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Fitness Assessment Protocols

Resting Measures

Height – Participant should stand with back against the wall and look straight ahead. Head, shoulders, rear end and heels should touch the wall. Gently press a ruler or any flat stick down on the top of the head; then mark the spot where the ruler touches the wall with a pencil. The participant then steps away from the wall and tape measure is used to record the distance from the floor to the mark, without rounding up fractions of centimeters or inches. Weight – Have participant remove any bulky clothing and shoes prior to weighing. Ensure scale is properly calibrated. Resting Heart Rate – Radial Pulse (wrist) - place index and middle fingers together on the wrist, about 1/2 inch to the inside of the joint, in line with the index finger. Carotid Pulse (neck) - place your first two fingers on either side of the neck just below the point of the jawbone. Be careful not to press to hard or results may be skewed. Count for 15 seconds and multiply by 4; 30 seconds and multiply by 2; or for a full 60 seconds. Record number of beats per minute. **A true resting heart rate is obtained in the morning prior to rising from bed. ***If using an automated heart rate monitor, heart rate is often calculated as well. Target Heart Rate – For Men: 220-age = est. max hr For Women: 226-age = est. max hr 75% of max hr is recommended upper limit for cancer survivors, in the absence of contraindications. Blood Pressure – o Participant should be seated quietly for at least 5 minutes in a chair with back support, feet on the floor and arm supported at heart level. o Wrap cuff around upper arm at heart level; align cuff with brachial artery. o Place stethoscope bell below the antecubital space over the brachial artery. o Quickly inflate cuff pressure to 20mm Hg above where you hear the first Korotkoff sound. o Slowly release pressure at a rate equal to 2 to 5 mm HG per second. o Systolic BP is the point at which the first two or more Korotkoff sounds is heard, and diastolic BP is the point before the disappearance of Korotkoff sounds. **If using automated blood pressure cuff follow instructions provided with the unit. Get Back To Being You! Circumference Measures  Measurements to be taken with flexible, but inelastic tape measure  Tape placed on skin surface without compressing subcutaneous adipose tissue  Administrator positioned to the right side of the individual being measured  Two measures taken in rotation with re-measure for any sites that are not within 5mm

Shoulders – With participant standing upright and relaxed, apply tape just below acromion process at maximum bulge of deltoid muscle. Chest – With participant standing upright and relaxed, apply tape at the midpoint of the sternum – around upper lats and below the arm pit. Once tape is in place arms should be relaxed by the side and measurement at the end of a normal expiration. Waist – With participant standing, arms at sides, feet together, and abdomen relaxed, a horizontal measure is taken at the narrowest part of the torso - above the umbilicus and below the xiphoid process. Abdomen – With participant standing upright and relaxed, a horizontal measure is taken at the greatest anterior extension of the abdomen, usually at the level of the umbilicus. Buttocks/Hips – With participant standing erect and feet together a horizontal measure is taken at the maximal circumference of the buttocks, above the gluteal fold. *This site is used for the hip measure in a waist/hip measure. Thigh/Hips – With the participant standing and legs separated, a horizontal measure is taken at the maximal circumference of the hip/proximal thigh for the right side, repeat on the left side. Note the distance in inches from the top of the knee cap (in inches) on your sheet so that anyone who follows your work can replicate the location and a true measure can be ascertained. Calf – With participant standing erect (feet apart ~20cm) a horizontal measure is taken at the level of the maximum circumference between the knee and the ankle, perpendicular to the long axis. Note the distance in inches from the bottom of the knee cap (in inches) on your sheet so that anyone who follows your work can replicate the location and a true measure can be ascertained. Biceps – With the participant standing erect and arms hanging freely at the sides, hands facing the thigh, a horizontal measure is taken midway between the acromion and olecranon processes. Note the distance in inches from the elbow (in inches) on your sheet so that anyone who follows your work can replicate the location and a true measure can be ascertained. Forearm – With the participant standing, arms hanging downward but slightly away from the trunk and palms facing anteriorly, measure perpendicular to the long axis at the maximal circumference. Note the distance in inches from the elbow (in inches) on your sheet so that anyone who follows your work can replicate the location and a true measure can be ascertained. Get Back To Being You! Body Composition – **Taken with a BIA unit, follow instructions provided with the unit.

Balance & Agility

Balance Test – Perform the tests in the order given since they are arranged by degree of difficulty. Practice once or twice before testing is fine. If unable to pass a test, stop at that level.

Preliminary Test: Stand in front of a support with feet side by side and touching. If you can remain in this position for 10 seconds without using hands for support, proceed with the test. If unable to do this, balance is extremely poor and do not attempt the other tests.

Test 1: Tandem Stand (Romberg test). Stand between 2 chairs, lightly holding on for balance. Position one foot directly in front of the other; the heel of the front foot should be touching the toes of the foot in back. Distribute body weight evenly on both feet. Steady yourself and let go of support. Hold this position for 10 seconds without the aid of hands. Feet should not leave the floor.

Test 2: Single leg stance. Stand between 2 chairs with feet together, lightly holding on for support. Shift weight to one foot. Bend the other knee to bring that foot up in back. When balanced on one leg, let go of the support with one hand, then the other. Start timing when both hands are released. 30 seconds indicates good balance, <20 seconds indicates increased risk for falls, client must hold 10 seconds to pass and go to next level.

Test 3: Tandem stand with eyes closed. Same as Test 1 but with eyes closed. Close eyes before letting go of support; steady yourself and let go. Hold for 10 seconds.

Test 4: Tandem stand with eyes closed and head turning. This adds an additional challenge to test 3. After closing eyes, steadying yourself and letting go of support, slowly turn head to the right, to the left and back to the center. (~10 seconds).

Test 5: Single leg stance with eyes closed. This is the same as test 2, except with eyes closed. Before releasing hands, close eyes. Hold for 10 seconds.

Highest Test Passed Balance Level

Test 5: One legged stand with eyes closed Excellent

Test 4: Tandem stand with eyes closed and head turning Very Good

Test 3: Tandem stand with eyes closed Good

Test 2: One legged stand Fair

Test 1: Tandem stand Poor

Unable to pass any tests Very Poor Get Back To Being You!

Irrespective of results, balance can be improved significantly with strength training and balance exercises, regardless of age.

1Miriam Nelson, Ph.D., School of Nutrition Science and Policy, Tufts University; 2000, Strong Women, Strong Bones, p 83-87 http://www.spokaneosteoporosis.com/balance_test.html

8 ft. Up & Go – Place straight back chair against wall, and cone 8’ in front of chair. Ensure path is clear. Participant begins sitting on chair, hands resting on knees, feet flat on the ground. Upon the word “Go”, timing starts, participant stands and walks as quickly as possible out/around the cone and back to a seated position in the chair. Timing stops when participant is reseated. Perform two trials. Take the best time of the two trials to the nearest 1/10 th second.

Cardiovascular Fitness (NOTE: 2 minute step test is the standard test to use, an alternate test for a more fit client would be the treadmill test)

2 Minute Step Test – Mark a point on the participant's thigh, half way between the participant's patella (knee) and iliac crest (top of the hip). Measure from this point to the ground with the tape measure or ruler. Place a mark on the wall with masking tape or a board with a white board marker at the height from the ground to the participant's mid-thigh position. On the instruction to start, participant will march in place lifting knees to the indicated mark on the wall. Continue stepping as fast as possible for 2 minutes.** Count the number of times the right knee is raised to the level of the mark on the wall or board. If either knee is not raised to the correct level, do not count the step. Encourage the participant to continue to raise both knees to the correct level. Record the total number of times the right knee reaches the tape level in two minutes. Note: Take two (2) Heart Rate readings for this test. The first should be recoreded at the end of the test, the second should be recorded one minute after the conclusion of the test. Also if possible, do not allow the subject to sit down right away have them walk around a bit to allow the heart time to recover.

** If the participant cannot do any steps without holding onto a walker or a chair placed to their side then the participant is not following the test protocol. The participant may still complete the test but if they complete the test holding onto a chair or assistive device their score will be saved as “Did Not Follow Protocol.” Only “Per Protocol” scores that are completed by the participant without holding onto any assistive devices are recorded in the overall group outcomes reports. Both “Per Protocol” scores and “Did Not Follow Protocol” scores are saved in the individual’s fitness assessment file.

Modified Bruce Protocol – Have the individual paw at the treadmill with their foot to begin a two minute warm up followed by Stage 1 which starts at 0% at 1.7 mph walking pace. Stage 2 the grade increases to a 5% grade but the speed stays the same. In stage 3 the percent grade is increased to 10% but the speed stays the same for one more stage. Stage 4 the percent grade and speed are increased simultaneously to 2.5mph at a 12% grade. Stage 5 has a similar increase in grade and speed to 3.4 mph at a 14% grade. Stage 6 is again an increase in speed and grade to 4.2 Get Back To Being You! mph at a 16% grade. Stage 7 the treadmill is set to 5.0 mph at 18% grade. Stage 8 the treadmill is set at 5.5 mph at a20% grade. Finally at stage 9 the treadmill is set at 6.0 mph at a 22% grade. IMPORTANT: Heart rate must be taken every minute. Once the participant has completed two consecutive stages with heart rate readings between 110-150 bpm, or when 75% of Heart rate max is reached, the test is complete and patron finishes with the cool down. ** Adhere to ACSM General Indications for stopping an exercise test (ACSM’s Guidelines for Exercise Testing and Prescription, 9th Ed, Wolter Kluwer Health: Lippincott Williams & Wilkins, 2014)

Muscular Strength

Chair Stand – Place straight back chair against wall for safety. Direct participant to sit on the middle of the seat, with feet shoulder width apart, and flat on the floor. Cross arms at wrist and rest them on the chest. From a sitting position, the participant stands all the way up and sits all the way down. Count the total number of chair stands completed in 30seconds. (one up and down equals one stand) last rep counts only if their gluteal muscle touches the chair.

Grip Strength— Use a Grip Strength Dynamometer. Ensure instrument is set at the correct grip for client (middle joint of finger should rest on pull bar). Conduct (2) grip strength tests per side, resetting device between measures. Record the results in KG. Bicep Curl – This test is conducted on both arms for each individual. Begin in a seated position with palm facing in, arm hanging vertically down toward the floor. With upper arm locked in position parallel to trunk (there should be no movement in this portion of the arm), curl the weight toward the upper arm, slowly rotating palm so that the palm faces the shoulder. Elbow must reach full flexion/extension. Do as many bicep curls as possible in 30 seconds, moving in a smooth, controlled manner. Use 5lb weight for women/8lb weight for men. ** If the participant cannot lift the appropriate weight for their gender then the participant may do the test without a weight, raising just the weight of their arm. The participant’s test will need to be scored as “Did Not Follow Protocol” if they do not use a weight or if they use a lighter weight such as a 3lb or 1lb weight if they are a woman, or if they are a man and use a 5 lb, 3 lb or 1 lb weight. Only “Per Protocol” scores are recorded in the overall group outcomes reports. Both “Per Protocol” scores and “Did Not Follow Protocol” scores are saved in the individual’s fitness assessment file. Muscular Endurance

Push ups – Males, use traditional ‘military’ style, hands and toes on floor, maintaining a straight line from shoulders to heels. Females, may choose to do modified push ups with hands and knees on the floor, using knees as the pivot point, maintaining a straight line from shoulders through hips. Participant will begin in the up position and return to a down position that allows the chin to touch the mat. A straight back must be maintained and the arm must reach full extension. Maximal number of pushups performed without rest is recorded. Test is stopped when participant strains forcibly, or is unable to maintain appropriate technique within two repetitions. Get Back To Being You! **Alternative: Wall Push Ups – To be used with participants who cannot complete one push up on the ground. Note “Did Not Follow Protocol” if wall push ups are done in lieu of traditional or modified push ups. Place hands against the wall at shoulder height, feet 3-4 feet away from the wall. Maintain a straight line from shoulders to heels, and lower body toward the wall. Elbows bend to 90 degrees, stop before fore head touches the wall. Maximal number of pushups performed without rest is recorded. Test is stopped when participant strains forcibly, or is unable to maintain appropriate technique within two repetitions.

Curl ups – Participant assumes a supine position on a mat with knees at 90 degrees. Arms are to the side, palms facing down with middle fingers touching a piece of tape. A second piece of tape is placed 10cm apart. Using a metronome set to 50 beats-min, the individual does slow, controlled curl ups, in time with the metronome, making sure to lift the shoulder blades off the mat. The test is done for 1 minute at the rate of 25 per minute. Ie. Tick - up, tock - down… Perform as many curl ups as possible without pausing, up to a max of 25. Ensure the trunk reaches a 30 degree angle with the mat.

Flexibility

Shoulder Flexibility (R/L)-(Straight arms raising to the front) Standing with back flat against a wall, start with arms down at side, raise arms slowly, in frontal plane raising toward the wall. Stop test at any point where: arms can no longer move up, form is compromised, or wrists touch the wall. Measure (to nearest ¼ inch) the distance from wrists to wall Shoulder Lateral External Rotation (R/L) – (Neutral to Goal post arms) Stand against a wall, back flat. Raise arms lateral to shoulder height, elbows bent to 90 degrees and held parallel to the floor. Rotate at shoulder bringing arms up toward ceiling (as close to a ‘goal post’ position as possible) Stop test at any point where: arms can no longer move up, from is compromised, or wrists touch the wall. Measure (to nearest ¼ inch) the distance from wrists to wall Shoulder Lateral Internal Rotation (R/L) – (Neutral to Scarecrow arms) Stand against a wall, back flat. Raise arms lateral to shoulder height, elbows bent to 90degrees and held parallel to the floor. Rotate at shoulder bringing arms down toward floor (as close to a ‘scarecrow’ position as possible) Stop test at any point where: arms can no longer move up, from is compromised, or wrists touch the wall. Measure (to nearest ¼ inch) the distance from wrists to wall. Shoulder External Rotation (R/L) – (Elbows at sides) Stand back flat against a wall. Start with arms held to the side, elbows into the waist. Bend elbows to 90degrees and held parallel to the ground. Palms facing one another in toward the body. Externally rotate the shoulder, bringing wrists toward the wall. Stop test at any point where: arms can no longer move up, from is compromised, or wrists touch the wall. Measure (to nearest ¼ inch) the distance from wrists to wall. Shoulder Mobility/Back Scratch – Reach one hand over shoulder palm down, and the other behind the back palm up (note: for accuracy/consistent reporting—record the right side when RIGHT ELBOW is raised above the shoulders, LEFT SIDE is when LEFT ELBOW is up). With fingers extended try to cross fingers upper over lower hand. Measure the distance between middle fingers. Repeat with arms in opposite position. Get Back To Being You!

Trunk Flexion/Sit-and-reach – Canadian Trunk Forward Flexion Test OR YMCA sit-and-reach test  Canadian TFF Test-Using a flexometer (sit-n-reach box) the participant sits without shoes and soles of feet flat against the box at the 26 cm mark. Inner edges of soles are placed within 2cm of measuring scale.  YMCA sit-and-reach – a yardstick is placed on the floor and tape is placed across it at a right angle to the 15” mark. The participant sits with the yardstick between the legs, with legs extended at right angles to the taped line on the floor. Heels of feet should touch the edge of the taped line and be about 10-12” apart.

Participant reaches slowly forward, with both hands, as far as possible. Hold this position ~ 2 seconds. Ensure participants’ hands remain parallel and they do not lead with one hand. Fingertips can be overlapped and should be in contact with the measuring instrument, yardstick or box. Record the most distant point (Canadian TFF = centimeters; YMCA sit-and-reach = inches) reached with fingertips. Participant should exhale and allow head to drop between arms when reaching. Testers should ensure knees of participant stay extended. Best of two attempts is recorded.

Chair sit-n-reach (alternative) – Participant will sit on the edge of a chair (placed against a wall for safety), with one foot flat on the floor. The other leg is extended, knee straight, heel resting on the floor and ankle flexed to 90 degrees. The participant will place one hand on top of the other with middle fingers even, with hands resting on straight leg, exhale as hands reach toward toes. Back should remain straight with head up. Do not bounce, hold for 2 seconds. Measure distance between fingertips and toes. If fingers touch toes, score is zero, if short of toes measure (negative) distance, if fingers go past toes measure (positive) distance. Complete 2 trials, record best result in centimeters.