Hindawi Publishing Corporation
Pulmonary Medicine
Volume 2012, Article ID 542402, 10 pages
doi:10.1155/2012/542402
Research Article
Determination of Best Criteria to Determine Final and Initial
Speeds within Ramp Exercise Testing Protocols
Sidney C. da Silva,1 Walace D. Monteiro,2, 3 Felipe A. Cunha,2, 4
Jonathan Myers,5 and Paulo T. V. Farinatti2, 3
1Department of Sports Science, Brazilian Olympic Committee, Avenida das Am´ericas 899, 22631-000 Rio de Janeiro, RJ, Brazil
2Laboratory of Physical Activity and Health Promotion, Rio de Janeiro State University, Rua S˜ao Francisco Xavier 524, Sala 8121F,
20550-900 Rio de Janeiro, RJ, Brazil
3Graduate Program in Sciences of Physical Activity, Salgado de Oliveira University, Rua Marechal Deodoro 217, No. 2 Andar,
24030-060 Niteroi, RJ, Brazil
4Graduate Program in Medical Sciences, Rio de Janeiro State University, Avenida Professor Manoel de Abreu, 444/No. 2 Andar,
Vila Isabel, 20550-170 Rio de Janeiro, RJ, Brazil
5Cardiology Division, Palo Alto VA Health Care System, Cardiology 111C, 3801 Miranda Avenue, Palo Alto, CA 94304, USA
Correspondence should be addressed to Paulo T. V. Farinatti, pfarinatti@gmail.com
Received 20 May 2012; Revised 25 September 2012; Accepted 25 September 2012
Academic Editor: Darcy D. Marciniuk
Copyright © 2012 Sidney C. da Silva et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
This study compared strategies to deﬁne ﬁnal and initial speeds for designing ramp protocols. VO2 max was directly assessed in
117 subjects (29 ± 8 yrs) and estimated by three nonexercise models: (1) Veterans Speciﬁc Activity Questionnaire (VSAQ); (2)
Rating of Perceived Capacity (RPC); (3) Questionnaire of Cardiorespiratory Fitness (CRF). Thirty seven subjects (30 ± 9 yrs)
performed three additional tests with initial speeds corresponding to 50% of estimated VO2 max and 50% and 60% of measured
VO2 max. Signiﬁcant diﬀerences (P < 0.001) were found between VO2 max measured (41.5 ± 6.6 mL·kg−1·min−1) and estimated by
VSAQ (36.6±6.6 mL·kg−1·min−1) and CRF (45.0±5.3 mL·kg−1·min−1), but not RPC (41.3±6.2 mL·kg−1·min−1). The CRF had
the highest ICC, the lowest SEE, and better limits of agreement with VO2 max compared to the other instruments. Initial speeds from
50%–60% VO2 max estimated by CRF or measured produced similar VO2 max (40.7±5.9; 40.0±5.6; 40.3±5.5 mL·kg−1·min−1 resp.,
P = 0.14). The closest relationship to identity line was found in tests beginning at 50% VO2 max estimated by CRF. In conclusion,
CRF was the best option to estimate VO2 max and therefore to deﬁne the ﬁnal speed for ramp protocols. The measured VO2 max was
independent of initial speeds, but speeds higher than 50% VO2 max produced poorer submaximal relationships between workload
and VO2.
1. Introduction
Exercise capacity is an independent predictor of risk for car-
diovascular disease and mortality among asymptomatic and
symptomatic individuals [1–3]. Hence the determination of
maximal oxygen uptake (VO2 max) is considered to be one of
the most important health-related parameters and has been
widely used to evaluate cardiorespiratory ﬁtness in health
and illness [4–7].
However, the determination of exercise capacity is closely
related to the test protocol employed [8]. An extensive body
of evidence has shown that ramp exercise protocols oﬀer
advantages over traditional protocols, because the increase in
external work occurs in a constant and continuous fashion,
and when designing the protocol the rate of increase in
workload can be individualized by a previous estimate of
maximal exercise capacity [7, 9–12]. This is associated with
greater linearity between VO2 and work rate compared to
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traditional protocols with large and disproportionate work
rate increments [9, 11, 13]. Moreover, ramp protocols induce
more uniform hemodynamic and respiratory responses,
facilitating the acquisition of information at submaximal
intensities, such as the ventilatory threshold [9, 13].
Despite the apparent advantages over traditional exercise
testing, standardized criteria to guide the application of ramp
protocols remain sparse. For instance, a limitation of ramp
protocols is the requirement to estimate maximal exercise
capacity from an activity scale and then adjust the ramp
rate accordingly [14]. In practical terms, an underestimation
of maximal exercise capacity will result in a prolonged
total test duration, while an overestimation will result in
premature test termination and, therefore, inappropriate test
protocol for eliciting a true VO2 max [15]. However, there is
no consensus in the literature concerning this issue. Available
recommendations are generally vague and largely limited
to the premise that tests should last between 8 and 12 min
[4, 7, 14–17]. The same occurs with regard to the initial work
rate of the test—actually we could not ﬁnd recommendations
of standard procedures for its determination [18].
Thus, the ﬁrst objective of the present study was to
compare three nonexercise models to predict maximal
exercise capacity as criteria to determine the ﬁnal speed of
maximal treadmill ramp protocols. A second purpose was
to investigate how diﬀerent initial speeds calculated from
%VO2 max inﬂuenced the VO2 max measured in the tests.
2. Material and Methods
2.1. Subjects. A group of 117 subjects (47 women) aged
between 18 and 51 years (mean: 29.1 ± 7.6 yrs), with no
previous experience in high performance physical training,
volunteered for the study. Exclusion criteria included a
clinical diagnosis of any clinical condition that could limit
exercise performance and the use of any medication with
potential cardiovascular inﬂuence. All participants were fully
informed about the procedures and potential risks before
giving written consent to take part in the study, which
was approved by the local Institutional Research Ethics
Committee.
2.2. Procedures. A ﬂowchart of the 1st and 2nd studies is
presented in Figure 1, detailing the procedures adopted to
determine the workload increments using the nonexercise
models (1st study—ﬁnal speed) and diﬀerent percent VO2 max
intensities (2nd study—initial speed).
All 117 subjects enrolled in the ﬁrst study. After
signing the informed consent, the subjects performed the
following procedures in a single visit to the laboratory:
(a) anthropometric measurements; (b) application of three
nonexercise models to estimate VO2 max (Veterans Speciﬁc
Activity Questionnaire (VSAQ), [19, 20]; Rating of Perceived
Capacity (RPC) [21]; Questionnaire of Cardio-respiratory
Fitness (CRF) [22]); (c) cardiopulmonary exercise testing.
The VSAQ was originally developed by Myers et al.
[19, 20] with the speciﬁc purpose of individualizing ramp
protocols. The VSAQ includes a list of physical activities
with scores ranging from 1 to 13. The responder indicates
which of the listed activities would cause fatigue or shortness
of breath. Subjects evaluated in the initial studies with
the VSAQ had low cardiorespiratory ﬁtness and a high
prevalence of overweight/obesity, hypertension, or coronary
disease. Even though further studies have demonstrated
that the instrument also provided adequate estimation of
VO2 max in healthy active populations [5, 8], there is a lack of
research speciﬁcally designed to assess its validity within the
application of ramp protocols in healthy subjects. The RPC
may be considered a variation of the VSAQ [21], presenting
diﬀerent maximal MET levels (ranging from 1 to 20), which
are linked to physical activities of several intensities. Subjects
rate their perceived capacity by choosing the most strenuous
activity they could sustain for 30 min. However, the RPC has
been not validated through direct comparison with exercise
capacity using cardiopulmonary exercise testing. The CRF
was not speciﬁcally developed to design ramp protocols,
but it has been extensively applied as a nonexercise model
to estimate the maximal cardiorespiratory capacity [22]. It
is a progressive scale with scores for the intensity of the
activities ranging from 0 to 7. The subjects must select the
most appropriate score according to the physical activities
performed in the last 30 days. The CRF was selected because
of the unusual methodological meticulousness applied to
its development. A large sample (N = 799) of men and
women aged 19 to 79 years was tested. The estimated
VO2 max was compared to directly measured data, and the
questionnaire was cross-validated with another population,
which is uncommon in studies assessing such instruments
[23, 24].
In the ﬁrst study, the increase in work rate within the
cardiopulmonary exercise test (CPET1) was individualized
to elicit each subject’s limit of tolerance in 10 min, and
treadmill grade was set at 0%. Final and initial speeds were
determined using ACSM equations for treadmill running
[7], considering the intensities corresponding to the highest
VO2 max estimated by the non-exercise models (ﬁnal speed)
and 50% of this value (initial speed). The choice of 50%
of the estimated VO2 max to determine the initial speed was
based on a previous pilot study involving 35 subjects. In
this pilot study, the initial speed was set at 1/3 of the
estimated VO2 max, which corresponded to a mean speed of
4.3 km·h−1 and a work rate increase of 0.88 km·h−1 each
minute. The protocols lasted approximately 12 min (11.3 ±
2.2 min) and subjects remained walking, for about 4 min.
Thus, an intensity of 50% VO2 max would probably shorten
the test and increase the time in which the subjects would be
actually running.
A subgroup of 37 subjects (17 women; age: 29.1±7.6 yrs)
was randomly selected to participate in the second study.
These subjects performed three additional cardiopulmonary
exercise tests, separated by 72 to 120 h intervals. The increase
in work rate and treadmill grade were the same applied in
CPET1. In the ﬁrst test (CPET1bis), the ﬁnal speed was
determined using the best non-exercise model as deﬁned
in the ﬁrst study, and the initial speed set at 50% of this
value. The other tests (CPET2 and CPET3) were then per-
formed using the results of CPET1bis as reference. In brief,
Pulmonary Medicine
3
CPET1 
CPET1bis
CPET2
CPET3
• Final speed calculated from the
the three questionnaires
(VSAQ, RPC ,and CRF).
• Initial speed calculated from
50% of the estimated value.
• Final speed calculated from
CRF.
• Initial speed calculated from
50% of the estimated value.
• Final speed calculated from
CPET1bis.
• Initial speed calculated from
50% of the measured value.
• Final speed calculated from
the
CPET1bis.
• Initial speed calculated from
60% of the measured value.
1st  study
2nd study
• Anthropometric measurements.
•
is reported as mL·kg−1·min−1
• Speed in m·min−1 (converted to km·h−1)
• G = grade expressed in decimal form
(ii) Speedinitial = speedﬁnal × percentage
(iii) Increment ratio = (speedﬁnal − speedinitial)/10 minutes
Stages for determining the ﬁnal and initial test speeds
(i) Speedﬁnal = (
− 3.5) × 100%/(0.2 + 0.9 × G)
(N = 117)
(N = 37)
highest 
estimated by
the
estimated by
the
measured during
VO2 max
VO2 max
VO2 max
VO2 max measured during
VO2 max
VO2
Figure 1: Flowchart of the 1st and 2nd studies including the procedures adopted to determine the workload increments, using nonexercise
models to estimate VO2 max and ACSM running equation to calculate the treadmill speeds. VO2 max: maximal oxygen uptake; CPET:
cardiopulmonary exercise test; VSAQ: Veterans Speciﬁc Activity Questionnaire; RPC: Rating of Perceived Capacity; CRF: Questionnaire
of Cardiorespiratory Fitness.
the ﬁnal speed in CPET1bis was estimated from the maximal
exercise capacity provided by CRF, whereas in both CPET2
and CPET3 it corresponded to the speed associated with
the VO2 max assessed in CPET1bis. The initial speeds corre-
sponded to 50% VO2 max estimated (CPET1bis), 50% VO2 max
measured (CPET2), and 60% VO2 max measured (CPET3).
This approach allowed to observe whether initial speeds
ranging from 50 to 60% VO2 max (estimated or measured)
inﬂuenced the results of the tests.
In the ﬁrst study the CPET1 was applied by a researcher
blinded for the results of the non-exercise models. In
the second study, the sequence of tests was deﬁned by
a counterbalanced crossover design. The participants were
blinded for the %VO2 used to establish the initial speeds,
and the evaluator was blinded for the purposes of the
study.
The cardiopulmonary exercise test protocols were per-
formed using a super-ATL treadmill (Inbramed, Florianop-
olis, SC, Brazil), and VO2 was averaged and recorded every
30 s. The 30 s time average provided a good compromise
between removing noise from VO2 data while maintain-
ing the underlying trend [25]. Data was assessed using
a mouthpiece and noseclip. Gas exchange was assessed
using a VO2000 analyzer (Medical Graphics, Saint Louis,
MO, USA), which was calibrated with a certiﬁed standard
mixture of oxygen (17.01%) and carbon dioxide (5.00%),
balanced with nitrogen. The ﬂows and volumes for the
pneumotachograph were calibrated with a 3 L syringe (Hans
Rudolph, Kansas, MO, USA). Heart rate was monitored
using a Polar S-810 device (Polar, Kempele, Finland). Mean
ambient temperature and relative humidity during testing
were 22.4 ± 1.8◦C (range 18–23) and 62.5 ± 4.1% (range 50–
75%), respectively.
The criteria for test interruption followed the recom-
mendations of the American College of Sports Medicine [7].
The test was considered to achieve peak capacity when at
least three of the following criteria were observed [26]: (a)
maximum voluntary exhaustion as reﬂected by a score of
10 on the Borg CR-10 scale; (b) ≥95% predicted HR max
(220—age) or presence of an HR plateau (ΔHR between
two consecutive work rates ≤4 beats·min−1); (c) presence
of a VO2 plateau (ΔVO2 between two consecutive work rates
<2.1 mL·kg−1·min−1); (d) respiratory exchange ratio > 1.15.
Participants were verbally encouraged to achieve maximal
eﬀort. Holding onto the side or front rails of the treadmill
was not permitted.
2.3. Statistical Analyses. Data normality was conﬁrmed by
univariate analysis. Therefore the intraclass correlation coef-
ﬁcient (ICC) was used to verify the concordance between
the VO2 max assessed in CPET1 and the VO2 max estimated by
the non-exercise models. Limits of agreement and bias for
measured and estimated VO2 max were determined according
to the Bland and Altman method [27]. Intraclass correlation
(ICC), R-square coeﬃcients (r2), and standard errors of
estimate (SEE) between actual and estimated VO2 max were
also calculated.
The VO2 max values obtained in CPET1bis, CPET2, and
CPET3 were compared by repeated measures ANOVA.
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Additionally, linear regression was performed for each sub-
ject on each protocol in order to compare the relationships
between workload and VO2, considering data in every 30 s
of exercise. Mean ± SD values of intercepts and slopes
were determined for each linear regression model. Student
t-tests for paired samples were used to test whether the
intercepts and slopes were signiﬁcantly diﬀerent from 0 and
1, respectively [12], and to test possible diﬀerences between
the regression lines, as described in detail elsewhere [28].
The r2 and SEE for the regression models obtained in all
tests were calculated as supplementary criteria to deﬁne the
best initial speed. Two-tailed statistical signiﬁcance for all
tests was accepted as P ≤ 0.05. All statistical analyses were
performed using Statistica 7.0 (Statsoft, Tulsa, OK, USA)
and SPSS 8.0 (IBM, Chicago, IL, USA) statistical analysis
software.
3. Results
An achieved statistical power of 0.96 for an eﬀect size of
0.25 was obtained by performing a post hoc power analysis
(GPower version 3.0.10, Kiel, University of Kiel, Germany)
based on the sample size, P value, number of repeated
measures, and groups. Table 1 presents the characteristics
of the samples comparing strategies to deﬁne ﬁnal and
initial speeds. Table 2 presents values for the assessed VO2 max
(mL·kg−1·min−1) by age and sex groups.
In the ﬁrst study, mean duration of CPET1 was 13.3 ±
2.1 min for initial and ﬁnal speeds of 5.9 ± 0.9 km·h−1
and 14.7 ± 2.1 km·h−1, respectively. Signiﬁcant diﬀerences
were detected between VO2 max assessed in CPET1 (41.5 ±
6.6 mL·kg−1·min−1) and VO2 max estimated from VSAQ and
CRF (VO2 max VSAQ = 36.6±6.6 mL·kg−1·min−1, P < 0.0001;
VO2 max CRF = 45.0 ± 5.3 mL·kg−1·min−1; P < 0.0001), but
not from RPC (VO2 max RPC = 41.3 ± 6.2 mL·kg−1·min−1,
P = 0.99).
Figure 2 shows the Bland-Altman analysis, including the
limits of agreement for estimated and measured VO2 max.
Table 3 presents values for R-square, SEE, and ICC between
VO2 max measured and estimated by the questionnaires.
The RPC provided the lowest mean diﬀerence between
VO2 max directly assessed in CPET1 and estimated from
the questionnaires (RPC = 0.24 mL·kg−1·min−1; CRF =
−3.54 mL·kg−1·min−1; VSAQ
=
4.94 mL·kg−1·min−1;
P
=
0.05). However, the CRF exhibited better limits
of agreement compared to the other instruments. The
higher values obtained for CRF with regard to R-square
and ICC were consistent with the results of the Bland-
Altman analysis. The SEE between assessed and estimated
VO2 max was also lower in CRF compared to VSAQ and
RPC.
Table 4 shows the distribution of VO2 max assessed in
CPET1 according to tertiles, as well the percent agreement
between estimated and measured VO2 max in each tertile. The
nonparametric Kendall’s tau-b correlation between tertiles
was similar across the three questionnaires and measured
VO2 max. However the correlation using the CRF was higher
over RPC and VSAQ—the proportion of subjects assigned
in the same tertile category was superior for CRF compared
to the other questionnaires, and the distribution was more
homogeneous.
With regard to the second study, mean durations of
CPET1bis, CPET2, and CPET3 were 13.7 ± 1.8 min, 10.7 ±
1.9 min, and 10.6 ± 0.9 min, respectively. No diﬀerences
were detected between VO2 max assessed in CPET1bis (used
as reference to deﬁne ﬁnal and initial speeds in CPET2
and CPET3), CPET2, and CPET3 (CPET1bis = 40.7 ±
5.9 mL·kg−1·min−1; CPET2 = 39.8 ± 5.6 mL·kg−1·min−1;
CPET3 = 40.3 ± 5.5 mL·kg−1·min−1; P = 0.142). Mean
initial speeds applied in CPET1bis, CPET2, and CPET3 were
5.7 ± 0.8 km·h−1, 8.1 ± 0.9 km·h−1, and 9.1 ± 1.1 km·h−1,
respectively. Table 5 shows the relationships between work-
load and VO2 in the ramp test protocols initiating with speeds
corresponding to 50% and 60% VO2 max either measured or
estimated (slopes, intercepts, R-square, and SEE). CPET1bis
showed the closest relationship with the theoretical identity
line (slope = 1 and intercept = 0), with the highest R-square
and lowest SEE in comparison with CPET2 and CPET3.
4. Discussion
The present study aimed to compare diﬀerent strategies to
deﬁne ﬁnal and initial speeds when designing ramp exercise
testing protocols for healthy young populations. Three
nonexercise models were employed to estimate maximal
cardiorespiratory capacity and therefore the ﬁnal speed. The
choice of VSAQ, RPC, and CRF to estimate the VO2 max was
due to the fact that these instruments have been frequently
applied in previous studies and have been shown to have
good potential to estimate the maximal cardiorespiratory
capacity in diﬀerent populations [23, 24]. Two relative
intensities (%VO2 max) using diﬀerent initial treadmill speeds
were tested.
The values obtained for the VO2 max assessed in CPET1
are consistent with reference values reported by previous
research [4, 7, 14, 16]. Our ﬁndings on the ICC, R-square,
SEE, and dispersion in the Bland-Altman plot (see Figure 2)
suggest that there are advantages in using the CRF to
determine the ﬁnal speed, in comparison with the other
instruments. In contrast, the VSAQ had the poorest precision
and highest variability with respect to VO2 max estimation. In
their original study, Myers et al. [19] reported a stronger
association between estimated and achieved cardiorespira-
tory capacity over the present data (r
=
0.79; SEE =
4.97 mL·kg−1·min−1; P = 0.001 versus r = 0.40; SEE =
7.63 mL·kg−1·min−1; P = 0.0001, resp.). However, subjects
in the two studies diﬀered considerably in terms of clinical
and ﬁtness status, which may have contributed to such
discrepancy, since poor conditioned individuals are more
likely to interrupt earlier the test due to peripheral fatigue.
Moreover, Myers et al. [19] did not directly assess the VO2 max
in their original research. In a later study, these investigators
[20] validated the VSAQ measuring VO2 max directly in a
larger sample (n = 337). Subjects had similar characteristics
as those in the original study, but the results were more
Pulmonary Medicine
5
Table 1: Characteristics of the subjects participating in the comparisons regarding the ﬁnal (N = 117) and initial (N = 37) speeds.
Age (years)
Body mass (kg)
Height (cm)
Body fat (%)
VO2 max (mL·kg−1·min−1)
G
M
F
G2
G
M
F
G2
G
M
F
G2
G
M
F
G2
G
M
F
G2
Mean
29.1
29.8
28.2
29.7
71.7
79.7
59.7
72.4
171.2
176.7
163.1
170.4
15.2
11.7
20.4
16.8
41.5
43.9
37.8
40.7
SD
7.6
7.9
7.0
8.6
14.9
12.6
8.8
17.9
9.1
5.9
6.5
10.0
7.0
5.8
5.3
6.5
6.6
5.8
6.1
5.9
Minimum
18
18
19
18
46.7
57.4
46.7
46.5
150.0
163.3
150.0
150.5
2.9
2.9
11.2
6.0
25.6
32.8
25.6
28.5
Maximum
51
47
51
51
92.9
92.9
91.8
90.3
190.0
190.0
176.0
190.0
32.8
27.1
32.8
28.3
61.6
61.6
54.8
52.4
G: total sample (n = 117); M: males (n = 70); F: females (n = 47); G2: subgroup for initial speed comparison (n = 37).
6
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Table 2: Descriptive values for VO2 max (mL·kg−1·min−1) by age and sex groups.
Age (years)
Males (N = 70)
Females (N = 47)
18–29 (N = 39)
30–39 (N = 20)
>40 (N = 11)
18–29 (N = 32)
30–39 (N = 10)
>40 (N = 5)
Mean
46.2
41.1
39.4
39.0
34.3
37.0
SD
5.8
4.4
3.9
5.9
6.3
4.6
Minimum
36.5
32.8
34.0
26.2
25.6
29.5
Maximum
61.5
47.9
44.2
54.8
45.3
40.4
Table 3: Mean diﬀerence (mL·kg−1·min−1), R-square coeﬃcient, standard error of estimate, and intraclass correlation between VO2 max
assessed and estimated by three non-exercise models (N = 117).
Total (N = 117)
Males (N = 70)
Females (N = 47)
VO2 max
VO2 max
VO2 max
Mean diﬀerence
r2
SEE ICC
P
Mean diﬀerence
r2
SEE ICC
P
Mean diﬀerence
r2
SEE ICC
P
VSAQ 4.94 (11.9%)
0.16 7.63 0.57 <0.0001
−1.81 (−4.1%) 0.05 7.92 0.36 <0.0317
−1.24 (−3.3%) 0.07 7.17 0.42
<0.040
RPC
0.24 (1.0%)
0.09 7.60 0.46
<0.001
3.22 (7.3%)
0.17 1.70 0.58 <0.0001
−3.49 (−9.2%) 0.07 8.35 0.42
<0.035
CRF
−3.54 (−8.5%) 0.53 5.75 0.83 <0.0001
−3.89 (−8.9%) 0.37 6.01 0.76 <0.0001
−2.90 (−7.7%) 0.47 5.36 0.81 <0.0001
VSAQ: Veteran Speciﬁc Activity Questionnaire using the following equation: VO2 (mL·kg−1·min−1) = (4.7 + 0.97 (VSAQ) − 0.06 (age) × 3.5); for women
this value was multiplied by 0.85 [8]; RPC: Rating of Perceived Capacity; CRF: Cardiorespiratory Fitness.
similar to our ﬁndings (r = 0.42; SEE = 9.1 mL·kg−1·min−1;
P = 0.001).
Maeder et al. [5] compared the VO2 max obtained in
tests using cycle ergometer and treadmill with the exercise
capacity estimated by the VSAQ in healthy subjects. The cor-
relations were similar to our data (cycle ergometer: r = 0.46
and treadmill: r = 0.50; P < 0.0001). More recently, Maeder
et al. [8] used the VSAQ to select the optimal treadmill
ramp protocol in highly trained individuals and reported a
similar correlation between estimated and measured VO2 max
(r = 0.47), even when using the VSAQ modiﬁed nomogram
(r = 0.56).
Although the VSAQ was developed to facilitate the
individualization of ramp protocols, previous research has
not ratiﬁed this purpose in all populations. Actually, the
available evidence does not support its use in determining
the ﬁnal speed within ramp protocols in healthy and well-
conditioned populations. Actually the VSAQ has been shown
to be more appropriate to estimate the VO2 max in unﬁt
individuals [20, 29]. The present results conﬁrm this idea.
Precision using the VSAQ was lower compared to the other
instruments, and the same categorization was obtained in
less than 40% of cases. Furthermore, the Bland-Altman plots
suggested that in our sample the VO2 max was systematically
overestimated by the VSAQ.
The RPC closely paralleled VO2 max assessed in CPET1
(mean diﬀerence of 0.24 mL·kg−1·min−1 or 1%), but exhib-
ited high variability, as evidenced by the Bland-Altman
method and SEE (7.60 mL·kg−1·min−1). This variation
accounted for the relatively low ICC and R-square values. It is
noteworthy that RPC was developed in a sample of 87 young,
healthy women (age = 48.4 ± 17.4 years) [21]. However, our
experience with this method suggests that strong agreement
between estimated and actual VO2 max can be also obtained in
men. Interestingly, although our sample consisted of young
women (age = 28.2 ± 7.0 years), the comparison between
VO2 max directly measured and estimated by RPC showed
greater concordance (ICC) and lower variation (SEE) among
men versus women (ICC = 0.58 versus 0.42 and SEE =
1.70 mL·kg−1·min−1 versus 8.35 mL·kg−1·min−1, resp.). A
possible explanation for this is that in the original RPC
study the VO2 max was estimated from the work performed on
cycle ergometer, and not directly measured. The VO2 max was
estimated using maximal work and body mass, assuming as
constants the amount of oxygen required for each Watt of
power during ramp cycling (10.93 mL·min−1·W−1) and VO2
at rest when sitting on the cycle (4.3 mL·min−1). However
these unpublished data have been previously determined in a
group of healthy men [21], and no information was provided
with regard to their possible application in females.
The CRF has been widely used to estimate maximal
cardiorespiratory capacity [12, 30–35]. Although it was not
originally developed to help designing ramp protocols, our
results indicate that it works well for this purpose. The
original study by Matthews et al. [22] showed a higher
correlation between VO2 max measured and estimated from
CRF than the present study, in a sample of 390 men (r =
0.82 versus r = 0.61, resp.) and 409 women (r = 0.83
versus r
= 0.69, resp.). However, the SEEs in the total
sample (5.7 mL·kg−1·min−1
versus 5.8 mL·kg−1·min−1)
and in gender subgroups (men: 6.3 mL·kg−1·min−1 ver-
sus 6.0 mL·kg−1·min−1; women: 5.0 mL·kg−1·min−1 ver-
sus 5.4 mL·kg−1·min−1) were similar in the two studies.
The Bland-Altman analysis showed limits of agreement
higher over VSAQ and comparable to RPC, but the CRF
had the greatest ICC. In addition, the tertile classiﬁcations
obtained from CRF were more accurate compared to the
other nonexercise models.
Overall, CRF showed higher concordance with measured
VO2 max, lower dispersion, and better capacity to discriminate
Pulmonary Medicine
7
20
30
40
50
60
70
−35
−30
−25
−20
−15
−10
−5
0
5
10
15
20
25
30
35
−12.1
22
Bias
4.9
diﬀerence (mL·kg−1·min−1)
Mean
(mL·kg−1·min−1)
Sd
Sd
VO2
VO2
(a)
−14.7
15.2
Bias
0.2
20
30
40
50
60
70
−35
−30
−25
−20
−15
−10
−5
0
5
10
15
20
25
30
35
diﬀerence (mL·kg−1·min−1)
(mL·kg−1·min−1)
Sd
Sd
MeanVO2
VO2
(b)
−12.5
5.4
Bias
20
30
40
50
60
70
−35
−30
−25
−20
−15
−10
−5
0
5
10
15
20
25
30
35
diﬀerence (mL·kg−1·min−1)
Mean
(mL·kg−1·min−1)
Sd
Sd
−3.5
VO2
VO2
(c)
Figure 2: Bland-Altman plot for the individual diﬀerences between VO2 max assessed in CPET1 and VO2 max estimated by VSAQ (a), RPC (b),
and CRF (c). The ﬁrst and third horizontal dashed lines in each graph represent the 95% limits of agreement for VSAQ, RPC, CRF, and
VSAQ, corresponding, respectively, to −12.1 to 22.0 (−29.1 to 53.0%); −14.7 to 15.2 (−35.5 to 36.6%); −12.5 to 5.4 (−30,0% to 13,0%). Sd:
standard deviation of the diﬀerences.
Table 4: Percentage of participants ranked in the same tertile, percentage of total agreement, tau-b correlation coeﬃcients between VO2 max
measured and estimated by three non-exercise models (VSAQ, RPC, and CRF) (N = 117).
1st Tertile (n = 39)
2nd Tertile (n = 39)
3rd Tertile (n = 39)
Total (N = 117)
R (tau-b)
VO2 max versus VSAQ
66.66% (26)
5.12% (2)
38.46% (15)
36.75% (43)
0.833
VO2 max versus RPC
43.58% (17)
25.64% (10)
43.58% (17)
37.60% (44)
0.992
VO2 max versus CRF
69.23% (27)
41.02% (16)
58.97% (23)
56.41% (66)
0.983
VSAQ: Veteran Speciﬁc Activity Questionnaire; RPC: Rating of Perceived Capacity; CRF: Questionnaire of Cardiorespiratory Fitness.
subjects with high and low cardio-respiratory capacity in
comparison to VSAQ and RPC. Notably, the CRF may be
limited when assessing cardiorespiratory capacity in subjects
with VO2 max > 55.0 mL·kg−1·min−1 [29], which could be
a problem when designing ramp protocols in highly ﬁt
individuals. However, fewer than 20% of ordinary healthy
individuals achieve this level [7]. It therefore seems unlikely
that the ﬁnal speed would be wrongly determined from
inaccurate estimation of VO2 max estimation, at least in most
healthy nonathletic subjects.
In what concerns the second study, the literature is
mixed regarding criteria to determine the initial speed
for ramp testing [9, 11]. Recommendations from diﬀerent
expert panels are also ambiguous with regard to this issue
8
Pulmonary Medicine
Table 5: Intercept, slope, R-square (r2), and standard error of estimate (SEE) for the regression models obtained in ramp protocols initiating
with speeds corresponding to 50% of the estimated VO2 max (CPET1bis), 50% of the measured VO2 max (CPET2), and 60% of the measure
VO2 max (CPET3).
Y intercept
Slope
r-Square
SEE (mL·kg−1·min−1)
VO2versus speed in CPET1bis
−4.882 ± 2.696∗
0.96 ± 0.027§
0.93 ± 0.050
2.14 ± 0.67
VO2versus speed in CPET2
−8.270 ± 6.312∗
0.94 ± 0.029§
0.89 ± 0.054
2.19 ± 0.55
VO2versus speed in CPET3
−14.666 ± 8.958∗
0.92 ± 0.036§
0.86 ± 0.065
2.48 ± 0.67
∗Intercept signiﬁcantly diﬀerent from zero (P < 0.0001).
§Slope signiﬁcantly diﬀerent from 1.0 (P < 0.0001).
[4, 7, 14, 15], and no formal criteria are available on this
important aspect of ramp protocols. Our ﬁndings suggested
that initial speeds within the range corresponding to 50% to
60% VO2 max inﬂuenced the duration of the test (CPET1bis
= 13.7 ± 1.8 min > CPET2 = 10.7 ± 0.9 min ∼= CPET3 =
10.6 ± 0.9 min, P < 0.0001), but not the achieved VO2 max
(CPET1bis = 40.7 ± 5.9 mL·kg−1·min−1 ∼= CPET2 = 40.0 ±
5.6 mL·kg−1·min−1 ∼= CPET3 = 40.3 ± 5.5 mL·kg−1·min−1,
P
= 0.14). From these results, any initial speed within
this range would be appropriate for performing ramp tests.
In contrast, the relationship between workload and VO2
among the tests was aﬀected by the initial speed. Considering
the identity line as a reference for the ideal regression
between workload and VO2, the current results suggest
that higher initial speed produced the lowest R-squares
(e.g., poorest adjustment to the identity line) (CPET3—
60% VO2 max < CPET2—50% VO2 max < CPET1bis—50%
VO2 max).
Early research conﬁrms the concept that the initial
speed applied does not inﬂuence measured VO2 max. Kang
et al. compared three incremental treadmill protocols
( ˚Astrand, Bruce, and Costill/Fox) in 25 sedentary sub-
jects (10 women) [36]. The protocols began with speeds
of 9.7 km·h−1, 2.5 km·h−1, and 14.4 km·h−1, respectively,
and no diﬀerences in VO2 max were detected. The rela-
tionship between workload and VO2 was not speciﬁcally
addressed, but the authors considered that this could have
been good, at least in the Costill/Fox protocol. The high
initial speed signiﬁcantly shortened the tests (to about
5 min) and precluded the identiﬁcation of the ventilatory
threshold.
In 1991, Myers et al. compared VO2 max obtained during
ramp and conventional staged protocols (Bruce and Balke
modiﬁed), which were very diﬀerent with regard to the
combination of initial speed, treadmill grade, and workload
increment. The duration of tests was signiﬁcantly diﬀerent
(Bruce: 6.6 ±1.5 min versus Balke: 10.4 ±3.4 min and Ramp:
9.1 ± 1.4 min, P < 0.05), with little impact on VO2 max
(Bruce: 22.3 ± 8.0 mL·kg−1·min−1 versus Balke: 21.1 ±
8.0 mL·kg−1·min−1 and Ramp: 21.0 ± 8.0 mL·kg−1·min−1,
P
<
0.05). However, slopes and SEE for the regres-
sion curves between workload and VO2 showed more
linear relationships in the ramp protocol (Bruce: slope =
0.62 and SEE = 4.0 mL·kg−1·min−1; Balke: Slope = 0.79
and SEE = 3.4 mL·kg−1·min−1; Ramp: Slope = 0.80 and
SEE = 2.5 mL·kg−1·min−1). In other words, diﬀerences
in the protocol design may reﬂect on physiological rela-
tionships in submaximal workloads, but not necessarily
on the assessed VO2 max. Our ﬁndings seem to ratify this
idea.
In conclusion, CRF was superior in comparison with
RPC and VSAQ to estimate maximal cardio-respiratory
capacity and should be preferred when attempting to deter-
mine an appropriate speed for ramp testing. Initial speeds
within the range corresponding to 50–60% VO2 max estimated
or measured did not aﬀect assessed VO2 max. Nevertheless,
speeds higher than 50% VO2 max may inﬂuence the quality
of submaximal relationships between work rate and VO2.
Moreover, higher speeds applied at the beginning of ramp
protocols may hinder the performance of subjects with poor
ﬁtness levels and compromise test results. This information
should be considered when data from exercise testing is
used to establish relative exercise intensities for exercise
prescription.
Acknowledgments
This paper was supported by grants from FAPERJ (Carlos
Chagas Foundation for the Research Support in the State of
Rio de Janeiro, Rio de Janeiro, Brazil) and CNPq (Brazilian
Council for the Technological and Scientiﬁcal Development,
Bras´ılia, Brazil).
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Determination of Best Criteria to Determine Final and Initial Speeds within Ramp Exercise Testing Protocols.
da Silva, Sidney C,Monteiro, Walace D,Cunha, Felipe A,Myers, Jonathan,Farinatti, Paulo T V