The Counting Talk Test

Time to give you guys another tool. This one is especially important for patients with COVID-19, and it’s not terribly often that we get an objective measure for exertion. I’ve found the counting talk test to be critical in quantifying exertion in my patients with respiratory diagnoses. This measure is phenomenal for taking breathlessness in to account.

Here’s how it works:

1. At rest, have the patient take a breath and count out loud as high as they can. Record that last audible number. (FYI – this works best if done in standing, but be sure the patient is in the same position pretest and posttest)
2. Have the patient perform the exercise you intent to prescribe.
3. While they are working, have them perform the count again. Record the last audible number.
4. Do some math using this worksheet

I know, I don’t like math either, but it’s simple math and it gives you a lot of information like amount of effort expended with exercise and precent workload which then corresponds to the Borg RPE scale. I created this worksheet with outpatient cardiac rehab or subacute rehab/home health in mind, so the workload goal at the bottom is a bit on the high end for a patient with COVID-19, where you should be targeting 4-5/10 at first.

Why do you need another scale for measuring exertion? You already have the Borg scale, the Borg RPE scale, the Borg Dyspnea scale, and the VAS for exertion… Here’s the thing: those are all subjective and are difficult to understand for people who have delirium, confusion, or cognitive impairment, as do many of the patients who have COVID-19 once they reach rehab. Some clinicians have found that, when working with patients with COVID-19, these factors prevent effective use of the typical RPE scales in practice. Yes, you also have blood pressure, heart rate, and oxygen saturation to rely on, but these things are affected by medications like beta blockers. So, although they are objective, they don’t give you a true clinical picture of the exertion the patient is experiencing.

You need something truly objective. Of course, if the patient has severe delirium, confusion, or cognitive impairment, they may not be able to count to 30. So you will have to rely on vitals, but since we know these are not a great representation, we should use the best tool we have if the patient is able to participate in it. This is a great test for the post-COVID population because exercise intensities are generally on the lower end so speech-rate variability with exercise does not impact the test (see link in references for more on this).

Most patients with respiratory conditions can count to some number in the high 20’s. I’ve had coworkers reach up in to the low 40’s during training with this tool! The cool thing is, it doesn’t matter what number they reach, because you retest every day and use their top resting number as your baseline for that session. We all know that people with pulmonary conditions look pretty different from one day to the next, so it’s important that the tool be as flexible as their presentations are.

This test is also great because it can be incorporated into ADL performance. We know that with many patients who have advanced pulmonary diseases or who have COVID-19, their tolerance to ADL can be significantly diminished. The counting talk test can also be utilized during ADL performance (like taking a shower!) to determine energy expenditures and RANK activities according to expenditure! This can guide interventions and point a clinician toward what activities need to be modified to decrease energy expenditure! Energy conservation interventions just got a whole lot more clearly identifiable! Obviously you don’t want to do several ADL in a row for measurement as the total workload would increase the energy expenditure. But at least this gives you a quantifiable way to document tasks.

When prescribing interventions, you can also use the energy expenditure numbers (as a percentage) to demonstrate improvement over time. If one minute of squats utilized 46% of my energy today, but after 8 weeks of boot camp, only used 34% of my energy, I could document evidence of cardiovascular reconditioning.

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In the comments, tell me how you use the counting talk test in your practice!

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References

Validity of the CTT: https://www.ncbi.nlm.nih.gov/pubmed/18496320

Speech Rate Variability due to Exercise: https://www.ncbi.nlm.nih.gov/pubmed/30034101

Consistency of the CTT: https://www.ncbi.nlm.nih.gov/pubmed/21904237

Use in Cardiovascular Disease: https://www.ncbi.nlm.nih.gov/pubmed/25010379

Levenhagen, K., Gorman, S., Verma, A., Kumble, S., Lopker, M. (2020). Physical Therapy Considerations of Neurologic Presentations in COVID-19. [Webinar] Viewed May 8, 2020. https://register.gotowebinar.com/recording/8523389256235766031