~ i t y " ) .Descriptive
~~ results of the
health assessment are presented in Table 2. The person-
nel conducting the testing used this information (1) to
refer subjects with severe diseases or symptoms (Tab. 3)
to a phvsician for a health examination or (2) to exclude
them from selected fitness tests according to predeter-
mined safety instructions generated by the three physi-
cians of the research group (Fig. 1).
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
(BM1<30). Individuals who had answered "yes" in
response to the questions concerning possible cardiovas-
cular diseases (questions 1, 2, and 3 of the MPAR-Q
[Tab. 21) 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, <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. 21) 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 musculoskele-
tal problems (question 5 of the MPAR-Q [Tab. 21) 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. 21) were referred to the physician if they
reported having diseases or symptoms listed in Table 3.
Otherwise, they were treated according to the proce-
dures described. Individuals taking medications affect-
ing the heart rate (question 7 of the MPAR-Q [Tab. 21)
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 Sakty
The testers recorded all acute musculoskeletal injuries
or symptoms and cardiovascular complications during
the fitness testing. Delayed-onset muscle soreness was
Physical Therapy . Volume 78 . Number 2 . February 1998
Table 3.
Diseases or Symptoms for Which the Subiects 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 2 180/ 1 10
Severe anemia [hemoglobin level of < 1 10-1 00 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 ioints 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
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 func-
tional 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.+ 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 a1,49 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, adrnin-
ister, and score each mot evaluated by three fitness testers
'Polar Sport Tester, Polar Electro A, Professorintie 5 . 90440 kernpele. Finland.
Suni et a1 . 139
 FITNESS TESTERS
- with special training in the
I (
PHYSICIAN
-acquaintedwiththetestprotowl II
I testing protocd
I and exercise physiology

STANDARDIZED SCREENING OF HEALTH

LIMITATIONSTO FITNESSTESTING
Including.
-bodymassindor HEALTH EXAMINATION
- blood pressure - standardized mstmctions
- health questipnak: modified PAR-Q,
perceivedhealth status
-physical act~vityquestiomam

'A
SUBJECT EXCLUDEDFROM SELECTED
FITNESSTESTS ON HEALTH GROUNDS SUBJECT EXCLUDED FROM
- standardidinstmaions SELECTED FITNESS TESTS ON
HEALTH GROUNDS
ALL FITNESSTESTS ON
HEALTH GROUNDS

HEALTH-RELATEDFITNESS
ASSESSMENT OF ADULTS

I INTERPRETATIONOF THE RESULTS

AND EXERCISE COUNSELING

Figure 1.
Safety model for health-related fitness assessment in adult populations. Modified PAR-Q=modified Physical Activity Readness Questionnaire.26,2'

on a five-point scale (l=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 endur-
ance 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 127% 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

140 . Suni et a1 Physical Therapy. Volume 78 . Number 2 . February 1998

 4

r'lrlone O~odemte Isevere

LEISURE-TIME
UCERClSE INTEWSlTT
MEN ( n =228)
n=79
All
n= 1 49

<50 y 1142
n=91

>50 y n=37
n=58
WOMEN (nZ240)
ROnenQw n=87
All moderatehigh -
n=153

<SO y none/low n=47

modemtehigh n=99

>50 y none/low n-4

modemtelhigh n=54

0 10 20 30 40 50 60 70 80 90 100
Percentage of Subjects (%)

Figure 2.
Occurrence and severity of delayedanset muscle soreness by leisuretime exercise intensity in younger versus older men and women.

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%.
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.
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

Physical Therapy . Volume 7 8 . Number 2 . Februaiy 1998 Suni et al . 141

Table 4.
Descriptive Heart Rate Values, Mean Percentage of Agepredicted Maximum Heart Rate (%HR,), and Percentage of Subiects With Heart Rates
Over 85% of Their Age-Predicted Maximum Level (>85%), Recorded Immediately After Each Fitness Test

Descriptive Heart Rate (bpm)

-
Fitness Component Gender X SD Range N %HR,, ~85%

Motor fitness
Balance (standing on one leg) Men 94 16.0 62-148 205 52 0
Women 100 16.1 60-156 213 55 0
Musculoskeletal fitness
Flexibility
Shoulder-neck mobility Men 96 15.7 60-1 38 2 10 53 0
Womer: 100 15.6 62-140 214 55 0
Trunk side-bending Men 91 15.7 56-1 35 208 50 0
Women 94 15.4 60-140 215 52 0
Knee extension range of motion Men 82 12.7 55-121 208 45 0
Women 84 12.6 50-1 36 21 1 46 0
Muscle performance
Handgrip Men 95 15.2 59-1 38 196 52 0
Women 92 15.3 56-1 34 199 51 0
Modified push-ups Men 140 18.0 72-1 83 196 77 19
Women 144 17.5 82-1 86 188 79 24
Isometric back endurance Men 12 1 18.3 59-1 76 20 1 67 2
Women 121 19.8 57-1 76 209 67 4
Jump and reach Men 1 10 15.9 61-164 206 60 0
Women 110 16.3 71-167 210 60 0
One-leg squat Men 112 17.4 61-169 204 62 0
Women 111 17.8 65-170 208 61 1
Cardiorespiratory fitness
Walk test Men 153 17.4 96-208 208 84 43
Women 151 18.3 100-194 21 1 82 37

percentage of subjects who were excluded due to inter-
rupting 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.
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, flexi-
bility, 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-extremityjoints 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.
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.
Practica/iiy 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 exten-
sion 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
(meanz2.7 points). The average time to perform the

142 . Suni et al Physical Therapy . Volume 78 . Number 2 . February 1998


. . . . . . .. ..
.. ... .... . . . . . .. . .
37 42
Figure 3.
The overall percentage of subjects in each age group excluded due to health limitations,
interrupting, or refusing to participate in one or more tests.
whole test battery was 80 minutes. This time included 40
to 45 minutes for the motor and musculoskeletal testing,
10 t~ 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
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 pro-
grams or population surveys are often difficult to Con-
duct due to the time needed and financial costs. We
believe, however, that a standard health screening pro-
cedure should be an integral part of any HRFI assess-
ment.525"n our study, the fitness testing personnel used
a standard protocol to refer the subjects with potentially
consequential health problems to a physician and stan-
dard 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 rnajor health hazards occurred. The results indi-
cate that, among middle-aged adults, HRFI assessment
can be safely and effectively performed with minor
physician participation.
Physical Therapy . Volume 78 . Number 2
Most of the subjects experienced some
DOMS. Women experienced DOMS
more often than men did, and physi-
cally 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 accor-
dance with findings that training may
prevent or reduce muscle damage and
soreness." Four subjects who reported
47 52 57 severe knee problems (arthrosis, pain,
Age gmup (Y) 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.
~h~ one-leg squat test was developed to assess restric-
tions in the lowerextremity 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 contrac-
tions 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
subjects developing negative attitudes toward fitness
testing and training.
Despite the risk o f ~ O ~inclusion
S , of the lowerextremity
test in the H m test battery is warranted because it may be
indicator of mobility and functional independence in
older adUlts447,52,53
There is a well-validatedlowerextremity
performance test for elderly persons." We developed the
squat test when we could not find any other easily admin-
istered test of lowerextremity muscle force designed for
middle-aged adults. Suni et a18 have established the reliabil-
ity measurements obhined with *e test (interrater
ICC=.~~, of variation= 12.1%).Further studies
,e needed to ensure the safety of the test in terms of
DOMS.
Heart rate is a good indicator of cardiovascular exertion
in tests requiring movements of large muscles. The
. Februarj 1998 Suni et al . 143

Figure 4.
Percentage of subjects in each age group excluded from the upper-body and trunk muscle
endurance tests, lower-extremity muscle tests, and walk time (ie, time to complete the 2-km walk
[in minutes]) and predicted maximal oxygen uptake (Vo2 max) in the walk test.
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 compli-
cations other than minor muscle injuries have been
reported, 1 8 1 9 5 0 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
§
SF-Sportfire Weight Belt, Urheiluareena, Tampereen Valtatie 19, 33100 Tam-
pere, Finland.
144 . Suni et al
Feasibility
Proportion of subjects qualified for the
tests. Ninety percent or more of the
subjects in each age group were quali-
fied 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 pop-
ulation study in Finland. 58 A substantial
proportion of the subjects over 50 years
of age were not qualified for the mod-
ified push-up test (22%) or the isomet-
ric back extension muscle endurance
test (16%). The exclusion rates are
similar to those reported in surveys
assessing cardiorespiratory fitness of
adults by submaximal tests. 181958 Prev-
alence 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 medica-
tions 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.* Stan-
dardization of subject positioning required careful prep-
aration 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 con-
suming. We used a special weight belt § with additional
cuffs. The equipment helps to keep the extra load near
* Vinkelmatare Myrin, LIC, Rehab Vardrum, Solna, Sweden.
Physical Therapy . Volume 78 . Number 2 . February 1998
to the center of body mass. All other motor and muscu-
loskeletal fitness tests (one-leg balance, shoulder-neck
mobility, trunk side-bending, handgrip, modified push-
up, isometric back extension, jump and reach) were
quick and easy to administer. The average time needed
lo perform the complete HRFI test battery was 80
ininutes. 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 accord-
ing 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 HRFl 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 instruc-
tions to refer subjects with severe health limitations to a
physician for further examination, and (3) standard
instructions to exclude subjects with minor health limi-
tations 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."
Genemi Applicabili~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."53 The
participants had somewhat higher education and were
healthier and more physically active than the nonpartic-
ipating 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 sub-
jects with chronic diseases and physically inactive life-
styles who were successhlly screened to prevent severe
complications. The selection bias of the sample, how-
ever, ma.y 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.
Physical Therapy . Volume 78 . Number 2 . February 1998
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 evalu-
ating 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 dif-
ferent 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 phys-
ical activity program, with good adherence.
Interpretation of the test scores according to the health-
related fitness concept7 is aimed to give feedback to the
individual in terms of the adequacy of fitness with
respect to health criteria.' The health criteria relate to
disease prevention or functional adequacy and reten-
tion." More studies with representative samples are
needed to assess the relationships of different compo-
nents 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 (cardiovas-
cular 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, they
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 thera-
pists, have optimal qualifications to conduct HRFI
testing.
Suni et al . 145
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 impor-
tance of a standard health screening procedure. Safe
testing is ensured, minor physician participation is
needed, and most individuals qualify for the majority of
tests.
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Physical Therapy. Volume 78 . Number 2 . February 1998
Appendix. Description of the Health-elated FitnessAssessment Methods
MOTOR FITNESS
Balance:
Whole body. Test: Standing on one leg with y s open for assessment of the
eficiency of static postural control while the area of support is reduced. M,s
Outcome: duration of balance task up to 60 seconds,as measured with a stopwatch.
Specific contraindications: dizziiess, severe symptoms of the spine or lower
extremities that might be aggravated by the test movements.
MUSCULOSKELETAL FITNESS
Upper body. Test: Shoulder-neck mob;/;@for a rough estimate of functional
shoulder flexion range ofmotion (ROM)?
Outcome: visual estimation of the movement resbiction in maximal
overhead flexion on a Uuee-point scale based on the end-point position oithe anns.
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?'
Outcome: the distance (in millimeters) the fingertip moves down the lower extremity
during maximum lateral bending, as measured with a tape measure.
Specific wntraindications: severe spinal symptoms Ulat might be aggravated by the
test movements.
Legs. Active knee extension range of motion for hamstring muscle extensibility.
" Outcome: end-point rangeaf-motion angle inknee extension,as measured with the
T-.E-iM*! inclinomety . 30Y0, and 40% using a weight belt.
-
cL.2L * Speclfic contralnd~catlons:severe symptoms of the lumbar spine or lower
extremities that hinder the subject &om getting on or up from the floor or that might
be aggravated by the test movements.
Muscle performance:
Upper body. Handgtip for the maximal m.p strength.
Outcome: maxilllal 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. Mod~jiedpush-ups for the short-time endurance capacity of the upper-
- extremity extensors and the ability to stabilize the hunk?
Q
Outcome: number of push-up cycles completed in 40 seconds.
Specificcontraindications: moderate to severe disase 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.
T d Back extension for the endurance capacity of the tnmk extensor ~ u s c I ~ s . ~ ~ ~ ~
$&$3 Ou- the endurance time(in seconds) of the task up to 4 minutes, as measured with a
stopwatch.
Specific conhaindications:moderate to severe diseases or symptoms of the
cardiovarmlar system (listed in Tab. 3) and severe spinal symptoms that might be
aggravated by the test movements.
Y3
Lower extremities. Jump andreach for the lower-extremity extensor power.
Outcome: the difference between the reach height and the jump height (incentimders), as
measured with a jumpan&reach bxud and a tape measure.
+
Specific contraindications: severe obesity, dizziness, or severe w p t o m s 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 exten~ors.~
Outcome: the load limit for successful squatting task measured as maximum weight
relative to the subject's body weight up to 140%. ?he test started with body weight,
and 10% increments of body weight were added at four su&ve steps of IWo, 20%,
Specific umhaindications: 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 w l k test for the prediction of maximal oxygen uptake ( v o ~ )
on the basis of walk time, heart rate at the end of the walk, body mass index, and age.29-3'
Outcome: walk time and the pred~cted~ o ~ m a x .
Specific umhaindications: moderate to severe diseases or symptoms of the
cardiovascular system (listed in Tab. 3). severe d i z z i i s , and severe musculoskeletal
symptoms that might be aggravated by walking.
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41 Lakka TA, Venaliinen JM, Rauramaa R, et al. Relation of leisure-
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Physical Therapy . Volume 78 . Number 2 . February 1998