It is remarkable, however, that these higher dropout rates are only presented at the start of the study and not at the end. Protas et al41 hypothesise that this is based on psychosocial fear-avoidance associated with pretesting rather than a true indication of physical

deconditioning. Smeets and van Soest35 suggested strict adherence to the testing protocol and extensive training of the health care providers to increase the acceptability of the exercise tests. Practical experiences show that acceptability of treadmill and bicycle tests is lower in psychosomatic institutions than in outpatient settings. This is attributed to disease severity and other demographic features. In four of the 14 studies,38, 39, 40 and 42 assessment of the

psychometric properties Rapamycin cost of the submaximal tests was not the primary purpose of the study. Data Ku-0059436 purchase of measurement properties were sparse and the methodological shortcomings of the psychometric measurements could have led to bias. Five out of 14 studies investigated test batteries of physical performance tasks.42, 43, 44, 45 and 46 Submaximal exercise tests such as the 5-minute, 6-minute or 10-minute walk tests were merely one item of the test battery. This could have generated an unclear risk of bias and could cause underestimation or overestimation of the effect measure because participants had to do the test battery completely, and not just one exercise test. Some uncertainties arose about the reliability and criterion

validity of the conventional Åstrand test.27, 30 and 34 Good test-retest reliability (ICC 0.96) was reported in people with chronic low back pain32 and moderate Thymidine kinase concurrent validity with the modified Åstrand test (ICC 0.79) in people with musculoskeletal pain disorders.35 However, the ICC is strongly influenced by the variation between subjects32 and the low number of participants in the included studies, which may have resulted in a spuriously high estimate of reliability. Despite good reliability and moderate criterion validity, all the studies showed low levels of perceived exertion. The low levels of perceived exertion may be more likely to be due to fear avoidance than physical deconditioning. The gold standard for exercise testing is maximal calorimetry, with detailed assessment of lactate, VO2max, blood pressure and electrocardiographic data. However, these detailed assessments are not available to many physiotherapists. Measuring people’s subjective perception with standardised assessment (such as rating of perceived exertion), monitoring heart rate, and performing submaximal exercise tests seem to be the most applicable methods in daily practice. All of the submaximal exercises identified in this review are useful, feasible, and applicable to the population of interest. At most, one session of 20 to 30 minutes is necessary for a submaximal test, although a treadmill or a cycle ergometer are also needed for some of the tests.