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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> The maximal oxygen uptake &#40;VO<span class="elsevierStyleInf">2max</span>&#41; is a basic measure of physical fitness for athletes&#44; mainly in the cases where the performance is influenced by the aerobic power&#46; The direct measurement is considered the gold standard to assess it&#44; but this is rather complex and expensive&#46; In consequence&#44; a variety of indirect tests have been developed to estimate VO<span class="elsevierStyleInf">2max</span>&#44; such as &#197;strand-Rhyming 6-minute cycle ergometer test&#44;<span class="elsevierStyleSup">1 </span>Balke 15-minute run&#44;<span class="elsevierStyleSup">2 </span>Cooper 12-minute run&#44;<span class="elsevierStyleSup">3 </span>Bruce treadmill test&#44;<span class="elsevierStyleSup">4 </span>the multistage 20-metre shuttle run tests of L&#233;ger and Lambert<span class="elsevierStyleSup">5 </span>and L&#233;ger et al&#46;&#44;<span class="elsevierStyleSup">6 </span>1-mile track jog<span class="elsevierStyleSup">7 </span>and Yo-Yo endurance test&#46;<span class="elsevierStyleSup">8 </span>The Yo-Yo endurance test &#40;YET&#41; is a continuous multistage field test that is widely implemented to estimate VO<span class="elsevierStyleInf">2max</span> as an alternative to the direct laboratory measurement&#44; because of its specificity&#44; its practical and easy implementation and the simple testing environment required&#46; It is one of the three Yo-Yo tests&#46;<span class="elsevierStyleSup">8 </span>The other ones are the Yo-Yo intermittent endurance test &#40;YIET&#41; and the Yo-Yo intermittent recovery test &#40;YIRT&#41;&#44; the last one also providing an estimation of VO<span class="elsevierStyleInf">2max</span>&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara"> The Bland-Altman approach<span class="elsevierStyleSup">10-12 </span>has been extensively applied to compare methods of measurement in diverse research areas&#46; It allows to assess the degree of agreement between two measurement techniques&#44; to determine if they can be used interchangeably&#46; However&#44; method comparison studies are sometimes analysed inappropriately&#44; by comparing the mean responses&#44; by using correlation coefficients or by testing the slope of the linear regression between the methods&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara"> Different studies have compared the direct VO<span class="elsevierStyleInf">2max</span> measurement obtained through a treadmill exercise test with the outcomes of the Yo-Yo tests in athletes&#46;<span class="elsevierStyleSup">13-26 </span>In most cases the population under study was football players&#46; In these works&#44; the direct assessment of VO<span class="elsevierStyleInf">2max</span> was compared with the performance &#40;distance covered&#41; in the Yo-Yo tests&#44; or with the indirect estimation of VO<span class="elsevierStyleInf">2max</span> obtained from YET or YIRT&#46; Linear correlations were examined or mean responses were contrasted&#46; Some of the studies that compared the VO<span class="elsevierStyleInf">2max</span> estimation given by the Yo-Yo test &#40;YET or YIRT&#41; with the direct measurement also reported Bland-Altman limits of agreement&#46;<span class="elsevierStyleSup">15&#44;21&#44;25 </span>However&#44; confidence intervals for these limits were not included&#46; Furthermore&#44; it would be ideal to define the acceptable limits of agreement <span class="elsevierStyleItalic">a priori</span>&#46; Although it may be difficult for physiologic variables&#44; an attempt should be made&#59; the opinion of experts may be used&#46; Without <span class="elsevierStyleItalic">a priori </span>setting of limits of agreement&#44; widely discrepant limits may be selected&#46;<span class="elsevierStyleSup">27</span></p><p class="elsevierStylePara"> The uncertainty due to sampling error should be considered not only when estimating the difference between methods &#40;bias&#41;&#44; but also when estimating the limits of agreement&#46;<span class="elsevierStyleSup">12 </span>This issue is of crucial importance when the sample size is small&#46; The Bland-Altman approach provides statistical methodology to quantify the precision of the estimated limits of agreement&#46; Nevertheless&#44; no method comparison studies were found between the direct measurement of VO<span class="elsevierStyleInf">2max</span> and the indirect estimation by the Yo-Yo test &#40;YET or YIRT&#41; that include confidence intervals for the limits of agreement&#46; This study aimed to examine the extent of agreement in the assessment of VO<span class="elsevierStyleInf">2max</span> in athletes between the Yo-Yo endurance test and the direct measurement performed in an incremental treadmill running test&#44; and to quantify the precision of the estimated limits of agreement&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Material and methods</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Participants</span></p><p class="elsevierStylePara"> Data were obtained from a group of 11 competitive male field hockey players&#46; All subjects or their guardians gave consent to participate in the study after being informed of the aims and procedures&#46; The study was conducted based on the ethical principles of the Declaration of Helsinki of the World Medical Association&#46; Each participant underwent a physical examination before the testing sessions&#46; Table 1 displays a statistical summary of the kinanthropometric characteristics of the athletes&#46; Age was calculated in decimal years&#44; by subtracting the date of birth from the date of assessment&#46; Percentages of fat mass and muscle mass were estimated using the four-compartment model based on the strategy of De Rose and Guimaraes&#46;<span class="elsevierStyleSup">28 </span>This model was adapted using the simple regression equation for male athletes developed by Withers et al&#46;&#44; which was cited by Norton&#44;<span class="elsevierStyleSup">29 </span>to estimate body density&#44; and Siri formula<span class="elsevierStyleSup">30 </span>to calculate the percentage of fat mass&#46;</p><p class="elsevierStylePara"><img alt="Table 1&#46; Kinanthropometric characteristics of the athletes&#46;" src="276v52n193-90460847fig1.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Study design</span></p><p class="elsevierStylePara"> The present research is a study of simple cross-over design&#44; in order to evaluate agreement in assessing VO<span class="elsevierStyleInf">2max</span> in ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1 </span>between the Yo-Yo endurance test and the direct measurement&#59; a special focus is on the interval estimation of the limits of agreement&#46; The direct measurement of VO<span class="elsevierStyleInf">2max</span> &#40;DM&#41; was conducted in the Exercise Physiology Laboratory of the National Center of High Performance Athletics &#40;CeNARD&#44; Buenos Aires&#44; Argentina&#41;&#44; using an incremental running test on a motorized treadmill &#40;Technogym Excite Run 700i&#59; Technogym SpA&#44; Gambettola&#44; Italy&#41;&#46; Breath-by-breath data collection was obtained by means of a computerized open-circuit metabolic system &#40;Medgraphics Cardiopulmonary Exercise System CPX&#47;D&#44; Breeze Ex v3&#46;06 software&#59; Medical Graphics Corporation&#44; St&#46; Paul&#44; MN&#44; USA&#41;&#46; Increments in treadmill speed of 1 km h<span class="elsevierStyleSup">&#8722;1</span> every minute were stipulated until volitional exhaustion &#40;initial speed &#61; 9 km h<span class="elsevierStyleSup">&#8722;1</span>&#41;&#46; Heart rate was controlled with a heart rate monitor &#40;Polar 610i&#59; Polar Electro Oy&#44; Kempele&#44; Finland&#41;&#46; VO<span class="elsevierStyleInf">2</span>plateau &#40;change in VO<span class="elsevierStyleInf">2</span> difference less than 2&#46;1 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1 </span>with a further increase in workload&#41; was the primary criterion for the attainment of VO<span class="elsevierStyleInf">2max</span>&#59; secondary criteria were&#58; respiratory exchange ratio greater than 1&#46;1 and heart rate within 10 beats min<span class="elsevierStyleSup">&#8722;1 </span>of age-predicted maximum heart rate&#46;<span class="elsevierStyleSup">31&#44;32 </span>The Yo-Yo endurance test level 1 was performed indoor at CeNARD&#44; in a sport hall with wooden sprung floor&#46; It consisted of repeated 20-m shuttle runs at a progressively increased speed &#40;initial speed &#61; 8 km h<span class="elsevierStyleSup">&#8722;1</span>&#41;&#44; which was controlled by audio beeps from a portable audio player&#46; The test was considered ended when the participant was unable to maintain the currently indicated speed&#46; The final speed level and the number of performed 20-metre distances at this speed level were recorded&#46; The estimation of VO<span class="elsevierStyleInf">2max</span> was then obtained using the corresponding nomogram&#46; Both YET and DM took place at the same time of day &#40;&#177;2 hours&#41;&#44; to minimize the effects of diurnal biological variation on the results&#44; and were carried out at least 72 hours apart from each other to avoid residual fatigue&#46; The order of the tests was randomly assigned for each subject&#46; Prior to the evaluations&#44; the participants had a 20-minute related warm-up&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistical analysis</span></p><p class="elsevierStylePara"> The kinanthropometric characteristics of the athletes and the heart rate and respiratory exchange ratio values reached when achieving VO<span class="elsevierStyleInf">2max</span> were reported as mean &#177; standard deviation &#40;SD&#41;&#46; Summary statistics were produced to describe the VO<span class="elsevierStyleInf">2max</span> values obtained by means of YET and DM&#46; Bland-Altman analysis was employed for assessing agreement between the two methods of measurement&#46;<span class="elsevierStyleSup">10-12</span> In accordance to Bland&#44;<span class="elsevierStyleSup">33 </span>the acceptable 95&#37; limits of agreement were established on the basis of experience&#44; and were set <span class="elsevierStyleItalic">a priori </span>at &#177;5 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; The 95&#37; confidence intervals for the limits of agreement were also computed&#46; In view of the small sample size&#44; they were estimated using the exact expression for the estimator of the variance of the limits of agreement instead of the approximate one<span class="elsevierStyleSup">12</span>&#58;</p><p class="elsevierStylePara"><img src="276v52n193-90460847fig2.jpg"></img></p><p class="elsevierStylePara"> where <img alt="F&#243;rmula" src="277v52n193-90460721figsi4.gif"></img> is the mean difference between methods and <span class="elsevierStyleItalic">s<span class="elsevierStyleInf">d </span></span>is the standard deviation of the differences&#46; Pearson&#8217;s and Spearman&#8217;s correlation tests were implemented to evaluate possible associations of the difference between YET and DM with the magnitude of the measurement&#46; Statistical significance was set at the 0&#46;05 probability level&#46; All analyses were performed using the R software environment&#44; version 3&#46;2&#46;0 &#40;R Core Team&#44; Vienna&#44; Austria&#41;&#46;<span class="elsevierStyleSup">34</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara"> The VO<span class="elsevierStyleInf">2max</span> values obtained for each individual using the two methods of measurement were quite similar&#46; The VO<span class="elsevierStyleInf">2max</span> values estimated by YET were&#44; on average&#44; only 0&#46;6&#37; lower than those determined by DM&#46; Table 2 presents a descriptive summary of the outcomes of YET and DM and of the differences between them&#46; The heart rate and respiratory exchange ratio values reached when achieving VO<span class="elsevierStyleInf">2max</span> are summarized in Table 3&#46;</p><p class="elsevierStylePara"><img alt="Table 2&#46; VO2max assessment&#58; comparative summary of both methods of measurement&#46;" src="276v52n193-90460847fig3.jpg"></img></p><p class="elsevierStylePara"><img alt="Table 3&#46; Heart rate and respiratory exchange ratio values reached when achieving VO2max&#46;" src="276v52n193-90460847fig4.jpg"></img></p><p class="elsevierStylePara"> A non-statistically significant bias was found between YET and DM &#40;&#8722;0&#46;31 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#59; 95&#37; confidence interval&#58; &#8722;1&#46;69 to 1&#46;07 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41;&#46; The estimates of the lower and upper 95&#37; limits of agreement were &#8722;4&#46;34 and 3&#46;72 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; And the 95&#37; confidence intervals for these limits were&#44; respectively&#44; from &#8722;6&#46;78 to &#8722;1&#46;90 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; and from 1&#46;29 to 6&#46;16 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; As previously mentioned&#44; given the small sample size&#44; the confidence intervals for the limits of agreement were constructed using the exact expression for the estimator of the variance of these limits &#40;Eq&#46; &#40;1&#41;&#41;&#46; The region determined by the estimated 95&#37; limits of agreement was narrower than the region bounded by the acceptable limits defined <span class="elsevierStyleItalic">a priori</span>&#46; However&#44; the total region covered when considering the 95&#37; confidence intervals for the 95&#37; limits of agreement was wider than the <span class="elsevierStyleItalic">a priori </span>acceptable limits&#46; The typical Bland-Altman plot with estimated bias and 95&#37; limits of agreement between methods is shown in Fig&#46; 1&#44; while all the aforementioned results are presented graphically in Fig&#46; 2&#46;</p><p class="elsevierStylePara"><img alt="Figure 1&#46; VO2max&#58; Difference between methods against the average measurement with bias and 95&#37; limits of agreement&#46;" src="276v52n193-90460847fig5.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 1&#46; </span>VO<span class="elsevierStyleInf">2max</span>&#58; Difference between methods against the average measurement with bias and 95&#37; limits of agreement&#46;</p><p class="elsevierStylePara"><img alt="Figure 2&#46; VO2max&#58; Mean and 95&#37; limits of agreement of the difference between methods with 95&#37; confidence intervals&#46;" src="276v52n193-90460847fig6.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 2&#46; </span>VO<span class="elsevierStyleInf">2max</span>&#58; Mean and 95&#37; limits of agreement of the difference between methods with 95&#37; confidence intervals&#46;</p><p class="elsevierStylePara"> It was observed in the data that neither the difference nor the absolute value of the difference appeared to be correlated to the magnitude of the measurement&#46; In that order&#58; Pearson&#8217;s <span class="elsevierStyleItalic">r </span>&#61; 0&#46;02 &#40;95&#37; confidence interval&#58; &#8722;0&#46;59 to 0&#46;61&#41;&#59; Spearman&#8217;s rho &#61; &#8722;0&#46;06 &#40;95&#37; confidence interval&#58; &#8722;0&#46;64 to 0&#46;56&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara"> The indirect measurement of VO<span class="elsevierStyleInf">2max</span> is frequently performed in sport evaluation&#46; Maximal and submaximal effort protocols have been proposed to estimate the maximal aerobic power of an individual&#46;<span class="elsevierStyleSup">1-9 </span>Good agreement with the direct measurement should be the main objective of these tests&#46; The Yo-Yo endurance test is a continuous multistage field test broadly used to indirectly assess VO<span class="elsevierStyleInf">2max</span>&#46;<span class="elsevierStyleSup">15 </span>Its mechanical characteristics make it suitable for athletes participating in sports that involve stop&#44; start and change of direction movement patterns&#46;</p><p class="elsevierStylePara"> Diverse studies have been conducted to compare the outputs provided by the Yo-Yo tests with the VO<span class="elsevierStyleInf">2max</span> obtained by direct measurement in an incremental running test on treadmill&#46; The comparisons involved contrasting the VO<span class="elsevierStyleInf">2max</span> values or testing the correlation between directly measured VO<span class="elsevierStyleInf">2max</span> values and distances covered in the Yo-Yo tests&#46; Some of the studies that compared the VO<span class="elsevierStyleInf">2max</span> results of both methods also included the evaluation of agreement&#46; For instance&#44; Metaxas et al&#46;<span class="elsevierStyleSup">22 </span>found in male football players &#40;<span class="elsevierStyleItalic">n </span>&#61; 35&#41; statistically significant differences &#40;<span class="elsevierStyleItalic">p </span>&#60; 0&#46;05&#41; when comparing the VO<span class="elsevierStyleInf">2max</span> estimations given by YET level 1 with the VO<span class="elsevierStyleInf">2max</span> values obtained by DM in either a continuous or an intermittent running protocol on a treadmill &#40;YET level 1 values lower than DM values by 11&#46;4&#37; and 13&#46;4&#37;&#44; respectively&#41;&#46; Castagna et al&#46;<span class="elsevierStyleSup">15 </span>contrasted the VO<span class="elsevierStyleInf">2max</span> results of YET level 2 with the ones of DM in male football players &#40;<span class="elsevierStyleItalic">n </span>&#61; 24&#41;&#44; evidencing a non-statistically significant bias &#40;<span class="elsevierStyleItalic">p </span>&#61; 0&#46;10&#41; of 1&#46;17 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; and 95&#37; limits of agreement of &#8722;5&#46;44 and 7&#46;79 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; Nazarali et al&#46;<span class="elsevierStyleSup">23 </span>reported a higher mean for the VO<span class="elsevierStyleInf">2max</span> values provided by YIRT level 2 &#40;50&#46;8 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41; in comparison to the mean of the values determined by DM &#40;43&#46;6 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41;&#44; in a study conducted with female football players &#40;<span class="elsevierStyleItalic">n </span>&#61; 20&#41;&#46; In contrast&#44; Mart&#237;nez-Lagunas and Hartmann<span class="elsevierStyleSup">21 </span>found in female football players &#40;<span class="elsevierStyleItalic">n </span>&#61; 18&#41; that VO<span class="elsevierStyleInf">2max</span> was significantly underestimated &#40;<span class="elsevierStyleItalic">p </span>&#60; 0&#46;001&#41; by YIRT level 1 &#40;45&#46;2 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41; compared to DM &#40;55&#46;0 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41;&#44; expressing the 95&#37; limits of agreement on a percentage scale &#40;&#8722;31&#46;8&#37; to &#8722;3&#46;8&#37;&#41;&#46; And S&#225;nchez-Oliva et al&#46;<span class="elsevierStyleSup">25 </span>examined the assessments of the two methods in male football players &#40;<span class="elsevierStyleItalic">n </span>&#61; 15&#41; and also found a statistically significant underestimation of VO<span class="elsevierStyleInf">2max</span> using YIRT level 1 &#40;51&#46;00 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41; in comparison to DM &#40;60&#46;85 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41;&#44; with 95&#37; limits of agreement of 3&#46;37 and 16&#46;33 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46;</p><p class="elsevierStylePara"> On the other hand&#44; no research articles were found reporting method comparison studies by using Bland-Altman analysis between the direct measurement of VO<span class="elsevierStyleInf">2max</span> and the indirect estimation by the Yo-Yo test &#40;YET or YIRT&#41; that consider the computation of confidence intervals for the limits of agreement&#46; This is a matter of particular importance in the case of small sample size&#44; which is a frequent situation in studies involving maximal effort testing&#46; The variance of the mean difference and that of the limits of agreement are inversely proportional to the sample size&#46; Therefore&#44; the corresponding confidence intervals are wide when the sample size is small&#44; reflecting the great variation of the differences between methods&#46;</p><p class="elsevierStylePara"> This research presents a thorough method comparison study between the direct assessment of VO<span class="elsevierStyleInf">2max</span> in laboratory conditions and the indirect estimation by means of the Yo-Yo endurance test&#44; which is a continuous multistage field test especially useful for athletes of endurance disciplines&#44;<span class="elsevierStyleSup">8 </span>but also suitable for sports teams<span class="elsevierStyleSup">35</span>&#44; such as field hockey&#44; football and rugby players&#46; Estimates of bias and 95&#37; limits of agreement between methods are reported&#46; Furthermore&#44; accurate 95&#37; confidence intervals for the limits of agreement are also reported for the current sample size&#46; A small bias was observed between the two techniques&#44; which resulted to be not statistically significant &#40;<span class="elsevierStyleItalic">p </span>&#61; 0&#46;63&#41;&#46; The estimated 95&#37; limits of agreement set at &#177;4&#46;03 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1 </span>from the mean difference between them&#46; In the model proposed&#44; for the mean and standard deviation of the differences between methods to be meaningful estimates it must be assumed that they are constant throughout the range of measurement&#46;<span class="elsevierStyleSup">12&#44;36&#44;37 </span>It is worth emphasizing that the mean difference and the standard deviation of the differences appeared not to depend on the magnitude of the measurement&#44; which complies with the assumptions underlying the simple 95&#37; limits of agreement method applied&#46; The region determined by the estimated limits of agreement was within the acceptable limits defined <span class="elsevierStyleItalic">a priori</span>&#46; However&#44; these estimates have a large variance due to the small sample size&#44; so this last result has to be considered with caution&#46; Taking into account the 95&#37; confidence intervals for the 95&#37; limits of agreement&#44; the total region extended beyond &#177;6 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; exceeding the acceptable 95&#37; limits of agreement established <span class="elsevierStyleItalic">a priori</span>&#46;</p><p class="elsevierStylePara"> The confidence intervals for the mean difference and for the limits of agreement provide a measure of precision of the point estimates&#44; based on sampling error&#46; The variances of the estimators of these quantities are crucially affected by the sample size&#46; The smaller is the number of observations for the assessment of the difference between the methods&#44; the wider are the confidence intervals&#44; and the higher is the level of uncertainty&#46; Moreover&#44; although the Bland-Atman approach provides the methodology for constructing limits of agreement&#44; it does not state whether they are acceptable or not acceptable&#46; The acceptable limits should be defined <span class="elsevierStyleItalic">a priori</span>&#44; based on specific needs and goals&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Limitations</span></p><p class="elsevierStylePara"> The small sample size is a limitation of this study&#46; The 95&#37; confidence intervals for the 95&#37; limits of agreement given the current sample size are &#177;1&#46;19 units of the standard deviation of the differences between measurements of the two methods&#46; Therefore&#44; it would be advisable to reproduce the present analysis with larger sample sizes to increase the precision of the estimates produced&#46; Furthermore&#44; it would be relevant to simultaneously carry out a comparison of the repeatability of each method by collecting replicated data&#44; because the repeatabilities of two methods of measurement restrict the amount of agreement that is possible&#46;<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusions</span></p><p class="elsevierStylePara"> The point estimates of the 95&#37; limits of agreement were within &#177;5 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; satisfying the <span class="elsevierStyleItalic">a priori </span>requirement based on experience&#46; Thus&#44; a reasonable good agreement was found between the Yo-Yo endurance test and the direct laboratory measurement for the assessment of VO<span class="elsevierStyleInf">2max</span> in athletes&#46; According to this fact&#44; the two methods can be used interchangeably&#46; Nevertheless&#44; the need for caution in interpreting this result solely is further emphasized by the finding that the region covered when considering the 95&#37; confidence intervals for the 95&#37; limits of agreement was wider than the acceptable region of agreement defined <span class="elsevierStyleItalic">a priori</span>&#46; Hence&#44; although the estimated 95&#37; limits of agreement do not discredit the Yo-Yo endurance test as an alternative method to measure VO<span class="elsevierStyleInf">2max</span> in athletes&#44; the present study is limited in precision because of the small sample size and does not allow definitive conclusions&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interests</span></p><p class="elsevierStylePara"> Authors declare that they do not have any conflict of interests&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgments</span></p><p class="elsevierStylePara"> The authors wish to express special thanks to Mariela B&#46; Arangio&#44; Enrique D&#46; Balardini&#44; Claudio A&#46; Gillone&#44; Cristina Perez and Enrique O&#46; Prada for their technical assistance&#46;</p><hr></hr><p class="elsevierStylePara"><span class="elsevierStyleSup">&#9734;</span><span class="elsevierStyleItalic">Note</span>&#46; It is reported that a preliminary summary of this work was published given its presentation at &#8216;&#8216;57th Annual Meeting and inaugural World Congress on Exercise is Medicine of the American College of Sports Medicine&#8217;&#8217;&#46; The mentioned event took place in &#8216;&#8216;Baltimore Convention Center&#8217;&#8217; in Baltimore&#44; Maryland&#44; between 1 and 5 June 2010&#46; The summary was published in &#8216;&#8216;Medicine and Science in Sports and Exercise&#44; Volume 42&#58; 5 Supplement&#8217;&#8217;&#46;</p><p class="elsevierStylePara"> Received 12 April 2016&#59;<br></br> accepted 11 July 2016<br></br> Available online 15 September 2016</p><p class="elsevierStylePara"><span class="elsevierStyleSup">&#8727; </span>Corresponding author at&#58;<br></br> Exercise Physiology Laboratory&#44; National Center of High Performance Athletics &#40;CeNARD&#41; Miguel B&#46; S&#225;nchez 1050&#44; Buenos Aires &#40;Postal Code&#58; 1429&#41; Argentina&#46;<br></br><span class="elsevierStyleItalic">E-mail address&#58; </span><a href="mailto&#58;alongo&#64;deportes&#46;gob&#46;ar" class="elsevierStyleCrossRefs">alongo&#64;deportes&#46;gob&#46;ar</a> &#40;A&#46;F&#46; Longo&#41;&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"> Introducci&#243;n&#58; Si bien diferentes estudios han reportado l&#237;mites de concordancia en la valoraci&#243;n del VO<span class="elsevierStyleInf">2max</span> entre el Yo-Yo test y la medici&#243;n directa&#44; la precisi&#243;n de estos l&#237;mites en general no ha sido considerada&#46; El objetivo de este estudio fue examinar el grado de concordancia en la valoraci&#243;n del VO<span class="elsevierStyleInf">2max</span> en atletas entre el Yo-Yo endurance test &#40;YET&#41; y la medici&#243;n directa &#40;DM&#41;&#44; y cuantificar la precisi&#243;n de los l&#237;mites de concordancia estimados&#46;</p> <p class="elsevierStylePara"> Material y m&#233;todos&#58; Los datos fueron obtenidos de un grupo de 11 jugadores varones de hockey sobre c&#233;sped &#40;edad &#61; 22&#44;2 &#177; 3&#44;6 a&#241;os&#44; BMI &#61; 22&#44;1 &#177; 2&#44;4 kg m<span class="elsevierStyleSup">&#8722;2</span>&#41;&#46; La DM fue realizada usando un test de carrera incremental en cinta rodante&#46; El YET nivel 1 fue usado para la estimaci&#243;n indirecta del VO<span class="elsevierStyleInf">2max</span>&#46; El an&#225;lisis de Bland-Altman fue empleado para valorar la concordancia entre los 2 m&#233;todos&#46; Los l&#237;mites aceptables de concordancia del 95&#37; fueron fijados a priori en &#177;5 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46;</p> <p class="elsevierStylePara"> Resultados&#58; Un sesgo estad&#237;sticamente no significativo fue observado entre YET y DM &#40;50&#44;78 vs&#46; 51&#44;09 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; p &#62; 0&#44;05&#41;&#46; Las estimaciones de los l&#237;mites de concordancia del 95&#37; fueron &#8722;4&#44;34 y 3&#44;72 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; Y los intervalos de confianza del 95&#37; para estos l&#237;mites fueron&#44; respectivamente&#44; desde &#8722;6&#44;78 hasta &#8722;1&#44;90 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; y desde 1&#44;29 hasta 6&#44;16 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; La diferencia entre m&#233;todos pareci&#243; no estar correlacionada con la magnitud de medici&#243;n&#46;</p> <p class="elsevierStylePara"> Conclusiones&#58; Fue encontrada una razonable buena concordancia entre YET y DM&#46; Sin embargo&#44; la gran varianza de los l&#237;mites de concordancia debido al peque&#241;o tama&#241;o muestral hace necesario considerar este resultado con precauci&#243;n&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"> Introduction&#58; Although different studies have reported limits of agreement in assessing VO<span class="elsevierStyleInf">2max</span> between the Yo-Yo test and the direct measurement&#44; the precision of these limits in general has not been considered&#46; The aim of this study was to examine the extent of agreement in the assessment of VO<span class="elsevierStyleInf">2max</span> in athletes between the Yo-Yo endurance test &#40;YET&#41; and the direct measurement &#40;DM&#41;&#44; and to quantify the precision of the estimated limits of agreement&#46;</p> <p class="elsevierStylePara"> Material and methods&#58; Data were obtained from a group of 11 male field hockey players &#40;Age &#61; 22&#46;2 &#177; 3&#46;6 yrs&#44; BMI &#61; 22&#46;1 &#177; 2&#46;4 kg m<span class="elsevierStyleSup">&#8722;2</span>&#41;&#46; DM was performed using an incremental tread-mill running test&#46; YET level 1 was used for indirect estimation of VO<span class="elsevierStyleInf">2max</span>&#46; Bland-Altman analysis was employed for assessing agreement between the two methods&#46; The acceptable 95&#37; limits of agreement were set a priori at &#177;5 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46;</p> <p class="elsevierStylePara"> Results&#58; A non-statistically significant bias was observed between YET and DM &#40;50&#46;78 vs&#46; 51&#46;09 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; P &#62; &#46;05&#41;&#46; The estimates of the 95&#37; limits of agreement were &#8722;4&#46;34 and 3&#46;72 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; And the 95&#37; confidence intervals for these limits were from &#8722;6&#46;78 to &#8722;1&#46;90 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; and from 1&#46;29 to 6&#46;16 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; respectively&#46; The difference between methods did not appear to be correlated to the magnitude of measurement&#46;</p> <p class="elsevierStylePara"> Conclusions&#58; A reasonably good agreement was found between YET and DM&#46; However&#44; the large variance of the limits of agreement due to the small sample size means these results should be treated with caution&#46;</p>"
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VO 2max assessment in athletes: A thorough method comparison study between Yo-Yo test and direct measurement
Valoración del VO 2max en atletas: Un riguroso estudio de comparación de métodos entre el Yo-Yo test y la medición directa
Aldo F. Longoa, Gustavo D. Aquilinoa, Marcelo L. Cardeya, Néstor A. Lentinia
a Exercise Physiology Laboratory, National Center of High Performance Athletics (CeNARD), Buenos Aires, Argentina
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> The maximal oxygen uptake &#40;VO<span class="elsevierStyleInf">2max</span>&#41; is a basic measure of physical fitness for athletes&#44; mainly in the cases where the performance is influenced by the aerobic power&#46; The direct measurement is considered the gold standard to assess it&#44; but this is rather complex and expensive&#46; In consequence&#44; a variety of indirect tests have been developed to estimate VO<span class="elsevierStyleInf">2max</span>&#44; such as &#197;strand-Rhyming 6-minute cycle ergometer test&#44;<span class="elsevierStyleSup">1 </span>Balke 15-minute run&#44;<span class="elsevierStyleSup">2 </span>Cooper 12-minute run&#44;<span class="elsevierStyleSup">3 </span>Bruce treadmill test&#44;<span class="elsevierStyleSup">4 </span>the multistage 20-metre shuttle run tests of L&#233;ger and Lambert<span class="elsevierStyleSup">5 </span>and L&#233;ger et al&#46;&#44;<span class="elsevierStyleSup">6 </span>1-mile track jog<span class="elsevierStyleSup">7 </span>and Yo-Yo endurance test&#46;<span class="elsevierStyleSup">8 </span>The Yo-Yo endurance test &#40;YET&#41; is a continuous multistage field test that is widely implemented to estimate VO<span class="elsevierStyleInf">2max</span> as an alternative to the direct laboratory measurement&#44; because of its specificity&#44; its practical and easy implementation and the simple testing environment required&#46; It is one of the three Yo-Yo tests&#46;<span class="elsevierStyleSup">8 </span>The other ones are the Yo-Yo intermittent endurance test &#40;YIET&#41; and the Yo-Yo intermittent recovery test &#40;YIRT&#41;&#44; the last one also providing an estimation of VO<span class="elsevierStyleInf">2max</span>&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara"> The Bland-Altman approach<span class="elsevierStyleSup">10-12 </span>has been extensively applied to compare methods of measurement in diverse research areas&#46; It allows to assess the degree of agreement between two measurement techniques&#44; to determine if they can be used interchangeably&#46; However&#44; method comparison studies are sometimes analysed inappropriately&#44; by comparing the mean responses&#44; by using correlation coefficients or by testing the slope of the linear regression between the methods&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara"> Different studies have compared the direct VO<span class="elsevierStyleInf">2max</span> measurement obtained through a treadmill exercise test with the outcomes of the Yo-Yo tests in athletes&#46;<span class="elsevierStyleSup">13-26 </span>In most cases the population under study was football players&#46; In these works&#44; the direct assessment of VO<span class="elsevierStyleInf">2max</span> was compared with the performance &#40;distance covered&#41; in the Yo-Yo tests&#44; or with the indirect estimation of VO<span class="elsevierStyleInf">2max</span> obtained from YET or YIRT&#46; Linear correlations were examined or mean responses were contrasted&#46; Some of the studies that compared the VO<span class="elsevierStyleInf">2max</span> estimation given by the Yo-Yo test &#40;YET or YIRT&#41; with the direct measurement also reported Bland-Altman limits of agreement&#46;<span class="elsevierStyleSup">15&#44;21&#44;25 </span>However&#44; confidence intervals for these limits were not included&#46; Furthermore&#44; it would be ideal to define the acceptable limits of agreement <span class="elsevierStyleItalic">a priori</span>&#46; Although it may be difficult for physiologic variables&#44; an attempt should be made&#59; the opinion of experts may be used&#46; Without <span class="elsevierStyleItalic">a priori </span>setting of limits of agreement&#44; widely discrepant limits may be selected&#46;<span class="elsevierStyleSup">27</span></p><p class="elsevierStylePara"> The uncertainty due to sampling error should be considered not only when estimating the difference between methods &#40;bias&#41;&#44; but also when estimating the limits of agreement&#46;<span class="elsevierStyleSup">12 </span>This issue is of crucial importance when the sample size is small&#46; The Bland-Altman approach provides statistical methodology to quantify the precision of the estimated limits of agreement&#46; Nevertheless&#44; no method comparison studies were found between the direct measurement of VO<span class="elsevierStyleInf">2max</span> and the indirect estimation by the Yo-Yo test &#40;YET or YIRT&#41; that include confidence intervals for the limits of agreement&#46; This study aimed to examine the extent of agreement in the assessment of VO<span class="elsevierStyleInf">2max</span> in athletes between the Yo-Yo endurance test and the direct measurement performed in an incremental treadmill running test&#44; and to quantify the precision of the estimated limits of agreement&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Material and methods</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Participants</span></p><p class="elsevierStylePara"> Data were obtained from a group of 11 competitive male field hockey players&#46; All subjects or their guardians gave consent to participate in the study after being informed of the aims and procedures&#46; The study was conducted based on the ethical principles of the Declaration of Helsinki of the World Medical Association&#46; Each participant underwent a physical examination before the testing sessions&#46; Table 1 displays a statistical summary of the kinanthropometric characteristics of the athletes&#46; Age was calculated in decimal years&#44; by subtracting the date of birth from the date of assessment&#46; Percentages of fat mass and muscle mass were estimated using the four-compartment model based on the strategy of De Rose and Guimaraes&#46;<span class="elsevierStyleSup">28 </span>This model was adapted using the simple regression equation for male athletes developed by Withers et al&#46;&#44; which was cited by Norton&#44;<span class="elsevierStyleSup">29 </span>to estimate body density&#44; and Siri formula<span class="elsevierStyleSup">30 </span>to calculate the percentage of fat mass&#46;</p><p class="elsevierStylePara"><img alt="Table 1&#46; Kinanthropometric characteristics of the athletes&#46;" src="276v52n193-90460847fig1.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Study design</span></p><p class="elsevierStylePara"> The present research is a study of simple cross-over design&#44; in order to evaluate agreement in assessing VO<span class="elsevierStyleInf">2max</span> in ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1 </span>between the Yo-Yo endurance test and the direct measurement&#59; a special focus is on the interval estimation of the limits of agreement&#46; The direct measurement of VO<span class="elsevierStyleInf">2max</span> &#40;DM&#41; was conducted in the Exercise Physiology Laboratory of the National Center of High Performance Athletics &#40;CeNARD&#44; Buenos Aires&#44; Argentina&#41;&#44; using an incremental running test on a motorized treadmill &#40;Technogym Excite Run 700i&#59; Technogym SpA&#44; Gambettola&#44; Italy&#41;&#46; Breath-by-breath data collection was obtained by means of a computerized open-circuit metabolic system &#40;Medgraphics Cardiopulmonary Exercise System CPX&#47;D&#44; Breeze Ex v3&#46;06 software&#59; Medical Graphics Corporation&#44; St&#46; Paul&#44; MN&#44; USA&#41;&#46; Increments in treadmill speed of 1 km h<span class="elsevierStyleSup">&#8722;1</span> every minute were stipulated until volitional exhaustion &#40;initial speed &#61; 9 km h<span class="elsevierStyleSup">&#8722;1</span>&#41;&#46; Heart rate was controlled with a heart rate monitor &#40;Polar 610i&#59; Polar Electro Oy&#44; Kempele&#44; Finland&#41;&#46; VO<span class="elsevierStyleInf">2</span>plateau &#40;change in VO<span class="elsevierStyleInf">2</span> difference less than 2&#46;1 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1 </span>with a further increase in workload&#41; was the primary criterion for the attainment of VO<span class="elsevierStyleInf">2max</span>&#59; secondary criteria were&#58; respiratory exchange ratio greater than 1&#46;1 and heart rate within 10 beats min<span class="elsevierStyleSup">&#8722;1 </span>of age-predicted maximum heart rate&#46;<span class="elsevierStyleSup">31&#44;32 </span>The Yo-Yo endurance test level 1 was performed indoor at CeNARD&#44; in a sport hall with wooden sprung floor&#46; It consisted of repeated 20-m shuttle runs at a progressively increased speed &#40;initial speed &#61; 8 km h<span class="elsevierStyleSup">&#8722;1</span>&#41;&#44; which was controlled by audio beeps from a portable audio player&#46; The test was considered ended when the participant was unable to maintain the currently indicated speed&#46; The final speed level and the number of performed 20-metre distances at this speed level were recorded&#46; The estimation of VO<span class="elsevierStyleInf">2max</span> was then obtained using the corresponding nomogram&#46; Both YET and DM took place at the same time of day &#40;&#177;2 hours&#41;&#44; to minimize the effects of diurnal biological variation on the results&#44; and were carried out at least 72 hours apart from each other to avoid residual fatigue&#46; The order of the tests was randomly assigned for each subject&#46; Prior to the evaluations&#44; the participants had a 20-minute related warm-up&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistical analysis</span></p><p class="elsevierStylePara"> The kinanthropometric characteristics of the athletes and the heart rate and respiratory exchange ratio values reached when achieving VO<span class="elsevierStyleInf">2max</span> were reported as mean &#177; standard deviation &#40;SD&#41;&#46; Summary statistics were produced to describe the VO<span class="elsevierStyleInf">2max</span> values obtained by means of YET and DM&#46; Bland-Altman analysis was employed for assessing agreement between the two methods of measurement&#46;<span class="elsevierStyleSup">10-12</span> In accordance to Bland&#44;<span class="elsevierStyleSup">33 </span>the acceptable 95&#37; limits of agreement were established on the basis of experience&#44; and were set <span class="elsevierStyleItalic">a priori </span>at &#177;5 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; The 95&#37; confidence intervals for the limits of agreement were also computed&#46; In view of the small sample size&#44; they were estimated using the exact expression for the estimator of the variance of the limits of agreement instead of the approximate one<span class="elsevierStyleSup">12</span>&#58;</p><p class="elsevierStylePara"><img src="276v52n193-90460847fig2.jpg"></img></p><p class="elsevierStylePara"> where <img alt="F&#243;rmula" src="277v52n193-90460721figsi4.gif"></img> is the mean difference between methods and <span class="elsevierStyleItalic">s<span class="elsevierStyleInf">d </span></span>is the standard deviation of the differences&#46; Pearson&#8217;s and Spearman&#8217;s correlation tests were implemented to evaluate possible associations of the difference between YET and DM with the magnitude of the measurement&#46; Statistical significance was set at the 0&#46;05 probability level&#46; All analyses were performed using the R software environment&#44; version 3&#46;2&#46;0 &#40;R Core Team&#44; Vienna&#44; Austria&#41;&#46;<span class="elsevierStyleSup">34</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara"> The VO<span class="elsevierStyleInf">2max</span> values obtained for each individual using the two methods of measurement were quite similar&#46; The VO<span class="elsevierStyleInf">2max</span> values estimated by YET were&#44; on average&#44; only 0&#46;6&#37; lower than those determined by DM&#46; Table 2 presents a descriptive summary of the outcomes of YET and DM and of the differences between them&#46; The heart rate and respiratory exchange ratio values reached when achieving VO<span class="elsevierStyleInf">2max</span> are summarized in Table 3&#46;</p><p class="elsevierStylePara"><img alt="Table 2&#46; VO2max assessment&#58; comparative summary of both methods of measurement&#46;" src="276v52n193-90460847fig3.jpg"></img></p><p class="elsevierStylePara"><img alt="Table 3&#46; Heart rate and respiratory exchange ratio values reached when achieving VO2max&#46;" src="276v52n193-90460847fig4.jpg"></img></p><p class="elsevierStylePara"> A non-statistically significant bias was found between YET and DM &#40;&#8722;0&#46;31 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#59; 95&#37; confidence interval&#58; &#8722;1&#46;69 to 1&#46;07 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41;&#46; The estimates of the lower and upper 95&#37; limits of agreement were &#8722;4&#46;34 and 3&#46;72 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; And the 95&#37; confidence intervals for these limits were&#44; respectively&#44; from &#8722;6&#46;78 to &#8722;1&#46;90 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; and from 1&#46;29 to 6&#46;16 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; As previously mentioned&#44; given the small sample size&#44; the confidence intervals for the limits of agreement were constructed using the exact expression for the estimator of the variance of these limits &#40;Eq&#46; &#40;1&#41;&#41;&#46; The region determined by the estimated 95&#37; limits of agreement was narrower than the region bounded by the acceptable limits defined <span class="elsevierStyleItalic">a priori</span>&#46; However&#44; the total region covered when considering the 95&#37; confidence intervals for the 95&#37; limits of agreement was wider than the <span class="elsevierStyleItalic">a priori </span>acceptable limits&#46; The typical Bland-Altman plot with estimated bias and 95&#37; limits of agreement between methods is shown in Fig&#46; 1&#44; while all the aforementioned results are presented graphically in Fig&#46; 2&#46;</p><p class="elsevierStylePara"><img alt="Figure 1&#46; VO2max&#58; Difference between methods against the average measurement with bias and 95&#37; limits of agreement&#46;" src="276v52n193-90460847fig5.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 1&#46; </span>VO<span class="elsevierStyleInf">2max</span>&#58; Difference between methods against the average measurement with bias and 95&#37; limits of agreement&#46;</p><p class="elsevierStylePara"><img alt="Figure 2&#46; VO2max&#58; Mean and 95&#37; limits of agreement of the difference between methods with 95&#37; confidence intervals&#46;" src="276v52n193-90460847fig6.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 2&#46; </span>VO<span class="elsevierStyleInf">2max</span>&#58; Mean and 95&#37; limits of agreement of the difference between methods with 95&#37; confidence intervals&#46;</p><p class="elsevierStylePara"> It was observed in the data that neither the difference nor the absolute value of the difference appeared to be correlated to the magnitude of the measurement&#46; In that order&#58; Pearson&#8217;s <span class="elsevierStyleItalic">r </span>&#61; 0&#46;02 &#40;95&#37; confidence interval&#58; &#8722;0&#46;59 to 0&#46;61&#41;&#59; Spearman&#8217;s rho &#61; &#8722;0&#46;06 &#40;95&#37; confidence interval&#58; &#8722;0&#46;64 to 0&#46;56&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara"> The indirect measurement of VO<span class="elsevierStyleInf">2max</span> is frequently performed in sport evaluation&#46; Maximal and submaximal effort protocols have been proposed to estimate the maximal aerobic power of an individual&#46;<span class="elsevierStyleSup">1-9 </span>Good agreement with the direct measurement should be the main objective of these tests&#46; The Yo-Yo endurance test is a continuous multistage field test broadly used to indirectly assess VO<span class="elsevierStyleInf">2max</span>&#46;<span class="elsevierStyleSup">15 </span>Its mechanical characteristics make it suitable for athletes participating in sports that involve stop&#44; start and change of direction movement patterns&#46;</p><p class="elsevierStylePara"> Diverse studies have been conducted to compare the outputs provided by the Yo-Yo tests with the VO<span class="elsevierStyleInf">2max</span> obtained by direct measurement in an incremental running test on treadmill&#46; The comparisons involved contrasting the VO<span class="elsevierStyleInf">2max</span> values or testing the correlation between directly measured VO<span class="elsevierStyleInf">2max</span> values and distances covered in the Yo-Yo tests&#46; Some of the studies that compared the VO<span class="elsevierStyleInf">2max</span> results of both methods also included the evaluation of agreement&#46; For instance&#44; Metaxas et al&#46;<span class="elsevierStyleSup">22 </span>found in male football players &#40;<span class="elsevierStyleItalic">n </span>&#61; 35&#41; statistically significant differences &#40;<span class="elsevierStyleItalic">p </span>&#60; 0&#46;05&#41; when comparing the VO<span class="elsevierStyleInf">2max</span> estimations given by YET level 1 with the VO<span class="elsevierStyleInf">2max</span> values obtained by DM in either a continuous or an intermittent running protocol on a treadmill &#40;YET level 1 values lower than DM values by 11&#46;4&#37; and 13&#46;4&#37;&#44; respectively&#41;&#46; Castagna et al&#46;<span class="elsevierStyleSup">15 </span>contrasted the VO<span class="elsevierStyleInf">2max</span> results of YET level 2 with the ones of DM in male football players &#40;<span class="elsevierStyleItalic">n </span>&#61; 24&#41;&#44; evidencing a non-statistically significant bias &#40;<span class="elsevierStyleItalic">p </span>&#61; 0&#46;10&#41; of 1&#46;17 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; and 95&#37; limits of agreement of &#8722;5&#46;44 and 7&#46;79 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; Nazarali et al&#46;<span class="elsevierStyleSup">23 </span>reported a higher mean for the VO<span class="elsevierStyleInf">2max</span> values provided by YIRT level 2 &#40;50&#46;8 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41; in comparison to the mean of the values determined by DM &#40;43&#46;6 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41;&#44; in a study conducted with female football players &#40;<span class="elsevierStyleItalic">n </span>&#61; 20&#41;&#46; In contrast&#44; Mart&#237;nez-Lagunas and Hartmann<span class="elsevierStyleSup">21 </span>found in female football players &#40;<span class="elsevierStyleItalic">n </span>&#61; 18&#41; that VO<span class="elsevierStyleInf">2max</span> was significantly underestimated &#40;<span class="elsevierStyleItalic">p </span>&#60; 0&#46;001&#41; by YIRT level 1 &#40;45&#46;2 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41; compared to DM &#40;55&#46;0 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41;&#44; expressing the 95&#37; limits of agreement on a percentage scale &#40;&#8722;31&#46;8&#37; to &#8722;3&#46;8&#37;&#41;&#46; And S&#225;nchez-Oliva et al&#46;<span class="elsevierStyleSup">25 </span>examined the assessments of the two methods in male football players &#40;<span class="elsevierStyleItalic">n </span>&#61; 15&#41; and also found a statistically significant underestimation of VO<span class="elsevierStyleInf">2max</span> using YIRT level 1 &#40;51&#46;00 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41; in comparison to DM &#40;60&#46;85 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#41;&#44; with 95&#37; limits of agreement of 3&#46;37 and 16&#46;33 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46;</p><p class="elsevierStylePara"> On the other hand&#44; no research articles were found reporting method comparison studies by using Bland-Altman analysis between the direct measurement of VO<span class="elsevierStyleInf">2max</span> and the indirect estimation by the Yo-Yo test &#40;YET or YIRT&#41; that consider the computation of confidence intervals for the limits of agreement&#46; This is a matter of particular importance in the case of small sample size&#44; which is a frequent situation in studies involving maximal effort testing&#46; The variance of the mean difference and that of the limits of agreement are inversely proportional to the sample size&#46; Therefore&#44; the corresponding confidence intervals are wide when the sample size is small&#44; reflecting the great variation of the differences between methods&#46;</p><p class="elsevierStylePara"> This research presents a thorough method comparison study between the direct assessment of VO<span class="elsevierStyleInf">2max</span> in laboratory conditions and the indirect estimation by means of the Yo-Yo endurance test&#44; which is a continuous multistage field test especially useful for athletes of endurance disciplines&#44;<span class="elsevierStyleSup">8 </span>but also suitable for sports teams<span class="elsevierStyleSup">35</span>&#44; such as field hockey&#44; football and rugby players&#46; Estimates of bias and 95&#37; limits of agreement between methods are reported&#46; Furthermore&#44; accurate 95&#37; confidence intervals for the limits of agreement are also reported for the current sample size&#46; A small bias was observed between the two techniques&#44; which resulted to be not statistically significant &#40;<span class="elsevierStyleItalic">p </span>&#61; 0&#46;63&#41;&#46; The estimated 95&#37; limits of agreement set at &#177;4&#46;03 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1 </span>from the mean difference between them&#46; In the model proposed&#44; for the mean and standard deviation of the differences between methods to be meaningful estimates it must be assumed that they are constant throughout the range of measurement&#46;<span class="elsevierStyleSup">12&#44;36&#44;37 </span>It is worth emphasizing that the mean difference and the standard deviation of the differences appeared not to depend on the magnitude of the measurement&#44; which complies with the assumptions underlying the simple 95&#37; limits of agreement method applied&#46; The region determined by the estimated limits of agreement was within the acceptable limits defined <span class="elsevierStyleItalic">a priori</span>&#46; However&#44; these estimates have a large variance due to the small sample size&#44; so this last result has to be considered with caution&#46; Taking into account the 95&#37; confidence intervals for the 95&#37; limits of agreement&#44; the total region extended beyond &#177;6 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; exceeding the acceptable 95&#37; limits of agreement established <span class="elsevierStyleItalic">a priori</span>&#46;</p><p class="elsevierStylePara"> The confidence intervals for the mean difference and for the limits of agreement provide a measure of precision of the point estimates&#44; based on sampling error&#46; The variances of the estimators of these quantities are crucially affected by the sample size&#46; The smaller is the number of observations for the assessment of the difference between the methods&#44; the wider are the confidence intervals&#44; and the higher is the level of uncertainty&#46; Moreover&#44; although the Bland-Atman approach provides the methodology for constructing limits of agreement&#44; it does not state whether they are acceptable or not acceptable&#46; The acceptable limits should be defined <span class="elsevierStyleItalic">a priori</span>&#44; based on specific needs and goals&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Limitations</span></p><p class="elsevierStylePara"> The small sample size is a limitation of this study&#46; The 95&#37; confidence intervals for the 95&#37; limits of agreement given the current sample size are &#177;1&#46;19 units of the standard deviation of the differences between measurements of the two methods&#46; Therefore&#44; it would be advisable to reproduce the present analysis with larger sample sizes to increase the precision of the estimates produced&#46; Furthermore&#44; it would be relevant to simultaneously carry out a comparison of the repeatability of each method by collecting replicated data&#44; because the repeatabilities of two methods of measurement restrict the amount of agreement that is possible&#46;<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusions</span></p><p class="elsevierStylePara"> The point estimates of the 95&#37; limits of agreement were within &#177;5 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; satisfying the <span class="elsevierStyleItalic">a priori </span>requirement based on experience&#46; Thus&#44; a reasonable good agreement was found between the Yo-Yo endurance test and the direct laboratory measurement for the assessment of VO<span class="elsevierStyleInf">2max</span> in athletes&#46; According to this fact&#44; the two methods can be used interchangeably&#46; Nevertheless&#44; the need for caution in interpreting this result solely is further emphasized by the finding that the region covered when considering the 95&#37; confidence intervals for the 95&#37; limits of agreement was wider than the acceptable region of agreement defined <span class="elsevierStyleItalic">a priori</span>&#46; Hence&#44; although the estimated 95&#37; limits of agreement do not discredit the Yo-Yo endurance test as an alternative method to measure VO<span class="elsevierStyleInf">2max</span> in athletes&#44; the present study is limited in precision because of the small sample size and does not allow definitive conclusions&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interests</span></p><p class="elsevierStylePara"> Authors declare that they do not have any conflict of interests&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgments</span></p><p class="elsevierStylePara"> The authors wish to express special thanks to Mariela B&#46; Arangio&#44; Enrique D&#46; Balardini&#44; Claudio A&#46; Gillone&#44; Cristina Perez and Enrique O&#46; Prada for their technical assistance&#46;</p><hr></hr><p class="elsevierStylePara"><span class="elsevierStyleSup">&#9734;</span><span class="elsevierStyleItalic">Note</span>&#46; It is reported that a preliminary summary of this work was published given its presentation at &#8216;&#8216;57th Annual Meeting and inaugural World Congress on Exercise is Medicine of the American College of Sports Medicine&#8217;&#8217;&#46; The mentioned event took place in &#8216;&#8216;Baltimore Convention Center&#8217;&#8217; in Baltimore&#44; Maryland&#44; between 1 and 5 June 2010&#46; The summary was published in &#8216;&#8216;Medicine and Science in Sports and Exercise&#44; Volume 42&#58; 5 Supplement&#8217;&#8217;&#46;</p><p class="elsevierStylePara"> Received 12 April 2016&#59;<br></br> accepted 11 July 2016<br></br> Available online 15 September 2016</p><p class="elsevierStylePara"><span class="elsevierStyleSup">&#8727; </span>Corresponding author at&#58;<br></br> Exercise Physiology Laboratory&#44; National Center of High Performance Athletics &#40;CeNARD&#41; Miguel B&#46; S&#225;nchez 1050&#44; Buenos Aires &#40;Postal Code&#58; 1429&#41; Argentina&#46;<br></br><span class="elsevierStyleItalic">E-mail address&#58; </span><a href="mailto&#58;alongo&#64;deportes&#46;gob&#46;ar" class="elsevierStyleCrossRefs">alongo&#64;deportes&#46;gob&#46;ar</a> &#40;A&#46;F&#46; Longo&#41;&#46;</p>"
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            0 => "Consumo m&#225;ximo de ox&#237;geno&#59; Medici&#243;n directa y Yo-Yo endurance test&#59; Precisi&#243;n de los l&#237;mites de concordancia"
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            0 => "Maximal oxygen uptake&#59; Direct measurement and Yo-Yo endurance test&#59; Precision of the limits of agreement"
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        "resumen" => "<p class="elsevierStylePara"> Introducci&#243;n&#58; Si bien diferentes estudios han reportado l&#237;mites de concordancia en la valoraci&#243;n del VO<span class="elsevierStyleInf">2max</span> entre el Yo-Yo test y la medici&#243;n directa&#44; la precisi&#243;n de estos l&#237;mites en general no ha sido considerada&#46; El objetivo de este estudio fue examinar el grado de concordancia en la valoraci&#243;n del VO<span class="elsevierStyleInf">2max</span> en atletas entre el Yo-Yo endurance test &#40;YET&#41; y la medici&#243;n directa &#40;DM&#41;&#44; y cuantificar la precisi&#243;n de los l&#237;mites de concordancia estimados&#46;</p> <p class="elsevierStylePara"> Material y m&#233;todos&#58; Los datos fueron obtenidos de un grupo de 11 jugadores varones de hockey sobre c&#233;sped &#40;edad &#61; 22&#44;2 &#177; 3&#44;6 a&#241;os&#44; BMI &#61; 22&#44;1 &#177; 2&#44;4 kg m<span class="elsevierStyleSup">&#8722;2</span>&#41;&#46; La DM fue realizada usando un test de carrera incremental en cinta rodante&#46; El YET nivel 1 fue usado para la estimaci&#243;n indirecta del VO<span class="elsevierStyleInf">2max</span>&#46; El an&#225;lisis de Bland-Altman fue empleado para valorar la concordancia entre los 2 m&#233;todos&#46; Los l&#237;mites aceptables de concordancia del 95&#37; fueron fijados a priori en &#177;5 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46;</p> <p class="elsevierStylePara"> Resultados&#58; Un sesgo estad&#237;sticamente no significativo fue observado entre YET y DM &#40;50&#44;78 vs&#46; 51&#44;09 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; p &#62; 0&#44;05&#41;&#46; Las estimaciones de los l&#237;mites de concordancia del 95&#37; fueron &#8722;4&#44;34 y 3&#44;72 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; Y los intervalos de confianza del 95&#37; para estos l&#237;mites fueron&#44; respectivamente&#44; desde &#8722;6&#44;78 hasta &#8722;1&#44;90 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; y desde 1&#44;29 hasta 6&#44;16 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; La diferencia entre m&#233;todos pareci&#243; no estar correlacionada con la magnitud de medici&#243;n&#46;</p> <p class="elsevierStylePara"> Conclusiones&#58; Fue encontrada una razonable buena concordancia entre YET y DM&#46; Sin embargo&#44; la gran varianza de los l&#237;mites de concordancia debido al peque&#241;o tama&#241;o muestral hace necesario considerar este resultado con precauci&#243;n&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"> Introduction&#58; Although different studies have reported limits of agreement in assessing VO<span class="elsevierStyleInf">2max</span> between the Yo-Yo test and the direct measurement&#44; the precision of these limits in general has not been considered&#46; The aim of this study was to examine the extent of agreement in the assessment of VO<span class="elsevierStyleInf">2max</span> in athletes between the Yo-Yo endurance test &#40;YET&#41; and the direct measurement &#40;DM&#41;&#44; and to quantify the precision of the estimated limits of agreement&#46;</p> <p class="elsevierStylePara"> Material and methods&#58; Data were obtained from a group of 11 male field hockey players &#40;Age &#61; 22&#46;2 &#177; 3&#46;6 yrs&#44; BMI &#61; 22&#46;1 &#177; 2&#46;4 kg m<span class="elsevierStyleSup">&#8722;2</span>&#41;&#46; DM was performed using an incremental tread-mill running test&#46; YET level 1 was used for indirect estimation of VO<span class="elsevierStyleInf">2max</span>&#46; Bland-Altman analysis was employed for assessing agreement between the two methods&#46; The acceptable 95&#37; limits of agreement were set a priori at &#177;5 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46;</p> <p class="elsevierStylePara"> Results&#58; A non-statistically significant bias was observed between YET and DM &#40;50&#46;78 vs&#46; 51&#46;09 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; P &#62; &#46;05&#41;&#46; The estimates of the 95&#37; limits of agreement were &#8722;4&#46;34 and 3&#46;72 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#46; And the 95&#37; confidence intervals for these limits were from &#8722;6&#46;78 to &#8722;1&#46;90 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; and from 1&#46;29 to 6&#46;16 ml kg<span class="elsevierStyleSup">&#8722;1 </span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; respectively&#46; The difference between methods did not appear to be correlated to the magnitude of measurement&#46;</p> <p class="elsevierStylePara"> Conclusions&#58; A reasonably good agreement was found between YET and DM&#46; However&#44; the large variance of the limits of agreement due to the small sample size means these results should be treated with caution&#46;</p>"
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Article information
ISSN: 18866581
Original language: English
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