Understanding CPET Examinations with Guest Dr. Betsy Keller

Welcome to Season 5, Episode 19 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "Understanding CPET Examinations with Guest Dr. Betsy Keller."

What if one test could offer the hard proof patients with ME/CFS, Long COVID, and fibromyalgia have been waiting for? Join disability law expert Nancy L. Cavey as she dives into one of the most important – and misunderstood – tools in chronic illness advocacy today: Cardiopulmonary Exercise Testing, or CPET. Often overlooked or mischaracterized, CPET isn’t just another stress test. It’s a scientifically rigorous way to measure functional limitations that traditional tests often miss. In this episode, Nancy is joined by Dr. Betsy Keller, a nationally recognized leader in exercise science and a pioneer in using CPET to support patients in both medical and legal arenas. Together, they break down what CPET is, how it works, and why it’s gaining traction in disability claims – especially for those whose conditions have long been doubted or dismissed. But CPET isn’t without controversy. We’ll explore how insurers evaluate these tests, what makes a CPET legally credible, and the ethical challenges of asking chronically ill patients to push their limits in pursuit of validation. This is more than a medical deep dive – it’s a critical conversation about science, strategy, and the fight to have invisible illnesses taken seriously in the eyes of the law. Don’t miss it.

If you'd like to follow along with slides mentioned in this episode, follow this link: https://www.youtube.com/watch?v=NrZiDVo3W8Q

In this episode, we'll cover the following topics:

One - Introduction to and Foundations of CPET

Two - CPET in the Context of Long-Term Disability

Three - Best Practices and Advice

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Listen to Our Sister Podcast:

We have a sister podcast - Winning Isn't Easy: Navigating Your Social Security Disability Claim. Give it a listen: https://wiessdpodcast.buzzsprout.com/


Resources Mentioned in This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://mailchi.mp/caveylaw/ltd-robbed-of-your-piece-of-mind

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://mailchi.mp/caveylaw/professionals-guide-to-ltd-benefits

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Transcript

Nancy Cavey [00:00:15]:
 Hey, I'm Nancy Cavy, national ERISA and individual disability attorney. Welcome to this episode of Winning Isn't Easy. Before we get started, I've got to give you a legal disclaimer. This podcast is not legal advice. The Florida Bar association says that I've got to say this, and now that I've done that, nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games that disability carriers play, and what you need to know to get the disability benefits you deserve. So, off we go. I am so excited about today. We are going to be diving into a topic that is increasingly vital in not only the worlds of medicine, but disability advocacy and disability insurance.
 
 Nancy Cavey [00:00:58]:
 And what we're going to be talking about today are cardiopulmonary exercise testing, or cpet. Now, if you've never heard of it before, or if you only heard that term in passing, you're not alone. But this powerful diagnostic tool is playing a growing role in helping patients with complex chronic diseases like me, cfs, Long, Covid, Pfizer, fibromyalgia, to prove something that they've long known, and that is that their symptoms are real, measurable, and physically and cognitively limiting. So to help us unpack all of this, I'm thrilled to have Dr. Betsy Keller, a leading expert in C pets. She has decades of experience in exercise science, and she's been at the forefront of using CPETs to better understand complex chronic illnesses and to support patients in both a clinical setting and in a disability claim setting. So in this episode, we're going to talk about basics. What's a cpet, what it measures, how it differs from other forms of exercise testing.
 
 Nancy Cavey [00:01:56]:
 But we're even going to go deeper. We're going to talk about how a CPET is used in disability claims, what makes that test valid in the eyes of disability insurance carriers or plans, and how to balance the need for objective data with a very real risk of triggering harm in vulnerable patients. And, and this is a conversation that I've been looking forward to. So let's get into it. As I said, we're going to talk about the introduction to and foundations of CPETs, CPETs in the context of long term disability claims and best practices and advice. So we're going to take a quick break. We're going to be coming back and Dr. Keller is going to be talking about this whole process and we've got some great slides.
 
 Nancy Cavey [00:02:39]:
 So look, we'll be back in a second.
 
 Speaker B [00:02:41]:
 You've been robbed of your peace of mind. By your disability insurance carrier. You owe it to yourself to get a copy of Robbed of your Peace of Mind, which provides you with everything you need to know about the long term disability claims process. Request your free copy of the book@kvlaw.com today.
 
 Dr. Betsy Keller [00:03:12]:
 Foreign.
 
 Nancy Cavey [00:03:23]:
 Welcome back to Winning Isn't Easy. So Dr. Keller, let's talk about the introduction to and foundations of cpet. Can you please introduce yourself and tell us a bit of your background and how you work with CPET testing and then talk about what CPET testing is, how it measures things and how it's different from other testing.
 
 Dr. Betsy Keller [00:03:46]:
 Thanks Nancy. Thank you for having me. First of all and for doing this. I have a doctoral degree, a PhD in exercise science and I've been doing cardiopulmonary exercise testing on all levels of functional ability for since the the 80s, but more specifically for people who have fatiguing illnesses since the early 2000s. So 22, almost 23 years now for people with myalgic encephalomyelitis, fibromyalgia, Lyme cancer related fatigues, and more recently of course with patients who have long Covid. And we've been doing the two day or using the two day cardiopulmonary exercise test protocol because it's an objective measure of one's ability to produce energy to do work. And when I say work I mean not only physical hard work, but I mean work like sitting at your desk for prolonged periods of time or climbing a flight of stairs or doing your laundry, any kind of exertion whatsoever, from very low level to very high level exertion. The reason that we do a two day test is because, as your listeners are most aware, the hallmark symptom, for example of me CFS and now long Covid is post exertional malaise and exertion intolerance.
 
 Dr. Betsy Keller [00:05:23]:
 So they have a poor ability to recover following an exertional effort. And if you only do a single cpet and I'll get back to this later on that you can't really measure the whether or not somebody was able to recover normally or not. Get us started.
 
 Nancy Cavey [00:05:41]:
 I guess it started. So I know you have a slide presentation. Do you want to start with that?
 
 Dr. Betsy Keller [00:05:48]:
 Sure. Let's go to the next slide and take a look at a little bit more of what cardiopulmonary exercise tests might look like. So you can see here the machinery, the equipment that we use is fairly sophisticated. It's called a metabolic measurement System or a MetCart. And we can test using a variety of Modalities of exercise. Here you see a treadmill modality and a cycle modality. Typically, if you were going to do a cardiopulmonary exercise test, you would be on one or the other of these. We tend to use the cycle for a variety of reasons, which I'll spare you from, but essentially, the cardiopulmonary exercise test measures the effectiveness of your heart, your lungs, and your muscles to both deliver and use oxygen to produce energy to do work.
 
 Dr. Betsy Keller [00:06:41]:
 So the cardiopulmonary protocol is a very intentional protocol. It starts at a very low level of effort and gradually increases over time. But it's not very long, and I'll talk about that in a minute as well. If you could go to the next slide, Josh, that would be great. I just wanted to preface what I'm going to talk about with regard to the protocol a little bit about what we've seen time and time again over many years now with not just me cfs, but we see it with long Covid. We see it with most of the fatiguing illness that we are assessing. That is a poor ability to get blood with oxygen where it needs to go. Circulation is impaired.
 
 Dr. Betsy Keller [00:07:25]:
 And when circulation of blood is impaired, circulation of lymph is impaired. A lot of that's related to our ability to ventilate or move air through our lungs. And almost across the board, everybody has impaired ventilation. And when you can't ventilate well, it impacts your ability to circulate well, lymph and blood. And of course, it allows for toxins to build up in areas of your body, contributing to inflammation. So these are things that we see over and over again in the people that we're testing.
 
 Nancy Cavey [00:08:01]:
 With COVID patients, correct?
 
 Dr. Betsy Keller [00:08:03]:
 Absolutely, yes. True. Next slide, please. This is a little bit of information about a cardiopulmonary exercise test that you would expect if you were going to do one, you would be on a cycle or treadmill. As I mentioned, we use a cycle and we use what's called a ramping protocol, which means that during the course of one minute, the workload or the friction that you're pedaling against increases very, very gradually. It's almost imperceptible at the beginning of the. But it continues to increase throughout each minute, throughout each minute of the test. It doesn't jump from one minute to the next, which is called a step protocol.
 
 Dr. Betsy Keller [00:08:47]:
 The actual time that you exercise is not very long. It's about eight to 12 minutes. If we've done our job right and match the protocol to you. And this is very important with the individuals who we test with fatiguing illnesses, particularly with me, CFS and Long Covid. We don't do what's called a traditional warm up because that actually some people's level of function is low enough that in the warm up we already see things that we're measuring starting to increment in a way that they shouldn't be. We use the very beginning of the very low intensity efforts to begin our test. And not a traditional warm up, but we measure a lot of things. Some of them I have listed here, and I won't go into a lot of detail, but what you can expect.
 
 Dr. Betsy Keller [00:09:36]:
 If you can see the picture of the person, person on the bike there, you would have a mask on your face of some sort. You would have a blood pressure cuff on, you would have a pulse oximeter on your finger, you would have EKG on your torso. And all of the air, and this is the really important part, that you breathe out during the test is collected through that face mask apparatus that you're looking at and it's analyzed to determine how much oxygen you're consuming to produce energy to do work.
 
 Nancy Cavey [00:10:08]:
 You mentioned something about matching protocol. What did you mean by that?
 
 Dr. Betsy Keller [00:10:13]:
 Well, if we were testing an athlete, we would still want the test to be 8 to 12 minutes. So the rate at which we would ramp up the work during the exercise test would be more aggressive than the rate at which we would ramp up the work during an exercise test with somebody with a fatiguing illness. So instead of doing, if you look at the second line there, it says we typically use a protocol that's ramping at 15 watts per minute. What that means is that the rate at which the work or the friction that they're pedaling against is increasing is fairly low level. We would not use 15 watts per minute if we were testing an athlete because it would be a very long test and we want the test to be 8 to 12 minutes. So we need to match the protocol with the person's perceived functional abilities.
 
 Nancy Cavey [00:11:07]:
 Got it? Okay.
 
 Dr. Betsy Keller [00:11:10]:
 Nancy might wanna speak to this more than I do. But typically what we've experienced is that attorneys are usually seeking three major pieces of evidence to help support a case of disability. If there is indication of orthostatic intolerance, or oi, then they might ask for a tilt table test, or sort of what we would call the poor man's tilt table test, a test that can be done in the doctor's office, the nasaline test, a neurocognitive assessment, because as you know, brain fog is part and parcel of the illness. Both Long Covid and ME cfs. And then the third would be the two day cardiopulmonary exercise test to provide objective evidence of your ability to produce energy and your ability to recover normally or not following an exercise challenge. Other.
 
 Nancy Cavey [00:12:07]:
 You're absolutely correct because we have a lot of POTS cases, so we absolutely want to see the tilt table test or the poor man's equivalent. I will tell you we are somewhat reluctant to get neurocognitive assessments if the disability insurance policy has what I call the Monty Python wafer thin mental nervous limitation where it says benefits are limited to just two years if the person's disability is caused. And here's the key word contributed to as a result of any psychological condition, and often I'm sure you encounter this too, is our clients are legitimately depressed or anxious or even have post traumatic stress disorder syndrome. And sometimes disability carriers will seize on that diagnosis to try to limit benefits to just two years. So if we're going to be using the neurocognitive testing, we are really trying to tease out what in fact is going on and establish that any psychological issues do not contribute to the person's disability. And then of course, obviously we're using the CPET exam.
 
 Dr. Betsy Keller [00:13:27]:
 Yes. And the interesting thing about that is that people who have primary depression, it's well established, there are many studies that show exercise, graded exercise therapy helps people with primary depression. And we don't typically see primary depression, maybe if they've been sick for a very long period of time, maybe with the ME cfs, because oftentimes they've been sick longer. But usually we see a secondary depression. And exercise therapy does not help necessarily with secondary depression if they have a fatiguing illness. So, you know, if it's primary depression, they might get a graded exercise therapy prescription to help with that. And you'll see improvements but. But you won't with people who have depression related to their illness as a secondary effect.
 
 Nancy Cavey [00:14:23]:
 So thank you for clarifying that. How does the CPET exam differ from any other standard stress tests, for example, that you might see in a cardiac type situation?
 
 Dr. Betsy Keller [00:14:34]:
 Well, the term stress test has been used a lot and stress tests might, might include everything that I showed in the previous picture, except the mask on the face where they're collecting oxygen and analyzing oxygen, carbon dioxide. So you, you could do a cardiac stress test with the EKG on, because what they're primarily interested in is that the ticker is working well when we, when we exercise, challenge you. Right. But it may not and oftentimes does not include the gas exchange measures. So there'd be no face mask on there. There would, there would be a blood pressure cuff and probably a pulse oximeter or two, but not the face mask necessarily. I think more clinics and more cardiac rehab testing is involving gas exchange measures now too. But not necessarily.
 
 Nancy Cavey [00:15:28]:
 And obviously it's that exchange that goes to the fatigue issue.
 
 Dr. Betsy Keller [00:15:31]:
 That's the real important part for assessing again, your ability to use oxygen to produce energy to do work. So, yes, we need that gas exchange measure. A few other items that I've listed down below there are also helpful from a person with fatiguing illness, from their perspective, if they're keeping track of a very simple way of identifying what they would consider a good day versus a bad day, some real simple way of tracking that. And, you know, if they've electronically saved their story, I call it their story about what was life before and after the onset of your illness symptoms. And then one of the things that we ask in our preliminary questionnaires is what percentage of your day do you spend lying or sitting down? And I guess the sort of the converse of that is how many hours are you upright? And either one of those kind of, if you're paying attention to that, is also helpful to be able to report that as well. It's not objective, but it's, it's helpful.
 
 Nancy Cavey [00:16:45]:
 Okay, so this has been really cool. Let's take a break and we will come back in in a moment with.
 
 Dr. Betsy Keller [00:16:59]:
 Sa.
 
 Nancy Cavey [00:17:27]:
 Welcome back to Winning isn't Easy. We have as a special guest, Dr. Keller. And now we're going to switch gears a little bit and talk about CPET in the context of long term disability. I've got a number of questions for you. So why is CPET considered such a valuable tool in the context of longer term disability claims? And are there particular conditions like me CFS or long Covid or fibromyalgia, where it really proves especially helpful?
 
 Dr. Betsy Keller [00:17:55]:
 Sure, Josh, if you could go to the next slide, please. It's been long established that the measures that we get from a cardiopulmonary exercise test, again, which are objective, not self report measures, not something you can fake when you do the test. One of the measures that we get is called VO2MAX or VO2PEAK. VO stands for Volume of oxygen consumed at peak effort. And we also refer to that as the aerobic capacity. And there's a very strong and well established relationship between aerobic capacity or VO2 max. And illness status. And the other thing that we've learned over many studies and I can show you, I might be able to show you some, I can't remember if I put that slide in or not.
 
 Dr. Betsy Keller [00:18:43]:
 But there are many studies that have shown that CPET measurements are valid and reproducible in a variety of illness populations as well as healthy individuals, even low fit and healthy, if you can be both of those at the same time. But certainly in athletes, but in heart disease patients, patients with cystic fibrosis, all sorts of disease statuses that you can do a test on one day and come back and have them do a test on the next day. They may not like it, but they can reproduce the results. That is not what we're finding, particularly in people who have ME CFS or long Covid. And so that makes the CPET measurement a very valuable objective indicator and also a means of establishing whether somebody is recovering normally following an exertional stressor on the first day. Also, Social Security disability recognizes an abnormal exercise test as evidence of a medically defined impairment. So medically determined impairment.
 
 Nancy Cavey [00:19:53]:
 Yeah, so that's important. I also do Social Security disability work. And one of the first things you have to prove in Social Security is that you have a medically determinable impairment. So the fact that this test is recognized really helps us get over the question of whether in fact a person has a determinable impairment. It's not so much an issue, I think in the context of long term disability. What the issue is not so much diagnosis, it's what is the person's functional, physical and cognitive restrictions and limitations. And as you know, most patients with these conditions will struggle with credibility because of their symptoms and feeling that doctors or people don't necessarily believe them. Can you touch a little bit more on how the CPET really objectively validates their functional limitations?
 
 Dr. Betsy Keller [00:20:47]:
 Sure, if you want to. Why 2 cpets for fatiguing illness here? I'll just preface this by saying that in 2015 the Institute of Medicine, which is now the National Academy of Medicine, produced a report in which they recognize the value of CPET. 2 day CPET to support or provide objective evidence of post exertional malaise. And that's, I'm just going to say that's a key point here because oftentimes we are, we have people who are looking for a diagnostic. We are not a diagnostic. We, we. This, this test is, allows us to show evidence of impaired recovery which is part and parcel of post exertional malaise. What you see here is the Two day protocol, which shows us that the first test is important for us to establish your aerobic capacity or your baseline ability to use oxygen to produce energy to do work.
 
 Dr. Betsy Keller [00:21:57]:
 And it also allows us to assess what's called your anaerobic threshold. And that's the point during incremental or graded exercise, when you start to produce more energy without the availability of oxygen. So we have several ways of producing energy, three ways, and most of the time you're using oxygen to produce energy. We are right now, as we're sitting down, doing this conversation, sitting at your desk, doing work, walking around at a normal speed, all of those kinds of activities are aerobic activities. But also running a 10k race, if you're fit for that, can be an aerobic activity. But at some point, even for the athlete, if you push yourself a little bit harder or you need energy produced very quickly, oxygen derived energy production is a slow process. So if you need energy, for example, to run out of a, you know, burning building, you need energy very quickly to be successful at getting out of the building. And we can do that, but it doesn't require oxygen for that.
 
 Dr. Betsy Keller [00:23:08]:
 So that we call that anaerobic or without oxygen energy production. And when you start to produce energy anaerobically, there's a shift in the data that we see during an exercise test, and it's a pivotal point for us because what we've learned with these fatiguing illnesses is when people begin to exceed that threshold, called the anaerobic threshold, that it seems to provoke their symptoms of pem. So if we can establish objectively when that happens, or what heart rate it corresponds to when you, when you exceed that threshold or change in energy production, shift in energy production, then what we can do is advise you, guide you to be able to try to stay below that level of effort at which you're going to exacerbate your illness symptoms. So we can learn that from the first test and then presumably the first test provokes your post exertional response because we force you to exercise above that threshold. And then when you come back the next day for the second test, everybody else can reproduce it. Remember, cardiac patients, pulmonary patients, they can all reproduce it on the second day. But if you have post exertional malaise, that interferes with your ability to use oxygen to produce energy, and we measure how much that interference is impacting your function. So when you come back on the second day, we measure your aerobic capacity again, we measure your anaerobic threshold again.
 
 Dr. Betsy Keller [00:24:51]:
 And we also look at a whole host of other things. And I'll point out here that all of those measurements that we're taking with the blood pressure cuff and allows us to look at a variety of different things that, that relate to your ability to move blood around with oxygen to get it where it needs to go, not just your muscles, but your brain and all of your tissues. That second test is critically important.
 
 Nancy Cavey [00:25:18]:
 That's a fantastic explanation of the two day cpet, but it also leads to the question and issues that we both get. And that is the concern I hear is that the CPET exam can be physically demanding, the traveling to get to the CPET facility in and of itself, the actual testing itself. The second day of testing and there's always this concern that we are exacerbating our client. Your, your patients risk of increasing their exertional malaise.
 
 Dr. Betsy Keller [00:25:58]:
 Sure.
 
 Nancy Cavey [00:25:58]:
 And sometimes my clients will say, well, I don't want to do that because I'm never going to recover, if you will. So could you address, please, the, the issue of the impact of travel, the impact of the CPET and whether any increased malaise is permanent.
 
 Dr. Betsy Keller [00:26:20]:
 Sure. There was a study produced by an, an internal study, an intramural study produced by the National Institutes of Health a couple of years ago, and they queried people with myalgic encephalomyelitis about their symptoms. And they produced these sort of heat maps here. And what you see on the left side is what was described as the symptoms and the severity of the symptoms that they experience daily associated with post exertional malaise. So you can see that exhaustion is first and foremost there, difficulty thinking. So cognitive dysfunction of some sort, pain. Those are the three that kind of stand out. Those are the biggies there.
 
 Dr. Betsy Keller [00:27:08]:
 If you look on the right side of the screen, you'll see the symptoms that they describe following a cardiopulmonary exercise test. And they don't look terribly different. You still see pain that might be a little bit more amplified. Exhaustion is about the same. Cognitive function is probably impacted more after the second after the exercise protocol compared to their daily pem. But you can see that they're not hugely different, that the symptoms might be amplified for a period of time, but they're not different. I also will add at this point too, especially if somebody's thinking about, oh, you know, we've had people travel to New York City and then come up to us for the exercise test. They've gone to New York City maybe to get the neurocognitive battery done or to get a tilt table test done.
 
 Dr. Betsy Keller [00:28:00]:
 And then they come to Ithaca for the two day test and they're trying to get it all done in one fell swoop. And that is not a great idea. I've had many people we've tested who say that they are, they are more pemmed, quote unquote after the neurocognitive battery than after the two day test. Wow. And I've also. Yes, and I've also heard the same about the tilt test. The tilt, not the poor man's tilt test, the NASA lean test, but a tilt table test. And so it can vary in how you respond to these tests.
 
 Dr. Betsy Keller [00:28:33]:
 But Josh, if you can put the next slide up, I'll show you a little bit of data that we have about recovery. And so how long does it take to recover following a 2 day CPET? We recently completed a 5 year NIH funded study and we looked at, we tracked symptoms and again it was self report. But symptoms were rated for at least 10 days following the two day CPET and longer because we wanted to see how long it would take for the people who did the two day CPA to get back to their baseline state. So this is the second study, it says 10 to 12 days. There were 80 people reported in the study by Moore and others. And 1012 days on average is what, over 90%? I think over 95% of the people took to recover. Some recovered and less. Data from the Workwell foundation at the top there that they, where they track their recovery times show that they, most of everybody recovers that they've tested recover in four to seven days.
 
 Dr. Betsy Keller [00:29:43]:
 And a study that we have that's in review right now where we had people wearing an accelerometer, so an activity monitor is showing that it was a pretty consistent with what we reported with the NIH study, about eight to 10 days. And this is back to their pre test baseline state. Okay. More than 90% and I'll even say 95% based on the data collected collectively from these three studies were recovered within one to two weeks. Okay. There, there is a nucleus of activity that's been out on the Internet for some time. Time with some people who claim that they did not recover. But that's not what we're, that's not what we're experiencing.
 
 Nancy Cavey [00:30:33]:
 Okay, great. Now I have my own thoughts about this question, but I'm going to ask it to have you.
 
 Dr. Betsy Keller [00:30:38]:
 Sure.
 
 Nancy Cavey [00:30:40]:
 As a practitioner, how do you believe the CPET results are received by disability insurance companies and plans? And have you seen a growing recognition of this data in disability claims? Or is there some continuing resistance, Far.
 
 Dr. Betsy Keller [00:30:57]:
 Less resistance than there used to be 15 years ago, 20 years ago, writing these reports. I mean, you would provide the subjective evidence. And if they got an independent medical examiner physician to say, well, but I think this all it took, even though here we have the objective evidence. When I say a plethora of data out there, we're talking many, many, many decades of data showing the objectivity of cardiopulmonary exercise testing. If a doc said, but I think in my professional opinion, blah, blah, blah, then you know, the insurance companies were looking for any little thing to latch onto and the heck with. And I've also had IMEs, you know, write their reports where they've reviewed all the medical records of the individual and talked about the cognitive function test, etc. Etc. And they said, and Keller did a two day test, boom, next paragraph.
 
 Dr. Betsy Keller [00:32:12]:
 And that was it. And that was it. Seriously, I'm not joking. And there was no comment about it because what are they going to say? And that's kind of where we're at now. It's like you can't refute it because we all have seen it around long enough, we've learned about it long enough and there's, you know, decades of data out there on cardiac and pulmonary patients. So it's become more and more difficult to refute a cardiopulmonary exercise test data. And so we are seeing it be more impactful than it's ever been before. That said, we'll still get the IME report that says, you know, in my professional opinion, blah, blah, blah.
 
 Dr. Betsy Keller [00:32:58]:
 And sometimes I'm asked to write a rebuttal to that and then I just dig back into the data and I pull out the studies and I explain again what this means and refute some of the most ridiculous statements I've ever heard about, about cardiopulmonary exercise testing that are just blatantly incorrect and refute that and I submit a rebuttal letter. But it's become much more impactful and accepted than it was certainly 15 years ago.
 
 Nancy Cavey [00:33:33]:
 And that's been my experience. I mean, we always argue that the CPET is scientifically valid and reliable and that and physicians should be hard pressed to challenge both its validity and its reliability.
 
 Dr. Betsy Keller [00:33:46]:
 So yes, and Josh, if you want to move to the next slide, I'll just. I forgot that I did put that in there. So let's take a quick look at that. And this. I know it's a lot of small print here, but basically what you're looking at is a table that was produced by the Workwell Foundation a while ago. And it, and then showing a bunch of different studies with different patient populations. So you've got, on the far left, you've got sedentary individuals. And it's showing the variability from, or the reproducibility of tests in various measures that we typically look at during an exercise, a cardiopulmonary exercise test.
 
 Dr. Betsy Keller [00:34:25]:
 So those measures are down the left side of the chart there, across the top or the, the different studies and across the very bottom are, you know, we have, as I said, sedentary people on the left, trained individuals next to that and a bunch of different diseases represented in the studies. For, you know, through the middle to the right of the table there. And the variability, if you can read those numbers, is small. You know, it's, it's within 7% that you should be able to reproduce your aerobic capacity or your VO2 max from test one to test two. And in many studies it's even smaller than that. So we kind of use 7% as our cutoff when we do these tests for determining whether somebody reproduced their peak oxygen consumption.
 
 Nancy Cavey [00:35:13]:
 I'm learning so much. But I think we need to take a break. So we'll be back in a second with more information about best practices and advice about CPETs.
 
 Speaker B [00:35:25]:
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 Nancy Cavey [00:36:10]:
 Welcome back to Winning Isn't Easy. So, Dr. Keller, let's talk about best practices and advice that you would give to someone who is thinking about undergoing a CPET exam. So let's talk about what advice you would give to a person about making the decision to undergo a cpet. What should they know going in?
 
 Dr. Betsy Keller [00:36:46]:
 Great question. And I'm going to give you the good, the bad and the ugly about this because there, there is good, bad and ugly. And we'll start with the ugly. And the ugly is there are not enough people who are really well versed in administering and more important, well, as importantly, interpreting the two day cardiopulmonary exercise test in the country. There's. We, we need more people to learn how to do this and over the years, I've had individuals say, well, you know, I can't get to Ithaca. I know we're in the middle of the state. We, we have a lot of wineries around here and some beautiful lakes.
 
 Dr. Betsy Keller [00:37:28]:
 We're in the Finger Lakes region, but still we're, we're four hours from New York City and, you know, two hours from Rochester and an hour from Syracuse, and we're, we're in the middle of the state, so I can't get there. And so I talked to my local hospital and they'll do two cpets for me. And so, you know, the devil is in the details when you do these. And the reason that we do them with a stationary cycle is because it's much easier to more precisely reproduce the workload on day one with the workload on day two. When you have somebody on the cycle, when you put them on a treadmill, if they grab the handlebars to steady themselves, they've automatically changed the work that they're doing. So there's much more variability when you use a treadmill. And for that reason we use a cycle. But to get back to the issue here is not only doing the protocol correctly, and we have published a paper on that, but still we find people doing five minute warm ups.
 
 Dr. Betsy Keller [00:38:33]:
 You can't do five minute warmups with these people. That will be the end of the test. But then what do you do with the data? And the important thing for somebody who's seeking, considering a two day cardiopulmonary test is they need some kind of report produced that's going to speak to their issues of not being able to sit at a desk for more than five minutes at a time. And how do you go about creating that kind of report based on the CPET data? And that's where it becomes problematic, where we have very few people who are experienced and knowledgeable to be able to translate that data to activities of daily living. Not only doing the test correctly, because I've actually sent the recipe to clinics and said, okay, please do this. And what I get afterwards send me the data is not what I asked them to do. And so now the poor person went through the testing and it wasn't done correctly. And, and you know, and for that reason, we typically don't analyze data that was collected elsewhere because we didn't have any control over it.
 
 Dr. Betsy Keller [00:39:51]:
 We didn't know if they did, if the lab or the clinic did bio calibration, which is really important to make sure that your measures are accurate. And then we get to the interpretation part of the thing, which is a whole other ball of wax too. So that's the ugly part of finding somebody who can do that. And there are people who have a lot of experience doing that. Certainly the Workwell foundation on the west coast has been doing it for over 20 years, as have I. But it's difficult, especially if you're in the middle of the country.
 
 Nancy Cavey [00:40:25]:
 Right.
 
 Dr. Betsy Keller [00:40:27]:
 So that's, that's the ugly. The bad is you sort of hinted to that it's how do we get you to our exercise test site even if you're not, even if you're only going 45 minutes and not pre fatigue you. And, and the answer to that is you don't. But Josh, if you could go to the next slide, Some of the things that I would encourage you to consider if you're thinking about doing a two day cardiopulmonary test is to pre rest before you come to wherever you're going to get the test done. Depending on the amount of travel and the modes of travel, airplane, train, whatever, bus, that might mean that you pre rest even more so for people with fatiguing illnesses. Certainly try to schedule a week before you come to us where you really don't have much high demand. And when I say demand, I mean not just physical, but I mean emotional and very importantly cognitive. So try to limit your cognitive stress screen time, you know, challenging thinking, all of that, and I'll get back to that in a second.
 
 Dr. Betsy Keller [00:41:45]:
 So try to pre rest before you come to us because we know travel is going to alter your baseline somewhat. All right. Sometimes people, if they're able, they'll, they'll come a day early. Everybody has to come a day before the protocol. You don't want to. We don't take people who travel in the day of the protocol unless they're less than an hour away. But everybody arrives a day before. We've had some people flying from the Midwest or the West Coast a couple of days ahead just so they could just rest in the hotel room, do the protocol, and then sometimes they'll add a day or two afterwards instead of traveling right away.
 
 Dr. Betsy Keller [00:42:23]:
 But know that we're going to provoke your post exertional response. To what extent, we don't know. And that varies from one person to the next. Actually, you know probably better than any of us what your post exertional response will be. So plan for that. Don't plan parties, appointments with your attorney, sorry, Nancy. Or your doctors right after you finish a two day test. If you can have a Support person with you.
 
 Dr. Betsy Keller [00:42:53]:
 If your doctor agrees that arranging for post test IV saline infusion, sometimes a liter of IV saline really helps because remember I said blood flow with oxygen to the muscles and the brain is impacted in everybody. So sometimes some people will find that getting a liter of IV saline after the test, even if after they get back home, is really helpful to jumpstart their recovery. That said, you would want to talk to your physician about it because I don't know necessarily before you walk in my door if, if you're hypertensive and I might not want to be putting a liter of saline in there if you are. Most of the people we test are not. And then plan your trip. So if you do have air transport, you know, arrange with the airlines that you're not walking through that airport and put your headphones on, put your sunglasses on, put you know, whatever you need to do your, whatever you need to do to tamp down the stimuli and you know, make sure you've got drinks. If you can go and get into, you know, US Airways lounge area or whatever quiet lounge area, that, that can be helpful too or whatever airline you're traveling. But those are the things you'd want to do in planning a trip to come for a two day test.
 
 Nancy Cavey [00:44:19]:
 So let me ask you this and I get this question, these two questions a lot. Should I take my medication as normally scheduled before the CPET exam? And you know, I am so anxious about this exam and the results and the impact that's going to have on my case. Is my anxiety going to screw up the results?
 
 Dr. Betsy Keller [00:44:39]:
 Great.
 
 Nancy Cavey [00:44:40]:
 Those two questions, great question.
 
 Dr. Betsy Keller [00:44:42]:
 And we get it all the time. So I send people back to their physician to discuss with their physician whether or not they should come out their meds. So there's two schools of thought. One is that if, if you're on your meds and your meds are helping you and we test you, then we're getting test results based on, you know, your, your best case scenario because you've got benefit of your meds helping you and is that going to impact, you know, your level of impairment that we might detect or may not detect because, because of the meds. So if you want the worst case scenario from, from your data, then you would want to talk to your physician about should I come off all my meds? Because that's you, right? That's you unmedicated, that's your personality, that's the most organic you you can get. And if you want to know, can your organic self produce, produce enough energy to you know, to do what you need to do or not, then if that's what you want us to evaluate with our cpet, then that's. Then you would come off your meds. For some people, they'll decide maybe I need to stay on this one for my anxiety.
 
 Dr. Betsy Keller [00:45:59]:
 But everything else, I'm coming off. And I ask you to make that decision with your physician because how you sometimes weaning off those meds takes a few days. And that's something you should discuss with them. Does that make sense?
 
 Nancy Cavey [00:46:14]:
 It does. Yeah, it does. And so obvious the question that we both get is how much is this going to cost and potentially who's going.
 
 Dr. Betsy Keller [00:46:23]:
 To pay for it? We provide the procedure codes so you can check with your insurer. We don't do anything with insurance. We are bare bones trying to provide the services inexpensively as possible. And I can't tell you what other clinics charge because I honestly don't know. We know that five years ago when we tried to, you know, survey where, you know, what other clinics were test charging that I think out on the west coast at Stanford, they were charging $10,000 per test.
 
 Nancy Cavey [00:47:01]:
 Right.
 
 Dr. Betsy Keller [00:47:02]:
 We don't do that. Our cost right now is 3500 for the whole protocol, including your report. So. And that's. Yeah, on average we, we spend about, from beginning to end, you know, beginning with the initial email and email time and testing and report generation. We spend about 20 to 25 hours per person. So. And we have multiple people and expensive equipment.
 
 Dr. Betsy Keller [00:47:29]:
 So $3,500 is pretty bare bones inexpensive. But the cardiopulmonary test protocol procedure number is very common. It's the same one they use, you know, for cardiac patients and everything else. So it just depends on whether your insurer is going to give you the song and dance about in network, out of network. And I always tell people, find somebody in network. You won't. It's not going to happen.
 
 Nancy Cavey [00:47:59]:
 Right.
 
 Dr. Betsy Keller [00:47:59]:
 You can go to the, you can go to the east coast, you can go to the west coast for this test protocol, but the chances of finding somebody in network is about zero. So, you know, you can tell that to your insurer and also remind them that you do the test twice. So the procedure code is applied twice. I would love to be able to say this insurer, you know, reimburses at this amount and I can't, I have no idea because we, we get everything from soup to nuts. And I honestly don't see it. You know, the person we're testing is the one that deals with that.
 
 Nancy Cavey [00:48:33]:
 Okay. So if someone wanted to contact you and your facility to explore undergoing a CPET exam, how would they go about doing it?
 
 Dr. Betsy Keller [00:48:42]:
 I will put a slide up here next and with some email addresses. But Josh, if you can go one more slide, I want to just show before. Go back to the last slide. Slide, please. That one, Yes. I just want to hammer home one point here. These are all a lot of the measurements that we get, not all of them that we get from doing a cardiopulmonary test on the right side of this slide. And I know they're tiny, so don't strain your eyes, but what is hugely important, if you're contemplating getting a test done somewhere and they are not measuring blood pressure, please don't do your test there because they need to be measuring what we call hemodynamic response to exercise is so important for this patient population.
 
 Dr. Betsy Keller [00:49:29]:
 So blood pressure before, during and after exercise is hugely important. The last slide, Josh, if you would. So you can contact the Workwell Foundation. They've been doing this for many, many, well, decades now. At infowerkwellfoundation.org we are collaborating with them and are literally this week in the process of getting our. Our clinic opened, our new space in Ithaca at. And you can go to infowerorkwelleast.org and connect with us that way as well.
 
 Nancy Cavey [00:50:06]:
 Neat. Well, I thank you for the time that you've taken today to put together this presentation and to be our guest. I've learned so much and I know that members of our audience are just going to be blown away by what you. You've shared with us today. So thank you for taking the time to be with us and for our listeners. Thank you for tuning in this week. I hope that you found this episode helpful. I certainly did.
 
 Nancy Cavey [00:50:29]:
 Please take a moment to like our page, leave a review, share it with your family or friends, and please subscribe to the podcast. Join us next week for another insightful discussion and episode of Winning Isn't Easy.
 
 Dr. Betsy Keller [00:50:42]:
 Thanks for listening and thank you, Nancy. Thank you.