Correlation between Fitness Parameters and An Occupational Rescue Simulation among Emergency Care Providers in North West Province, South Africa: A Pilot Study

Abstract

Objective: The purpose of the study was to examine the relationship between validated fitness parameters and an emergency rescue simulation (RS) circuit performed by emergency care providers (ECPs).

Methods: A cross-sectional study was selected to determine the relationship between the fitness tests and the RS. Twenty ECPs in the North West province of South Africa participated in the study. Demographic data were collected, followed by testing of anthropometric characteristics and field fitness tests measuring muscular strength, muscular endurance, aerobic capacity, anaerobic capacity and flexibility. Thereafter, participants had to complete a RS circuit. Pearson's correlation coefficient was used to assess the relationship between variables. Differences in age, gender and body mass index formed part of the descriptive statistics. A test-retest reliability method was applied to evaluate the reliability of the RS.

Results: Significant correlations were found between the RS and the 250 m shuttle run (r=0.83; p<0.01), flexed-arm hang test (r=-0.59; p<0.01), Cooper 12-minute test (r=-0.56; p<0.01), and the maximum push-up test (r=-0.51; p<0.05).

Conclusion: Findings demonstrate a possible association between aerobic capacity, anaerobic capacity, muscular strength, muscular endurance and ECP performance in an occupational task-related RS. Improved performance in these specific fitness areas may enable ECPs to be better prepared for the physical demands of their occupation. The RS may also be used as a tool to assess job (physical) preparedness of qualified ECPs during their recruitment, but this requires further validation.

Full text

01
Research
Correlation between tness parameters and an occupational
rescue simulation among emergency care providers in North
West province, South Africa: A pilot study
Solomon Mthombeni MPhil, is Researcher1; Yoga Coopoo PhD, FACSM; Habib Noorbhai PhD, is Associate Professor2
Afliation:
1National Assembly, Parliament of the Republic of South Africa
2Department of Sport and Movement Studies, Faculty of Health Sciences, University of Johannesburg, South Africa
https://doi.org/10.33151/ajp.18.862
Abstract
Objective
The purpose of the study was to examine the relationship between validated tness parameters and an emergency rescue
simulation (RS) circuit performed by emergency care providers (ECPs).
Methods
A cross-sectional study was selected to determine the relationship between the tness tests and the RS. Twenty ECPs in the North
West province of South Africa participated in the study. Demographic data were collected, followed by testing of anthropometric
characteristics and eld tness tests measuring muscular strength, muscular endurance, aerobic capacity, anaerobic capacity and
exibility. Thereafter, participants had to complete a RS circuit. Pearson’s correlation coefcient was used to assess the relationship
between variables. Differences in age, gender and body mass index formed part of the descriptive statistics. A test-retest reliability
method was applied to evaluate the reliability of the RS.
Results
Signicant correlations were found between the RS and the 250 m shuttle run (r=0.83; p<0.01), exed-arm hang test (r=-0.59;
p<0.01), Cooper 12-minute test (r=-0.56; p<0.01), and the maximum push-up test (r=-0.51; p<0.05).
Conclusion
Findings demonstrate a possible association between aerobic capacity, anaerobic capacity, muscular strength, muscular endurance
and ECP performance in an occupational task-related RS. Improved performance in these specic tness areas may enable ECPs
to be better prepared for the physical demands of their occupation. The RS may also be used as a tool to assess job (physical)
preparedness of qualied ECPs during their recruitment, but this requires further validation.
Keywords:
emergency medical care; physical tness; occupational demands; rescue simulation; physical preparedness
Corresponding Author: Habib Noorbhai, habibn@uj.ac.za

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Australasian Journal of Paramedicine: 2021;18
Introduction
Emergency care providers (ECPs) work in a pre-hospital
setting with a specic mandate to provide patient care
during emergencies. Activities in their mandate include, but
are not limited to, patient positioning and immobilisation,
cardiopulmonary resuscitation (CPR), uid therapy and lifting
and moving of patients (1). At times, ECPs are also required
to perform duties such as removal of injured patients from
dangers such as vehicle wreckage through patient extrication
using rescue equipment (2). Hunter et al (3) suggested that the
duties of paramedics responsible for frequent injuries include
manual handling and awkward tasks, combined with periods
of sedentary behaviours during shifts. Therefore, due to the
occupation of ECPs, it requires them to rescue casualties as
rapidly and efciently as possible (4), which places mental and
physical demands on the body (Figure 1).
Studies investigating the relationship between physical tness
components of ECPs and their occupational tasks in South
Africa and globally are uninitiated. Only a few studies have
investigated the tness levels and physical health measures
among ECPs (5,6), despite the literature detailing the
demonstration of the physical demands in the profession. For
example, Russo et al (7) examined the impact of physical tness
on the quality of external chest compressions during CPR and
found that rescuers of superior physical tness were able to
sustain high quality chest compressions and lower rescuer
fatigue. Furthermore, Coffey et al (1) assessed the physical
demands of the paramedic occupation in Canada. They found
that loading and unloading of ill/injured patients, pushing and
pulling of patient loaded stretchers, as well as the carrying of
medical and rescue equipment were among the most physically
demanding tasks of paramedics.
There is no pre-employment physical tness testing of ECPs,
nor is there policy advocating for such in South Africa when
compared to other emergency care professions such as
reghting, law enforcement and trafc ofcers (which conduct
pre-employment tness testing). In the rural areas of South
Africa, ECPs not only work in an ambulance setting but are also
formally trained to perform rescue operations in conjunction with
other rescue organisations (ie. re department). Therefore, the
purpose of the study was to determine the relationship between
physical tness parameters of ECPs and an occupation specic
rescue simulation (RS), designed in accordance with their
intensied job-related tasks (ie. performing CPR, lifting, carrying
and loading of patients and equipment, vehicle extrication).
Methods
Participants
A cross-sectional study was designed to assess the relationship
between the tness test battery and the RS parameters of
ECPs. For the study, ECPs were dened as basic ambulance
assistants, emergency care assistants, ambulance emergency
assistants, emergency care technicians, critical care assistants,
as well as emergency care practitioners, as recognised by the
professional board of emergency care at the Health Professions
Council of South Africa (8). Twenty male ECPs between the
ages of 30 and 48 years with a minimum of 2 years of work
experience as operational ECPs volunteered for the study. The
**HR = heart rate; MSD = musculoskeletal disorders; RF = risk factors; RPE = resting perceived exertion
Figure 1. Job related risk factors for ECPs

03
participants were free from any musculoskeletal injuries and
were qualied and recruited via email contact throughout the
32 emergency medical services (EMS) stations in the North
West province of South Africa. They responded by reading and
completing a participant information and consent form provided.
Standardised testing methods were used based on the American
College of Sports Medicine criteria (9). Principles of the Helsinki
agreement was followed with respect to the testing of human
subjects. Ethical clearance was obtained from the Faculty of
Health Sciences Research Ethics Committee at the University of
Johannesburg (REC-01-159-2016). Permission was also granted
by the North West Department of Health to conduct the study on
their personnel.
Data collection and procedures
On signing the informed consent form, the participants met
with the researcher on three occasions at the testing venue.
The rst visit was to conduct the tness test; the second and
third visits was for the completion of two attempts at the RS
circuit. Participants required a minimum of 48 hours lapse
time between attempts at the RS. During the collection of
anthropometric measurements, the participants had to be in a
fasted state. Participants were also requested not to participate
in any exercise for 48 hours before the tness testing and the
RS simulation and were asked to have a light breakfast on the
morning of testing. All tests were administered by a qualied
biokineticist (specialised exercise therapist) also trained as a
basic ambulance assistant. All 20 participants were tested over a
period of 10 days.
Anthropometric measurements
In a fasted state, participants weight and height were measured
and calculated [body weight (kg) x height (cm) squared] to
determine their body mass index (BMI). The subcutaneous body
fat percentage of participants was measured using a skinfold
calliper (Harpenden skinfold Body Calliper C-136, USA) on four
areas of the body (subscapular, suprailliac, bicep, tricep) as
described by Miller (10). Before the tness testing, participants
were only allowed to have a light meal or energy drink after the
anthropometric measurements.
Fitness parameters
The following nine eld tests were used to measure ve
components of tness – aerobic capacity, anaerobic capacity,
muscular strength, muscular endurance and exibility:
• 12 minute cooper test
• maximal push-up test
• 60 seconds sit-up test
• isometric torso lift
• isometric leg lift
• modied sit-and-reach test
• hand grip test
• exed arm hang test
• 250 m shuttle run.
Participants were taken through light warm-ups and dynamic
stretching by a qualied exercise therapist before the tests.
Rescue simulation
The RS was designed from ve different physical ability tests
(tasks commonly performed by ECPs in their line of duty)
derived from other related studies (11-15). The RS tests were
then formulated into a system of ve different stations whereby
the participant could perform one test after the other, moving
from one station to the next in a sequential form. The tests in
the RS were also organised in such a way that they imitated a
typical rescue scenario. The RS required participants to have
adequate recovery from the tness test. Thereafter, 48 hours
after the tness tests, the participants were required to complete
an RS consisting of ve stations with no rest period in between
the stations, organised in a time-trial format. Before the RS,
the participants were required to wear personal protective
equipment consisting of a jumpsuit, protective boots, helmet and
gloves. Participants were taken through a session to familiarise
themselves with the content of the simulation and were then
given an opportunity to ask questions or seek clarity before
beginning the RS. Once participants were familiar and condent
with the RS, they could start the circuit. The tness components
tested in the RS included aerobic and anaerobic capacity as
well as muscular strength and muscular endurance. The RS
was conducted in a temperature-controlled environment ranging
between 15ºC and 20ºC. The participants had to complete the
RS on two different occasions (after 48 hours) in order to do a
test-retest reliability of the RS.
Rescue simulation sequence
The RS circuit was designed in a manner that allowed
participants to move from station-to-station in sequence (ie. in
alphabetical order, from the start line to station A, B, C, D, E and
then to the nish line) (Figure 2).
Station A: Ascending stair test carrying a 16.5 kg medical/
rescue bag, electrocardiogram and a suction unit
The purpose of the test was to test the ability and efciency
of the ECPs to carry their medical equipment up four ights
of stairs in order to reach the patient (13). The apparatus that
the participant had to carry was a medical/rescue bag, medical
suction unit and ECG. The participants had to ascend then
descend four ights of stairs (step height of 0.17 m) with a total
vertical rise of 13 m (estimated to be four oors) while carrying
a medical bag, suction unit and ECG with a combined weight
of 16.5 kg. The test was scored by the ability of participants
to ascend and descend stairs carrying equipment within the
shortest time possible. The faster person was awarded a higher
score, which implied that in an emergency situation, the faster
person may attend to a patient rst, for various rescue tasks.
Station B: Vehicle extrication using a spreader
The purpose of the test was to determine the ability of ECPs to
lift and utilise heavy vehicle hydraulic extrication tools during
vehicle collisions in order to remove trapped casualties (13). A
19.6 kg ‘jaws of life’ hydraulic extrication spreader (Hurst ML-28)
Mthombeni: Fitness parameters and an occupational rescue simulation
Australasian Journal of Paramedicine: 2021;18

04
was used for the test. The participants had to hold the vehicle
extrication spreader ve times at three different heights (0.9
m, 1.2 m, 1.5 m) for at least 15 seconds at each height. The
test was scored according to the participants’ ability to hold the
spreader with the correct form in all three different positions
without rest breaks.
Station C: 30 m simulated victim drag with a 120 kg manikin
The purpose of the test was to determine the ECPs’ ability
to drag the patient out of dangerous situations at the scene
(11). A 120 kg Life Tec adult rescue training manikin and 2 m
kernmantle rope was used and due to the difculty in gripping
the manikin during the drag, a kernmantle rope was tied around
the manikin’s armpits, making it easier to grip and drag the
manikin. However, in a real-world setting, ECPs have to victim
drag under the armpits using their forearms or by using a rescue
blanket. The participants then had to reverse drag the manikin
for a 30 m distance. The test was scored by the shortest time the
participant covered the 30 m distance during the drag.
Station D: Five minutes of continuous chest compressions
The purpose of the test was to determine the ECPs’ ability
to perform adequate continuous chest compressions for ve
minutes without rest (14). A Laerdal CPR manikin was used
for the test. The participants had to complete ve minutes
of continuous chest compressions of at least 100 bpm. The
CPR manikin used had a clicking mechanism during each
compression which was used to measure the effectiveness
of the compressions. The test was scored according to the
participants’ ability to complete ve-minute chest compressions
without rest.
Station E: Imitation of carrying of the patient on a spine
board
The purpose of the test was to determine the ability of the
ECPs to lift and carry a patient with a scoop stretcher or spine
board off the ground towards an ambulance (12,15). Two 24 kg
kettlebells were used for the test as the scoop stretcher or spine
board stretchers would require more than one person to carry.
Therefore, kettlebells served as an alternative to stretchers.
The participants had to squat lift a pair of 48 kg (24 kg each)
kettlebells (26) and carry them for a distance of 20 m (12). The
test was scored by the ability of the ECP to safely squat lift and
carry kettlebells in the shortest time possible (without running)
for a 20 m distance.
Data analysis
Morphological measurements (height, weight, anthropometry),
tness test and RS results were recorded on a Microsoft Excel
spreadsheet. Inferential and descriptive statistical analyses
were computed on the obtained data and used to describe the
demographics, health and tness parameters of ECPs. Central
tendency was measured via means and standard deviations.
A correlation coefcient was used to determine the relationship
between two variables and to ascertain the strength of the
relationship.
A test-retest was conducted to evaluate the reliability of the RS
whereby participants had to complete two RS with a minimum
of 48 hours rest between them. A two-tailed t-test method was
used to determine the reliability of the RS. Pearson’s correlation
coefcient was used to assess the correlation between
the anthropometric measurements, tness test and the RS
Mthombeni: Fitness parameters and an occupational rescue simulation
Australasian Journal of Paramedicine: 2021;18
Figure 2. Rescue simulation sequence

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Mthombeni: Fitness parameters and an occupational rescue simulation
Australasian Journal of Paramedicine: 2021;18
completion time. SPSS (version 26) (IBM, Amronk, NY) was used
for the statistical analysis. Signicance was set at the level of
p≤0.05.
Results
Anthropometric characteristics
The anthropometric characteristics of participants are presented
in Table 1. The mean age of the participants was 37 ± 4.4 years,
with a BMI of 28.4 ± 5.5 kg/m2, and body fat percentage of 24.2
± 6.8. A total of 30% of participants were classied as overweight
(BMI ≥25) and 45% as clinically obese (BMI ≥30). More
participants with an elevated subcutaneous body fat percentage
than in the normal range (5% lean, 25% average vs. 55% high
and 15% very high) was found.
Table 1. Anthropometric characteristics of participants
Participant characteristics n Mean SD
Age (years) 20 37.0 4.4
Mean height (cm) 20 169.6 6.0
Mean weight (kg) 20 81.5 15.4
Mean BMI (kg/m2) 20 28.4 5.5
Mean body fat % 20 24.2 6.8
Fitness test results
The maximum push-up test produced a mean of 21 ± 14 and
one-minute sit-up at 26 ± 8 repetitions; the isometric torso lift
produced a mean of 105 ± 20.9 kg and the isometric leg lift at
115.1 ± 23.5 kg. In addition, the exed-arm hang text (FAHT)
produced a mean at 29 ± 18 seconds and the modied sit-and-
reach test 36 cm ± 6.6 (Table 2).
Rescue simulation results
The mean RS completion time was 8.42 ± 0.4 minutes. The
relationship between the RS and the tness tests are illustrated
in Table 3. The most signicant relationship was found between
the RS and 250 m shuttle runs, FAHT, Cooper 12-minute test and
the maximum push-up test. The results, therefore, indicated that
the better the participant performed in the various tness tests,
the faster they completed the RS.
Table 2. Fitness test results for participants
Test Values
Mean SD
Maximum push-up (repetitions) 21 14
One-minute sit-up (repetitions) 26 8
Isometric torso lift (kg) 105 20.9
Isometric leg lift (kg) 115.1 23.5
Flexed-arm hang test (seconds) 29 18
Grip strength (kg) 43.1 6.6
Modied sit-and-reach test (cm) 36 6.6
Cooper 12-minute test (m) 1866.5 416
250 m shuttle run test (seconds) 70 17
Table 3. Relationship between the rescue simulation (trial 2) and
tness parameters
Variables Rescue simulation (n=20)
R statistic p-value
250 m shuttles 0.83 0.000*
Flexed-arm hang test -0.59 0.006
Cooper 12-minute test -0.56 0.010
Maximum push-up test -0.51 0.020
One-minute sit-up test -0.43 0.060
Isometric leg lift -0.39 0.080
Isometric torso lift -0.05 0.840
Grip strength -0.16 0.510
Modied sit-and-reach test 0.12 0.600
*p<0.05
Discussion
The RS in the study was designed to determine the relationship
between the physical tness of ECPs and their ability to complete
job-specic physical tasks such as performing CPR, vehicle
extrication, lifting and carrying of patients among others as
quickly and efciently as possible. Their tasks are supported by
Coffey et al (1) who suggested that paramedics are routinely
exposed to physically demanding tasks while on duty, especially
those that require loading, unloading, pushing, pulling and
carrying of patients and rescue equipment. Tests that formed
part of the RS were extracted from different published studies
that included job tasks pertinent to ECPs and reghters (11-
14). However, it must be highlighted that the RS has not been
a scientically validated test to assess job task analysis within
EMS, but was composed of selected activities commonly
performed by ECPs in their line of duty.
The study found a moderate but statistically signicant
relationship between the RS and various tness tests (250 m
shuttle runs [p=0.000], FAHT [p=0.006], Cooper 12-minute run
[p=0.010], and maximum push-up [p=0.020]) indicating that those
participants who performed poorer during these tness tests
were likely to take longer to complete the RS. These ndings
were consistent with those of Williford et al (16) who investigated
the relationship between physical tness (pull-ups, push-ups, sit-
ups, 1.5-mile run) and reghting suppression tasks (stair climb,
hoist, forcible entry, hose advance, victim rescue), whereby
signicant correlations were also found. The ndings were also
consistent with those of Michaelides et al (17) who examined the
relationship between physical tness aspects of reghters and
their job abilities through the reghter ability test. They found
that the reghter ability test completion time was correlated with
upper-body muscular endurance (push-ups and sit-ups), upper
body strength and relative power. Both reghters and ECPs
occupations are physically demanding and have similarities in
terms of physically handling (lifting, carrying, loading) patients as
indicated by Poplin et al (18). Therefore, the results of the study
had to be compared to those of studies related to reghters as

06
Mthombeni: Fitness parameters and an occupational rescue simulation
Australasian Journal of Paramedicine: 2021;18
there are limited studies on physical tness standards of ECPs
globally (19).
The study found a correlation between the RS and muscular
(upper body) strength (FAHT). This indicates that ECPs with
higher levels of muscular strength completed the RS faster
than those with lower levels. Similar results were demonstrated
by Rhea et al (11) who examined the relationship between
physical tness and job performance of reghters, and found a
signicant relationship between upper-body strength levels and
pulling activities (hose pull and victim drag) in reghters. This
is important because victim drag formed part of the RS. Ock et
al (14) examined the inuence of physical tness on 5 minutes
of continuous chest compressions and found strong correlations
between higher muscular strength and prolonged effective chest
compressions during CPR. This indicates that good muscular
strength is necessary for effective chest compressions during
prolonged CPR (>5 minutes).
Signicant correlations were found between the RS and
muscular endurance (maximum push-ups and FAHT). Rhea et
al (11) found that upper-body muscular endurance correlated
with reghters’ job task activities such as stair climbing,
equipment hoist, victim drag and overall job performance. In
addition, Michaelides et al (17) found that upper-body muscular
endurance (push-ups) signicantly contributed to the predictive
power of a reghter’s test performance ability. Therefore,
aerobic and anaerobic capacity remains paramount for the
occupation-specic activities of ECPs.
Signicant relationships were also found between aerobic
(Cooper 12-minute run), anaerobic (250 m shuttle run test)
capacity and the RS. Lindberg et al (13) conducted a study
on eld tests useful for evaluating aerobic work capacity of
reghters. Correlations were found between maximal aerobic
capacity (VO2 max) and a range of reghting tasks (stair
climbing carrying hose baskets, demolition, cutting, victim
rescue, vehicle extrication, hose pulling and carrying hose
baskets over terrain).
These results suggest that these components of physical
tness may be important in the performance of the RS. Hansen
et al (20) investigated the impact of physical tness on CPR
quality among healthcare professionals and found that there
was early rescuer physical fatigue which resulted in declined
compression depth, indicative of poor cardiorespiratory
endurance and muscular strength. Similar ndings by Rhea
et al (11) demonstrated a signicant relationship between
anaerobic capacity (400 m run) and the overall job performance
of reghters during a simulated reghting job task. This further
highlights the importance of aerobic and anaerobic capacity for
the occupation-specic activities of ECPs.
Lastly, the study found an insignicant relationship between
the RS and one-minute sit-up test, isometric torso-lift, isometric
leg lift, grip strength and modied sit-and-reach test. It is
acknowledged that having a good level of overall tness is
useful, but these elements may not be useful in predicting RS
performance.
Historically, there has been limited research on scientically
designed occupation-specic tness testing such as the RS
to test the physical preparedness of ECPs. One of the main
challenges is that qualied ECPs in the North West province are
not tested for physical tness during recruitment for employment
due to limited research in the area to advise policy. The ECPs
are tested for physical tness only when enrolling for rescue
training or emergency medical care qualication at the local
provincial colleges and other institutions of higher learning. The
current system of physical tness testing of ECPs makes use
of the generic tness test battery (ie. eld tests such as 2.4 km
run, push-ups, hang-test and sit-ups, shuttle runs), which are
time-consuming and do not assess the actual job-specic tasks
of ECPs, hence, the designing of the RS.
Limitations
It is assumed that a larger sample would have yielded higher
correlations, and hence, the trends indicate that a further study
with larger numbers is required to achieve better results. The
eld tests pose an inherent limitation in that they cannot provide
a more accurate reection of strength such as the one-repetition
maximum test. The results of the study equated the success of
adequate physical tness with a faster RS completion time. This
is a limitation because other factors (ie. safe execution of a task
instead of the speed of performance of occupation-related tasks)
were not taken into consideration. During the RS, a rope was
tied around the manikin as an aide during victim drag in Station
C as it was difcult to grip when pulling. In a real-world setting,
the ECP would drag a victim with arms bent under the victim’s
armpits, or by using a rescue sling. The participants were not
randomly sampled and the researcher had to rely on participants
volunteering to complete the RS which limits the generalisability
of the ndings. Furthermore, the study was only composed
of male participants, which is not indicative of the workforce
composition. The RS was designed using job-related activities
from other research papers and, therefore, no job task analysis
was conducted.
Conclusion
These ndings demonstrate a possible association between eld
tness parameters of testing, namely aerobic capacity, anaerobic
capacity, muscular strength, muscular endurance and ECP
performance in an occupational task-related RS. These results
are encouraging as they show trends in the RS test and eld
tness testing components, which may enable ECPs to be better
prepared for the physical demands of their occupation. The RS
may be used as a tool to assess job (physical) preparedness of
qualied ECPs during their recruitment, but this requires further
validation of these results on a larger population study.

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Mthombeni: Fitness parameters and an occupational rescue simulation
Australasian Journal of Paramedicine: 2021;18
Competing interests
The authors declate no competing interests. Each author of this
paper has completed the ICMJE conict of interest statement.
Author contributions
Conception and design of the study: YC. Data acquisition:
YC, SM. Data analysis and interpretation of the data: all
authors. Drafting and critical revisions of the paper: all authors.
Accountability for all aspects of the work: all authors.
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