Index

1.
2.
3.
4.
5.
6.
7.

Blood Pressure (3-9 pages)

Resting Metabolic Rate (11-15 pages)
Lactate, Glucose and Triglyceride (17-23 pages)
Heart rate and ECG (25-30 Pages)
Spirometry (32-39 pages)
Anaerobic system (41-45 pages)
Aerobic System (47-52 pages)

Blood Pressure

Blood Pressure
Protocol: Recommendations from American Heart Association
o
o
o
o
o

o
o
o
o
o
o
o
o
o
o
o
o
o

Ask the patient about the medication he/she using. Medications may alter the
results.
Ask the patient not to consume alcohol or tobacco before the test.
Ask the patient not to exercise at least 3 hour before the measurement.
Ask the patient not to talk during the measurement
Make patient sit in the chair in a comfortable position with his/her back
supported by the back support of the chair. Patients leg should not be
crossed.
Make sure that patient is not wearing tight clothing. This may obstruct the
smooth flow of the blood and it may yield false result.
Room temperature should be kept at appropriate level. Ideal Room
temperature is 20-27 degree Celsius.
The arm should be supported at the level of the right atrium of the heart.
The bladder should cover 80% of the arm circumference.
Appropriate cuff size should be used based on arm size of the patient.
Palpate for the brachial artery on medial side of the arm just above capitulum
of the humerus.
If patient is wearing long sleeve clothes, roll up the sleeves. Make sure that
the rolled up sleeve is not obstructing the blood flow.
Keep the lower border of the cuff at least 2-3 cm above the elbow joint. so
that it leaves enough space for stethoscope placement.
Make sure that the reading on the manometer gauge reads 0 before you
inflate the cuff. Deflate the cuff completely before the measurement.
Check the valve properly before using it. Close the valve completely before
inflating the cuff
Check the stethoscope; Tap the bell area to check if it works properly or not.
Inflate the cuff 30 mmHg above the point at which the radial pulse
disappears.
2 readings should be recorded and the average of two reading should be
taken for record.

Blood Pressure Measurement:

Make Patient to sit in the chair with the patients back should rest on the beck
rest of the chair. Allow patient to relax at least 5-10 minute after sitting. Prepare
the apparatus. Wrap the cuff around patients arm at least 3-4 cm above the
cubital fossa, which will enable the observer to place the stethoscope.
Korotkoffs sounds are best heard with the bell of the stethoscope. The level of
the arm should be at the same level as the right atrium of the heart. Place the
stethoscope slightly medial side of the arm where the brachial artery runs.
4

Now close the valve and start to inflate the cuff. Cuff should be inflated 20-30
mmHg above the systolic pressure. Release the valve slowly at the rate of 3-5
mmHg/s. Hear for the korotkoffs sound. The first korotkoffs sound gives us the
Systolic blood pressure. In the last phase (Phase V) of Korotkoffs sound we get
the diastolic blood pressure. (Frese et al.,2011)

Korotkoffs Sounds: Korotkoffs sounds are rhythmic sound heard in the

stethoscope during the measurement. They are heard in 5 phases.
Phase I: In phase 1 clear tapping sounds appears and it corresponds to the
appearance of a palpable pulse
Phase II: In phase 2, Korotkoffs sounds become softer and longer
Phase III: In Phase 3, Korotkoffs sounds become crisper and louder
Phase IV: In Phase 4, Korotkoffs sounds become muffled and softer
Phase V: Phase 5 is marked by disappearance of Korotkoffs sounds completely.
The fifth phase is thus recorded as the last audible sound.
Equipment:

Apparatus used to measure blood pressure in human

beings is called sphygmomanometer. Along with
sphygmomanometer, stethoscope is also necessary to
measure blood pressure.

Manometer: The manometer (Fig.1) is a dial shaped

instrument with the marking of numbers on it.
It
measures the pressure of air in mmHg. It also has a watch
like hand which reads the pressure applied to the cuff. The
manometer can be seen in Fig. 1.

Figure Manometer Gauge

Bulb: The bulb (Fig.2) is used to pumps air into the cuff. A valve is placed at the end
of the bulb to prevent air from escaping.

Bladder: The bladder is the inflatable bag. When it is filled,

it compresses the arm to occlude the brachial artery.
Bladder is pouched within the cuff. Size of the bladder
varies according to the size of the cuff.
5
Figure Bulb

Cuff: The cuff (Fig.3) pouches the bladder in it. It

is wrapped around the arm. Different size of cuffs
is used depending upon the size of the arm. You
can see the size marked on the cuff. Proper size
of the cuff ensures that it will fit the individual
properly and yield correct result.
Valve: The valve (Fig.4) controls deflation of the
cuff. Valve is a critical tool for accurate
measurement of blood pressure. It comes with a
nob. It can be opened and closed to release or
obstruct the airflow out of the cuff.

Figure Cuff

Stethoscope: Stethoscope (Fig.5) is used to hear the

Korotkoffs sounds. It comes with ear piece and chest piece
(Bell) connected with tubes.

Figure Valve

Figure Stethoscope

Measurement Outcomes:

Blood pressure is defined as the lateral pressure exerted by blood on the walls of
artery. It is measured in mmHg. When blood flows through the arteries, it exerts
pressure on the arterial wall. (Sembulingam, 2012)

Blood pressure is expressed in Systolic and Diastolic blood Pressure.

Systolic blood Pressure: It is the maximum pressure exerted on arterial wall

during the systole of the heart. It is measured during first phase of the Korotkoff
sound. Normal systolic pressure is 120 mmHg.

Diastolic blood pressure: It is the minimum pressure exerted on arterial wall

during the diastole of heart. It is measure during phase 5 of the Korotkoffs sound.
Normal diastolic pressure is 80 mmHg.

Expected outcomes:

Blood pressure at rest: 120/80 mmHg

When blood pressure is measured at rest, normal measurement readings should be

120/80 mmHg.

Blood Pressure after and during Exercise: Exercise puts more demand for oxygen
and blood supply to the working muscles. In order to fulfil the demand, heart pumps
faster. In a result to that Systolic Blood pressure rises steadily during exercise. It
may go above 160 mmHg up to 200 mmHg in healthy individuals. However, there is
no or little increase in the diastolic blood pressure. It may remain at 80 mmHg.

Interpretation of the blood pressure measurement:

The chart below describes the different range for the blood pressure and what those
reading means. (American Heart Association)

Blood Pressure

Systolic

Diastolic

Category

mm Hg (upper #)

mm Hg (lower #)

Normal

less than 120

and

less than 80

Prehypertension

120 139

or

80 89

140 159

or

90 99

160 or higher

or

100 or higher

Higher than 180

or

Higher than 110

High Blood Pressure

(Hypertension) Stage 1
High Blood Pressure
(Hypertension) Stage 2
Hypertensive Crisis
(Emergency care needed)

Exercise and Blood Pressure:

Blood Pressure is measured during exercise to determine hemodynamic response to

exercise for the assessment of the cardiovascular health of an individual. Normally,
blood pressure rises gradually as the intensity of the exercise picks up. Blood
pressure returns to rest an hour after the exercise. Systolic blood pressure increases
as the exercise intensity increases. But, there is no or little change is noted in
diastolic blood pressure.

The rise in the systolic blood pressure can vary between individual. It may go up to
200 mm Hg in a healthy individual.
8

Regular exercise can help to lower your blood pressure. Endurance exercises make
the heart stronger. As heart gets stronger, it can pump more blood with less effort.
Moderate aerobic exercise that increases both your heart and breathing rates such
as swimming, bicycling, jogging, walking etc. can improve the cardiovascular
endurance. Aerobic exercise conditions heart, which enables heart to pump more
blood in single beat. Contractile property of the myocardium of the heart becomes
stronger in response to aerobic exercise. Peripheral resistance is decreases due to
pumping action of the working muscle which leads to decrease in resting blood
pressure in hypertensive individuals.

Sources

1. Ethel M Frese et al. (2011), Blood pressure measurement guidelines for Physical
Therapist Cardiopulmonary physical therapy journal. p. 5-12
2. Thomas G. Pickering et al. (2005), Recommendation for blood pressure
measurement in humans AHA scientific statement. p. 697-716
3. K. Sembulingam, P. Sembulingam (2012), Essentials of Medical Physiology. 6th
Edition (Jaypee Brothers)
4. American Heart Associations Guidelines for Blood Pressure Measurement..

10

Resting Metabolic Rate

11

Resting Metabolic Rate:

Introduction:

Resting metabolic rate is defined as the minimum amount of energy require by

human body to sustain normal metabolic functions at rest. Our body requires
energy to carry out normal metabolic functions, growth of the tissues and its
repair. Our body generates energy by metabolizing major dietary nutrients like
carbohydrates, fats and proteins.
Indirect calorimetry is used to measure resting metabolic rate. It analyzes
inhaled and exhaled air to measure resting metabolic rate. Metabolic processes
in the body are run at the expense of energy. It comprised of anabolic processes
and catabolic processes. Anabolic processes build up tissues; catabolic processes
break down tissues and fuel sources for energy. The rate at which these
processes occur is measured in calories per unit of time. RMR varies greatly with
age, sex and different weather condition.
Respiratory quotient helps in determining what type of fuel is burned. i.e.
Carbohydrates, fats or proteins. Resting metabolic rate slows down as the age
increases and weight decreases. Genes and environmental temperature play a
vital role in metabolic rate. Gain in muscle mass will increase your metabolic
rate. BMR is higher in men when compared to women. If we are ill or sick, our
resting metabolic rate increases to fight against the infection. Dietary
deficiencies like iodine deficiency lead to decreased metabolic rate. Effective
weight loss needs increased metabolic rate to burn extra calories, which can be
achieved by exercising.

Protocol:
(Tufts University Guidelines for the measurement of RMR,2009)
Instruct the patient not to eat or drink anything other than water for at least 8-12
hours before the test.
Ask the patient not to exercise at least for 48 hours before the test.
Allow the patient to rest for 20 minutes in a chair before the test.
If the patient is on medications, refer him/her to the physician and ask for the
modification or advise on the drugs he/she is taking.
Make sure that patient stay awake during the test.

12

 Make patient sit in the chair in relaxed position, with back of the patient is
supported by the back support of the chair.
Have the participant lie comfortably on his/her back on the bed.
Instruct the participant to relax but not to sleep during the measurement and inform
him/her that we will be looking in from time to time to make sure he/she is awake.
Inform the participant that he/she is free to remove the mask if he/she feels
uncomfortable.
Place the mask over the participants face making sure that the plastic skirt is lying
flat to prevent air from leaking in under the mask. As shown in the figure 1 below.
Check that the flowmeter in front of the mask is not obstructed. This flowmeter
permits room air to enter the bubble and allows the participant to breathe).
Run the test for 20 minutes.
If participant removes the mask at any time during the 20 minutes, make a note in
your data collection forms.
This should not affect the reliability of the test as long as the machine collects at
least 10 minutes of a steady state reading.
Following each measurement, clean the mask with hydrogen peroxide and change
the sheets on the bed and pillow.
The modified Weir equation is used to convert the volume of oxygen consumed and
the volume of CO2 produced per minute into a value for resting energy expenditure
expressed in calories. It differs from the standard Weir equation in that the gas
concentration measured by the RMR machine used by this study is in liters/minute,
not ml/min (Weir JB, J Physiol. 1949: 109, 1-9).

Equipment:

Hans Rudolph Mouthpiece (Mask):

Figure Mask

13

Figure Placement of the mask

Mask (Fig.1) is placed on the face covering mouth and nose

(Fig.2). Appropriate size should be used to ensure no air
should escape or enter into it except from the flowmeter.
The Flowmeter is attached on the front.
Flowmeter: Flowmeter (Fig.3) is attached to the mask. It
has turbine mounted in it. It allows the passage to air
inhaled and Exhaled.

Figure Flowmeter

Flowmeter Sensor:
Flowmeter sensor (Fig.4) is attached to the flowmeter. It
sends data to the analyzer. The sensor can be seen in the
figure 4 above.
Quark Analyzer:
Quark Analyzer (Fig.5) analyzes the air inhaled and exhaled
and transmits data to the
computer. The sensor
attached with flowmeter
sends exhaled air
Figure Flowmeter sensor
samples to the Quark
analyzer. It analyzes the room air as well. It
interprets the content of the exhaled air and
transmits the data to the Quark PFT Ergo
program.
Figure Quark analyzer
Quark PFT Ergo: Quark PFT ergo is a program installed in the computer which
records the data transmitted from the analyzer. Profile of the patient is created in
the program. Patients data is recorded and then the test is run.

Values being measured during RMR measurement.

Volume of O2 consumption per breath per minute per body weight

Breaths per minute
Calorie expenditure
Carbohydrate, fat and protein uptake for energy production
14

 Respiratory Quotient
These values will enable us to interpret the pattern of energy expenditure of the
patient. For example volume of O2 consumption per breath per minute per body
weight will tell us which dietary nutrient patient is burning to produce energy in the
body. Caloric expenditure will tell us about the minimum calories required to sustain
the body functions.

Exercise and Resting metabolic rate: Regular exercising can increase the
resting metabolic rate. Research shows that aerobic exercise increases the resting
metabolic rate. It helps us in weight loss. Moreover certain aerobic exercises help us
burn specific dietary nutrients like fat.

Sources

1. Weir JB (1949), Journal of Physiology. 109 p. 1-9

2. Tufts University guidelines for the measurement of resting metabolic rate, 2009.
3. Universitat de Berlin(2011), RMR and its implication, 2011

15

16

Lactate, Glucose and Triglycerides

17

Protocol:

Patient should not have any bleeding disorder

Patient should not engage into any physical activity before the test
Blood should be drawn from the healthy finger; devoid of any infection.
Lactate measurement device should be calibrated before testing.
Sensor code should match the code set on the device.
Clenching the fist or having the elastic band in place for a long time while having
blood drawn can result in a false increase in serum lactate level.
Explain the procedure of the test thoroughly to the patient. Keep all necessary
items ready (Alcohol swab, Lancet, Lactate scout, test strip, Band-Aid). Insert the
sensor in the device. This will turn on the device. Thoroughly clean the tip of the
finger with alcohol from where the blood is going to be drawn. Prick the finger
with lancet. Milk enough amount of blood. Bring the tip of the finger near the
sensor inserted into the device so that it can absorb the blood. When the
chamber of the sensor is filled with blood completely, the device will beep. After
the gap of ten seconds another beep sound will come out of the device. After
that beep, screen will show the test result. Lactate is measured in mmol/L. After
the test, used sensor should be disposed properly. If any blood droplets are
spilled on the device, the device should be thoroughly
cleaned. Used lancets should be disposed properly.

Equipment:

Lactate scout+ (Fig.1) measures the serum lactate

level.
Figure 1 Lactate Scout+ Device
It comes with lactate scout test strips or vial. When
used for the first time, two digit vial number should be entered on the device.
The code is printed on the vial container. Vial number and the number on the
device should match every time when used. The test strips are inserted on the
device before the test. The device will start automatically when the sensor or the
strip is inserted.

18

The test strip (Fig.2) must be inserted into the device before drawing blood from
the finger. The device should be stored with care. Excess heat or cold can
damage the device, so the device should never be
stored above 50+ degrees centigrade or below 0
degree centigrade temperature. The sensor should
always be stored in its original container at the
temperature ranging 8 degree centigrade to -18
degree centigrade. Lancets with various gauges are
available and should be used according to how well the
patient bleeds.

Figure Test strip

Lactate and Exercise

Normal Serum Lactate level: 0.5-2.2 mmol/L

Exercise increases the serum lactate level. During exercise, anaerobic metabolism
increase in the muscle. Anaerobic metabolism increases the production of lactate. In
the initial phase of the exercise, serum lactate level will rise gradually. At a certain
point, serum lactate level will rise sharply and it will become steadier at that level.
So measurement taken immediately after exercise will show the elevated level of
lactate in the blood. Level of serum lactate will come down at rest due to the
activity of the enzyme lactate dehydrogenase. Lactate dehydrogenase metabolizes
lactate.

Lactate is mainly produced in muscle cells and red blood cells. It forms when the
body breaks down carbohydrates to use for energy during times of low oxygen
levels. When the concentration of lactate increases inside the cell due to increased
anaerobic production of ATP, lactate will start to leak out of the cell into the blood.

Elevated serum lactate level at rest indicates Heart failure, Liver disease, Lung
disease, sepsis or very low level of oxygen in the blood. Higher serum lactate level
indicates lactic acidosis (Above 4.5 mmol/L).

19

Sources:
Baynes J, Marek H. D. (2015) Medical Biochemistry. 4th Edition (Elsevier)

Measurement of Serum triglyceride and serum glucose

Protocol:

Patient should not have any bleeding disorder

Patient should not engage into any physical activity before the test
Blood should be drawn from the healthy finger; devoid of any infection.
Tip of the finger should be thoroughly cleaned with alcohol swab before taking the
sample
Serum triglyceride and glucose measurement device should be calibrated before
testing.
Sensor code should match the code set on the device.
Patient should be in 8-12 h fasting state before the test
Ask the patient about the medications he/she takes

Equipment:

Serum triglyceride and glucose level are measured by

using cardio check device. Cardio check device (Fig.1)
comes with the sensors and memory chip. Sensors are
different for triglyceride and glucose measurement.
Different memory chips are used for the measurement
of serum triglyceride and glucose level. Memory chips
come with the sensors suitable to it. Only those
sensors should be used with corresponding memory
chips. Sensors are placed on the given space on the
device. Memory chips are inserted on the device and
the device is calibrated for the measurements. The
device can be connected to the printer.
20

Figure Cardiocheck Device

Memory chips stores the readings, it can be retrieved and printed later.
Different gauge of lancets are required. Device should be calibrated before
testing. Proper memory chip and sensor strip should be inserted for specific test.
Proper care should be taken in to store the device. Device should be protected
from direct exposure to sunlight, dust or humidity. It should be stored at the
optimum temperatures ranging from 18-35 degree Celsius.

Memory chips:
A memory chip recognizes
which test to run and it stores
the measurement. It tells the
expiration date of the sensor. It
contains the lot number of the
test strip. It controls the test
Figure Device with memory chip ans test strip mounted on it
sequence and timing of the
test. It establishes the measurement range of the test being done.

Test strips or sensor: Test strips come with the calibrated memory chips. Test
strip is inserted into the device and the blood is plunged on the window on the strip

Procedure:
Calibrate the device with the chip and the sensors
for the given test. Make sure, proper sensors and
memory chip are inserted on the device for given
test. Connect the device with printer.
Make patient sit on the chair in relaxed manner. Turn
on the device.
Figure Collecting blood with pipet
Place test strip on its place. Clean the area of the finger with alcohol from where
the blood is going to be drawn. Prick the finger with
lancet and milk the blood out of finger. Fill the pipet
with blood until it reaches the mark on the pipet.
(Fig.3)

21

Figure Plunging blood on test strip

Now plunge the blood (Fig.4) on the blood window on strip. When enough
amount of blood is plunged the device will beep. Within two minutes the results
will appear on the display. (Fig.5) Memory chip will store the result. Dispose the
used material used for test to ensure the sanity of the device.

Result:

Serum Triglycerides:

Serum Cholesterol : Normal range : below 200 mg/dL

Serum LDL : Normal range : less than 100 mg/dL
Figure Device Displaying Result
Serum Triglycerides : Normal: Less than 150 mg/dL
,Borderline High: 150 - 199 mg/dL High: 200 - 499 mg/dL,Very High: 500 mg/dL or
above
Serum HDL : Normal : More than 40 mg/dL
TC/HDL ratio : Normal 3.5-1
Serum Glucose Level:
Normal: Fasting plasma glucose level of 70130 mg/dL
After meals less than 180 mg/dL

Serum triglycerides and serum glucose level may vary and are highly related to the
diet of the individual. For example, patients suffering from diabetes may showcase
higher level of serum glucose level. A patient suffering from liver disease may
showcase abnormal level of serum triglycerides levels.

Implication of Exercise on serum triglycerides and serum glucose level:

22

Exercise helps in lowering serum triglyceride and serum glucose level. Exercise is
beneficial for patients suffering from diabetes and obesity. Exercise helps in
prevention of cardiovascular disease which results from higher serum triglyceride
levels. (Kisner & Colby 2012)

Intake of blood glucose by muscles is increased during exercise. Aerobic exercises

are known to burn fats. Vigorous exercise may produce acute hypoglycemia;
hypoglycemia is a state marked by lower serum glucose level. It may lead to
blackouts. (Kisner & Colby 2012)

Anaerobic exercise primarily uses glycogen (storage form of glucose) as a source of

energy in the muscle. So while performing anaerobic exercise (higher intensity
exercise of short burst), glycogen stored in the muscle is broken down for energy
production. Exercise also facilitates transport of the glucose from blood to the cell
by activating GLUT4 transportase enzyme activity. Individuals with deficient
production of insulin will benefit by performing exercise.

Aerobic exercise uses oxygen and fat to produce energy in the muscle. Products of
fat metabolism (beta oxidation) are used in the mitochondria to produce ATP. Obese
person can benefit by performing aerobic exercise to burn down fat. Aerobic
exercise helps in the prevention of atherosclerosis.

Sources:

1. Carolyn Kisner, Lynn Allen Colby (2012) Therapeutic Exercise, 6th Edition (F.A.
Davis)
2. K. Sembulingam, P. Sembulingam (2012), Essentials of Medical Physiology. 6th
Edition (Jaypee Brothers)
23

24

25

Heart Rate and ECG

26

Heart Rate
Protocol
Shave chest if it is hairy. Hair hampers conduction of electrical signals. Wet the
chest strap (fig.1) with some water for best conduction of signal. Wear the chest
strap (fig.1) on the chest such that it should be in direct contact with skin. Size of
the strap can be adjusted. The transmitter (fig.1) can be seen mounted on the chest
strap, should rest at the level of the xiphoid process of the sternum on the chest.

Figure 1 Chest Strap

Wear the Watch (fig.2) like receiver on the wrist. Turn on the watch by pressing start
button mounted on the sides of the dial. The watch will show the heart rate.

Equipment:
Heart rate monitor comes with two tools. A chest strap (fig.1) and a watch (fig.2).
A transmitter is mounted on the chest strap as it is seen in figure 1. The transmitter
transmits signals to the watch. Watch interprets the signal and it shows the value on
the dial of the watch.
Figure 2 Watch

Measurement:
Heart Rate: It is defined as number of times the heart contracts in a minute.
Normal Value: 50-100 beats per minute
Tachycardia: Tachycardia results when heart starts beating > 100 beats
per minute at rest
Bradycardia:
heart starts
minute at rest

Bradycardia results when

beating < 50 beats per

27

Electrocardiogram
Protocol
Prepare the patient for the placement of the ECG
leads. Remove hair from chest where the
electrodes are going to be placed. Presence of hair
hampers signal conduction from skin to electrodes.
Clean the area of chest with alcohol where
electrodes are going to be placed and allow it to
dry
completely
before
placing
electrodes.
Electrode should be placed over non-boney area.
Placement of Electrodes for 12 lead ECG:
RA: Just below mid line of the Right clavicle. It can
be seen in figure 1 (Black color).
LA: Just below midline of the left clavicle. It can be
seen in figure 1 (white color)
V1: It is placed at fourth intercostal space and just
right to the sternum (Fig.1 Red lead, just below
black lead)
V2: It is placed at fourth intercostal space just left
to the sternum (Fig.1 Yellow lead)

Figure Electrodes mounted on chest

V3: It is placed midway between V2 and V4 (Fig.1 green lead, just below yellow
lead)
V4: It is placed at 5th intercostal space on midclavicular line of
the left clavicle (Fig.1 Blue lead)
V5: It is placed on anterior axillary line at same level as V4.
(Fig.1 Orange lead)
V6: It is placed at mid axillary line at the same level of V4 and
V5
RL: It is placed just above the anterior superior iliac spine of
the right Hip bone. (Fig.1 Green lead just right to umbilicus)
LL: It is placed just above the anterior superior iliac spine of
the right Hip bone. (Fig.1 Red lead just left to umbilicus)
Figure Quark 12x device
28

All leads are connected to Quark 12x device (fig.2). Turn on Quark 12x device by
pressing start button. Open Quark resting ECG program on computer. Insert
Patients details like; name, age, sex,
weight.
After completion of filling patients
information, ECG graph will start
displaying on the computer screen
(Fig.5)

Equipment:
Quark 12x device is connected to
the leads placed on the chest. (Fig. 3)
It receives signals from the electrodes
placed on the chest. Quark 12x is a wireless device. It transmits signals received
from electrodes to the Tango receiver (Fig 4).
Tango receiver is connected with the computer.
Quark
Resting
ECG
program
installed on computer displays ECG

Figure 3 Quark 12x device connected to Electrodes

graph. (Fig. 5)

Figure 5 Quark resting ECG program displaying ECG graph

29

Figure Tango receiver

Measurement:
ECG detects the sequence of electrical events that occur during the contraction and
relaxation cycle of the heart. C Contraction of the heart is initiated by the sinoatrial
node which transmits the electrical stimulus to the atrioventricular node. From here
the impulse is conducted through the bundle of His and along the bundle branches
to the Purkinje fibres. It causes the heart to contract.
An ECG complex consists of five wave forms labeled with the letters P, Q, R, S, T, as
seen in the figure below, which represents the electrical events that occur in one
cardiac
cycle.
(Sembulingam
&
Sembulingam,2012)

P wave: it represents the atrial depolarization.

QRS complex: The QRS complex represents the ventricular depolarization.
PR interval: PR interval represents the time between the onset of atrial
depolarization and the onset of ventricular depolarization.

30

ST segment: ST segment represents the end of ventricular depolarization and the

beginning of ventricular repolarization.
T wave: T wave represents ventricular repolarization.
QT interval: QT interval represents the total time for ventricular depolarization and
repolarization.
U wave: It represents repolarization of the His-Purkinje system. It is not always
present on an ECG.

Expected Outcomes of ECG and Heart Rate and Its

Uses:
Heart rate remains normal before exercise. Normal range of heart rate at rest is 50100 beats per minute. As we start exercising, the heart rate will rise gradually until
reaching a peak point and that is will be the maximum heart rate of the individual.
Heart rate will not increase beyond that point. Heart rate will return to its normal
levels gradually once we stop exercising. Long term effect of exercise on the heart
leads to lower heart rate (near 50 BPM). It describes hearts efficiency to pump
more blood in one beat. It results from the cardiovascular conditioning resulted from
long term exercise. (Sandercock et. Al 2005) Heart rate is useful in determining the
intensity of the exercise. Exercise intensity in the individuals who are going through
cardiac rehabilitation is determined by calculating target heart rate.
While we monitor ECG at rest, it will show normal readings. During exercise the ECG
will show the spike in the different segment of the ECG. ECG monitoring during
exercise helps in determining the cardiovascular health of the individual. Heart rate
monitoring and ECG monitoring is employed in number of situations like
irregularities in your heart rhythm , heart defects, valvular heart disease, coronary
artery disease, heart attack, in emergency situations and previous heart attack.
Exercise stress testing is used to analyze hearts response to exercise and to detect
heart anomalies. In exercise stress testing different protocols are used like treadmill
test, 6 minute walk test, 12 minute walk test etc. Monitoring heart rate and ECG
during exercise can help in screening the health of the heart. Any abnormal function
of the heart will result in abnormal wave form on ECG. For example in atrial
fibrillation, P wave becomes absent and it is replaced by fine baseline oscillations,
RR interval becomes irregular. In premature ventricular contraction, P wave is
absent, QRS complex becomes wide and early and T wave becomes inverted.
While patient is performing exercise, if the ventricle contracts prematurely, that can
be detected on the ECG. It indicates impending fatal arrhythmias in patients with
heart disease. In premature ventricular contraction P wave becomes absent, QRS
complex appears wide and early, T wave appears inverted. In ventricular
31

tachycardia, ventricular rate is increased to 100-200 bpm, QRS complex appears

wide and P wave is absent on the ECG.

Sources:
1 K. Sembulingam, P. Sembulingam (2012), Essentials of Medical Physiology. 6th
Edition (Jaypee Brothers)
2 Gavin R. H. Sandercock, Paul D. Bromley, and David A. Brodie (2005), Effects of
Exercise on Heart Rate Variability: Inferences from Meta-Analysis American College
of Sports Medicine. P 433-439

32

Spirometry

33

Protocol:
Place the required equipment on the table. i.e. Computer, IXTA transmitter
unit, USB cable to connect IXTA unit to computer, Power supply cord for IXTA
unit,
head,
and

spirometer

flow

Plethysmograph
plastic

tubes

to

Figure IXTA unit power cord (black) and USB cord (white) connection

connect flow head with IXTA unit.

Figure USB cable (white) connects to computer

34

Now connect IXTA unit with power supply cord (Black). Plug the USB cable
(white) in the USB cable socket (fig.1). Other end of the USB cable connects
to computer (fig.2). IXTA unit transmits data to the computer. Power supply
socket and USB cable socket are located on the rare panel (A5) of the IXTA
unit. Plug in Plethysmograph cable pin (Fig.3 Black pin) to the front panel
(A5) of the IXTA unit. Now connect plastic tubes to the front panel (A1) of the
IXTA unit. Make sure you connect plastic tubes properly. Tube with red lid and
rugged surface connects to first socket and tube with white lid and smooth
surface connects to second socket (fig.3). Now connect the other end of the
tubes to spirometer flow head. Flow head has
the socket to connect tubes to it. Here also
make sure to connect the tubes properly. i.e.
tube with rugged surface connects to the
white nob and tube with smooth surface
Figure Front panel of the

connects to the white nob. (fig.4)

Now as everything is connected

turn

power

Confirm that

on

of

the

IXTA

unit.

the green power light is ON, on

the

the
front

panel of the IXTA unit.

Now,

open

the

Labscribe

software by

clicking on the Labscribe short

on the desktop of the computer.

cut
Figure 4 Flow meter head

located

Upon

opening of the software, it will display a message saying hardware found if

everything is connected.

35

Now select the test you want to perform. For this, click on the setting menu
then click on Lung-volumes and Heart rate then click on the Human

Figure 5 computer screen showing Lung volumes and heart rate settings

Spirometry program. After a while computer display will show lung volumes
and heart rate settings as configured. (fig. 5) Check the caliberation channel
and use internal spirometeter for the test.
As we have connected the apparatus, prepare the patient for the test. Before
proceeding to test ask the patient if he/she is suffering from any respiratory
or cardiac anomalies. Make the patient to sit in the chair with upright
posture. Now place the Plethysmograph (fig.6) as such that palmar surface of
the tip of the middle finger should rest on the Plethysmograph. Wrap the
finger and Plethysmograph with Velcro strap. Plethysmograph measures
heart rate of the patient. Clip the nose of the patient with nose clips so that
no air can escape from patients nose. Nose clip prevents air from escaping
the nose. If any air escapes from the nose it will produce error in the
measurement. Insert disposable cardboard mouthpiece into the flow meter
head from where the patient is going to breath. Make sure that the patient is
breathing into the flow meter head as such that nob with rugged tube
inserted in it should face patient. While breathing, patients lips should
36

encircle the outer surface of the mouthpiece. Ask the patient to start
breathing. Wait for 10 seconds before we start
recording. Click on the record button (Red fig.5) on
the

display.

Now

Labscribe

program

will

start

recording the data transmitted by the IXTA unit. We

will see a graphical line on the screen for each
module. i.e. Pulse, air flow from spirometer, lung
volume and heart rate. If the graphical line falls out
of the confined area we can adjust the margin of the

Figure 6 Plethysmograph

graph. We can export recorded data to save as an

excel file.
A hand held spirometer (Fig.7) can also be used to
determine FEV1, FVC by forcefully expiring into the
mouthpiece attached to the hand held spirometer.
Ask the patient to take a deep breath and exhale into
the mouthpiece of the hand held spirometer with as

Figure 7 Hand held Spirometer

much force as the patient can. After few seconds, Spirometer will show the
measurement of FEV1, FVC and FEV1/FVC ratio.
Measurement:
Spirometer measures how

much (volume) air inspired and expired.

Spirometer is a pivotal instrument in pulmonary function testing.

Spirometer is used for the assessment of lung function by measuring the
total volume of air the patient can expel from the lungs after a maximal
inhalation. Spirometry is performed to measure airflow obstruction to help
make a definitive diagnosis of Chronic Obstructive Pulmonary Disease
(COPD), confirm presence of airway obstruction, assess severity of airflow
obstruction in COPD, detect airflow obstruction in smokers who may have
few or no symptoms, monitor disease progression in COPD, perform preoperative assessment and in exercise stress testing.
37

Spirometer measures following Indices:

FEV1 - Forced expiratory volume in one second:

The volume of air expired

in the first second of the blow

FVC - Forced vital capacity: The total volume of air that can be forcibly
exhaled in one breath
FEV1/FVC ratio: The fraction of air exhaled in the first second relative to the
total volume exhaled
VC - Vital capacity: A volume of a full breath exhaled in the patients own
time and not forced. VC is often slightly greater than the FVC, particularly in
COPD.
Individual variation according to age, height, ethnicity and gender
-

Height - Tall people have larger lungs

Age - Respiratory function declines with age

Sex - Lung volumes smaller in females

Race - Studies show Blacks and Asians have smaller lung

volumes (-12%)

Posture - Little difference between sitting and standing; reduced

in supine position

Spirometry out comes in Obstructive

and restrictive Lung diseases.

38
Graph

Graph

shows

Bronchiectasis,

how

Cystic

obstructive
Fibrosis,

diseases

Post

like

Asthma,

Tuberculosis,

Lung

Bronchitis,

Cancer

and

Obliterative Bronchilitis affects lung volume. In obstructive lung diseases

airflow is obstructed by various structures of respiratory tract and lung.
Resulting into slow inflation of lung, i.e. very low FEV1.

Graph

Graph 2 above shows effect of restrictive lung disease i.e. Fibrosing lung
diseases, Pneumoconioses, Pulmonary edema, Parenchymal lung tumors,
Lobectomy

or

pneumonectomy,

Thoracic

cage

deformity,

Obesity,

Pregnancy, Neuromuscular disorders, Fibrothorax on Lung volume. In

restrictive lung diseases, lung is able to accomodate less air into it due to
external(Thoracic

cage

deformity)

and

internal

restriction(Lobectomy)

resulting in lower FEV1 and FVC.

Table below compares the values of FEV 1, FVC and the ratio of FEV1/FVC in
various conditions
Value
Normal
Obstructive Lung

FEV1 (Litres)
4
1.8

FVC (Litres)
5
3.2

FEV1/FVC
0.8
0.56

Disease
Restrictive Lung

1.9

2.0

0.95

Disease
39

Effect on Lung volume during exercise

Speed of metabolism increases multifold during exercise. Muscle cells put
increased demand for oxygen to carry out metabolic function, which in turn
makes our lungs to work more rapidly to fulfill the demand of oxygen. During
exercise, tidal volume increases by as much as 15%. Respiratory rate
increases greatly as breathing becomes deeper and more rapid. Thus, it
delivers more oxygen to our bloodstream to meet the increased needs of our
heart and muscle cells. A byproduct of respiration, carbon dioxide, is
released during expiration.
Diaphragm and accessory muscle of respiration contracts rapidly to inflate
and deflate lungs. Stronger contraction of the diaphragm leads to increased
tidal volume.
Impact of Exercise on Lung Volumes
Long term results of exercise includes, conditioning of diaphragm muscles
and accessory respiratory muscles leads to increase in the tidal volume and
greater percentage of oxygen saturation in the blood.
While we exercise, rate of respiration also increases. Long term exercise
results into the hypertrophy of the diaphragm and the accessory muscles of
respiration. So as a result of stronger diaphragm, amount of air inspired in a
normal tidal respiration is increased.
Spirometry is used in exercise stress testing to monitor lung volume during
the test. Data derived from Spirometry is used in definite diagnosis of the
cardio-respiratory disease. In clinical setting, a hand held spirometer is used
to monitor the progress of respiratory rehabilitation in patient recovering
from various obstructive and restrictive lung diseases.

40

Reference
1. K. Sembulingam, P. Sembulingam (2012), Essentials of Medical
Physiology. 6th Edition (Jaypee Brothers)
2. Belfer M. Office management of COPD in primary care: A 2009 clinical
update. Postgraduate Medicine 2009;121(4):82-90
3. Chavez,P.C. and Shokar,N.K. Diagnosis and management of chronic
obstructive pulmonary disease (COPD) in a primary care clinic. COPD
2009;6(6): 446-451

41

42

Anaerobic System

43

Protocol:
Educate Patient
Explain the procedure to the patient.
e.g. He/she will be pedaling for 30 seconds. He/she will be informed about the
time at the end of every 5 seconds. While he/she is cycling, ask him/her to
pedal as fast as he/she can.
Preparation of Monark Bike (fig.1)
Adjust the sit of the bike; Sit should
be at or below the level of the
patients waist.
Adjust the handle of the bike to
Patients comfort.
Suspend the weight in to produce
resistance in the flywheel. The
amount of weight being suspended is
calculated by the formula given
below.
Resistance = 0.075 X Patients Body
weight Kg

Figure Monark Bike

Panel (Fig.2) mounted on the front side of the bike shows RPM, HR, Time,
Speed, distance and Kcal per watt.
Before we start with the exercise on Monark bike, take the
measurement of the patients serum lactate level. This will
record the level of serum lactate in patients blood at rest.
Use lactate scout instrument to measure serum lactate level.
Now, put patient on Monark bike and allow him/her to warm
up for 2-3 minute by pedaling the bike. Now as the patient is
warmed up, suspend the calculated weight resistance.
Ask the patient to pedal as hard as he/she can. Record the
power output at the end of every 5 second. Also record the
Figure Front Panel Display
peak power output in the first five seconds.
At the end of the procedure again measure the serum lactate level.
We can record the readings manually as well as by video recording the front panel
display.
44

Allow some time for the patient to cool down after the exercise.

Measurement
From the recording we will have 6 values of power measured at the end of every 5
second for 30 seconds.
These recordings can be used to calculate Peak Power output, Relative Peak Power
output, anaerobic fatigue and Anaerobic Capacity.
Peak power output: It is measured by observing the highest power output recorded
in in the first 5 second interval of the exercise. Immediate energy system in the
body is employed in energy generation. Peak power output reflects the capacity of
ATP-Phosphocreatine system to produce energy for muscle contraction. This system
is depleted quickly. So it is used to produce short burst of intense power output.
Unit for the Peak Power output is Watt.
Relative Peak Power output: When we divide Peak Power output with body mass (in
Kg) we get Relative Peak Power output. Relative Peak Power output denotes the
power that can be generated in relation with body mass.
Anaerobic Fatigue: Anaerobic fatigue reflects the percentage decline in power
compared with the peak power output over the 30 seconds time. Anaerobic fatigue
reflects the capacity of the immediate energy system to generate ATP. Anaerobic
fatigue is calculated by subtracting lowest peak power from highest peak power and
dividing the result with highest peak power, multiplying the result with 100 gives
the value of anaerobic fatigue.
((Highest PP Lowest PP) / Highest PP) X 100 = Anaerobic Fatigue

Anaerobic capacity: It reflects the amount of work accomplished during 30 second

exercise. It is determined by adding all six recorded value and dividing the sum by
6. The unit for anaerobic capacity is Kilogram-Joule

Serum lactate level is tested before during and after exercise with lactate scout
equipment. Testing serum lactate level before, during and after the exercise will
give us an insight into the aerobic system. Lactate is an end product of the
glycolysis in anaerobic condition. Anaerobic system uses glucose as a source of
45

energy. End product of the glucose metabolism in the cell is lactate. More and more
glucose is metabolized to produce ATP during anaerobic exercise; as a result lactate
starts to build up in the cell. When the level of lactate increases too much, lactate
starts to leak out in from the blood. Serum lactate level will increase due to leaking
out of lactate from the cell.
Expected out comes Pre- Post and during exercise
The Wingate Anaerobic Test has been established as an effective tool in measuring
both muscular power and anaerobic capacity in a 3O-second time period. This test
can assess the athletes peak power and the functionality of the athletes anaerobic
system.
Highest power output will be observed in the first 5 second of the exercise. In the
beginning of the exercise, immediate energy system will be fresh and at its peak
capacity to generate ATP. As we progress with the exercise the power output will
decline gradually due to the gradual exhaustion of the anaerobic system. Power
output will be at its lowest at the end of the 30 second.
At rest, normal serum lactate level will be at 0.5-2.2 mmol/L. As we start exercising,
we will notice gradual increase in the serum lactate level. This is because; lactate is
the end product of the glycolysis in anaerobic condition. As we keep exercising,
serum lactate level will stop increasing. This is where serum lactate is at its
threshold.

Effects of anaerobic training

When our body generates energy through the immediate anaerobic system, it
requires no oxygen to produce energy. It generates energy in short bursts with high
intensity. It uses ATP and Phosphocreatine to generate energy. This kind of energy
is required in sprinters, i.e. Weight lifters, 100m and 200m sprinters, short distance
swimmers etc.
Training of anaerobic system of these types of athletes will
performance. Exercise like short interval training is especially
sprinters. Physiological effects of anaerobic train are increase in the
twitch muscle fibers, recruitment of more fast motor nerve fibers
greater force production in a single bout of muscle contraction.

enhance their
beneficial for
number of fast
into a muscle,

Calcium is an important ion in muscle contraction. When action potential reaches

the muscle cell, sarcoplasmic reticulum in the cell releases calcium to initiate
muscle contraction. Calcium is also a signal transduction molecule in protein
synthesis. Calcium activates protein kinase C enzyme in the cell which leads to
activation of the different pathways which will initiates protein and mitochondrial
46

synthesis in the muscle cell. As a result, there is an increased contractile tissue in

the muscle. (Muscle Hypertrophy)
Anaerobic exercise result into more recruitment of motor neurons to the cell. More
motor neuron will result into more secretion of Ach. into the post synaptic cleft.
More neurotransmitter secretion will result into generation of bigger action
potential, thus stronger muscle contraction and more power generation in a single
contraction

Sources
1. K. Sembulingam, P. Sembulingam (2012), Essentials of Medical Physiology.
6th Edition (Jaypee Brothers)
2. Zupan, MF. Arata, AW. Dawson, LH. Wile, AL. Payn, TL. and Hannon, ME.
(2009), Wingate Anaerobic Test peak power and anaerobic capacity
classifications for men and women intercollegiate athletes. JStrength Cond
Res 23(9): 2598-2604

47

48

Aerobic System

49

Protocol
Preparation of the Patient
Explain the procedure to the patient.
E.g. He/she will be pedaling for 20 minutes. He/She will be explained about
the time at the end of every 2 minutes. Resistance will be increased to
Monark bike at the end of every 2 minutes. He/She will be shown RPE (Rate of
perceived exertion) scale and asked about how he is feeling. Blood sample
will be taken to measure lactate level every 2 minutes.
Equipment
We will require equipment that we used in testing resting metabolic rate
(Refer lab 2 RMR).
We are going to use Monark bike for this test. (Refer lab 6 anaerobic system)
We will use lactate scout device to measure lactate. (Refer lab 3 lactate)
We will use Heart rate monitor for HR. (Refer lab 4 HR&ECG)

Before the test, we will measure patients resting heart rate, resting serum lactate
level, blood pressure, height and weight. Patient will be wearing heart rate
monitoring device on his chest.
Now put mask on the patients face making sure that the plastic lying flat to prevent
air from leaking. Check for any leakage of air by blocking front opening of the mask
with your hand and ask the patient to blow air. Now attach flowmeter to the mask.
(Refer lab 2)
Open the Quark PFT Ergo software in the computer. Create a new profile of the
patient by adding the detail of the patient such as, height, weight, birthdate. Now
choose modified Bruce protocol as testing protocol.
Allow the patient to warm up for 2-3 minute before the start of the test. Once the
patient is warmed up, start the test. Quark PFT Ergo program will record Patients
data such as VO2 and HR, while lactate, RPE, RPM and watts will be measured
manually. VO2, HR, Lactate, RPE, RPM and watts will be monitored at the end of
every 2 minutes and the observation will be noted. Resistance will be increased
gradually at the end of every two minutes. Patients lactate level will be measured
for 5 minutes after test; it will be recorded every minute for 5 minutes.
Patient will be allowed to cool down by pedaling for another 2-3 minutes after the
test.
50

Measurements
We measured resting HR, lactate and blood pressure of the patient. We
measured RPM, watts, HR, VO2, RPE and lactate during exercise at the end of
every 2 minutes. We also measure lactate in the recovery phase after the
exercise. Table below shows the observations.

Time

RPM

Watts

HR

0-2
2-4
4-6
6-8
8-10
10-12
12-14
14-16

81
79
81
79
80
91
91

160
234
290
316
324
360
376
380

96
102
112
121
134
157
171
181
(max)

VO2(L/min
)
28.22
30.98
35.11
43.99
52.36
58.00
60.73
60.95(ma
x)

RPE
1
2
3
3
4
6
8/9
5

Lactate
(mmol/L)
1.7
2.5
5.2
1.4
2.5
4.8
6.7

As the resistance increased power output, HR, VO 2 increased. Serum lactate

level increased gradually for first 2 readings and then it suddenly shot up.
Watts denotes the intensity of the exercise. As the resistance increased,
intensity of the exercise increased. Increased intensity of the exercise
demands more energy production, so that HR and VO 2 increase.
Rate of perceived exertion was used to know how patient is feeling at the end
of the every 2 minutes.
Lactate was measured to check the response of exercise on the aerobic and
anaerobic system.
Intensity of the exercise was measured by observing watts at the end of
every 2 minutes.
Maximum heart rate achieved during test was 181 bpm. And the maximum
oxygen consumption observed during test was 60.95 L/min.

51

Expected Outcomes Pre-Post and during exercise

Aerobic capacity is the maximal amount of work that an individual can do. It
is measured by oxygen consumption in ml/min. Before the exercise; at rest
HR and VO2 will be at normal level.
When we exercise our muscles are working harder than normal. As a result,
they require more energy than normal. ATP used by our muscles is generated
with the help of oxygen in the mitochondria aerobically and anaerobically in
cytosol. An increase in exercise intensity will result in an increase in muscular
ATP demands. To match the demand, rate of ATP production in the cell is
increased. Anaerobic system cannot supply ATP in a sustainable manner.
Aerobic system can produce ATP in a more number than anaerobic system.
Therefore, increased exercise intensity ultimately corresponds to an
increased VO2. Our respiration gets progressively faster and deeper as the
exercise intensity increases. Our body is trying to provide more oxygen to the
working muscles so that they can generate enough ATP to keep us moving. In
addition to that, nutrient material should be constantly supplied to the
working muscle to produce energy. The rapid increase in energy requirements
during exercise requires equally rapid circulatory adjustments to meet the
increased need for oxygen and nutrients and also to remove the end-products
of metabolism such as carbon dioxide, lactate and to dissipate heat. Faster
pumping of heart will ensure that the working muscle gets constant supply of
nutrients, oxygen and its utilization by the mitochondria to produce ATP. Thus
oxygen consumption (VO2) and HR increases as the intensity of the exercise
increase.
Anaerobic metabolism produces lactate as its end product. As a result, when
the intensity of the exercise increases, production of lactate increases in the
cell. When lactate concentration gets too high in the cell, it starts leaking out
in the blood. With increased intensity and time of the exercise, lactate will
start building up in the blood. At one point when the anaerobic system will be
working at its peak, there will be sudden sharp increase in the blood lactate
level. This will followed by steady higher blood lactate level throughout the
exercise. During recovery period, lactate level in blood will come down
gradually as it is metabolized by the enzyme lactate dehydrogenase.
Effect of exercise on the Aerobic system
52

Cardiovascular Response

Increase in myocardial contractility with a resultant increase in stroke

volume.
Increase in the blood flow through the working muscle
Generalized vasoconstriction occurs that allows blood to be shunted
from the non-working muscles, kidneys, liver, spleen and other area to
the working muscle.
Increased heart rate due to increase in frequency of sinoatrial node
depolarization
The veins of the working and non-working muscles remain constricted.
Decrease in the blood cholesterol and triglyceride levels
Lower blood lactate level at submaximal work

Respiratory Response

Respiratory exchanges occur rapidly.

Gas exchange increases across the alveolar-capillary membrane.
Increase in the muscle metabolism during exercise results in more O 2
extraction from arterial blood.
Minute ventilation increases as respiratory frequency and tidal volume
increases.
Larger lung volume develops because of improved pulmonary function,
with no change in tidal volume
Larger diffusion capacities develop because of larger lung volumes and
greater alveolar-capillary surface area

Neuro-Muscular Response
Increase in the nerve conduction velocity.
More motor neuron recruitment to the muscle
Number and size of the mitochondria are increased
Increase in the capacity to generate ATP aerobically
Muscle myoglobin concentration increases; increasing the rate of
oxygen transport and oxygen diffusion to mitochondria
Muscle hypertrophy
Increase in the muscle contraction force
Increased slow twitch muscle fibers in the muscle
Cardiac muscle conditioning leads decrease in the heart rate at rest
Conditioning of Respiratory muscle leads to increase in Lung
capacities.
Increase in the breaking strength of bones and ligaments and tensile
strength of tendons

53

Aerobic exercise improves exercise endurance of the individual. Muscle fatigue is

delayed due to improved endurance. A reduction in resting pulse rate occurs in
individuals because of decrease in sympathetic drive, with decreasing level of
norepinephrine and epinephrine. A decrease in blood pressure occurs due to
decrease in peripheral vascular resistance. Aerobic exercise helps in improving
blood pressure in hypertensive individual. Aerobic exercise also helps in decreasing
body fat.

54

Sources
1. Kisner C., Colby L A, 2007, Therapeutic Exercise. 5th Edition (F.A. Davis
Company)
2. K. Sembulingam, P. Sembulingam (2012), Essentials of Medical Physiology. 6th
Edition (Jaypee Brothers)
3. Osullivan S B, Schmitz T J, 2007, Physical Re habilitation. 5th Edition (F.A.
Davis Company)

55