Perceived Exertion : A Review

Susan B O'Sullivan
PHYS THER. 1984; 64:343-346.

The online version of this article, along with updated information and services, can
be found online at: http://ptjournal.apta.org/content/64/3/343
Collections

This article, along with others on similar topics, appears

in the following collection(s):
Cardiovascular/Pulmonary System: Other
Therapeutic Exercise

e-Letters

To submit an e-Letter on this article, click here or click on

"Submit a response" in the right-hand menu under
"Responses" in the online version of this article.

E-mail alerts

Sign up here to receive free e-mail alerts

Downloaded from http://ptjournal.apta.org/ by guest on October 24, 2012

Perceived Exertion
A Review
SUSAN B. O'SULLIVAN
Physical therapists are well aware of the physiological responses to exercise.
The process by which these underlying mechanisms contribute to the perceptual
response of perceived exertion is generally less familiar. The purpose of this
article is to summarize briefly some of the current major concepts about perceived
exertion and to indicate, where possible, the potential significance of these
concepts for physical therapy.
Key Words: Exercise test, Exertion, Physiology.

Interest in physical conditioning for preventative and rehabilitative purposes has prompted an increased interest in
understanding the physiological stresses of prolonged work.
Concurrent with this has been an increased awareness of the
psychological factors and the perceptions associated with prolonged work. Perceived exertion has been defined as the
subjective rating of the intensity of physical work and has
been the subject of increasing attention in the literature since
the late 1950s.1 The processing of sensory cues related to
physical performance enables an individual to perceive general feelings of exertion and more specific sensations of physiological performance such as shortness of breath, muscular
effort, and joint pain. Borg suggests that the overall perception
of exertion is a "gestalt" of many feelings and sensations
related to the performance of work.2
The purpose of this article is to summarize the literature
on perceived exertion and to discuss the therapeutic implications for physical therapy.
PSYCHOPHYSICAL RATING SCALE
The scientific study of perceived exertion and work intensity first concentrated on the development of methods to
establish perceptive estimation of work using a ratio scale.
The original work of Stevens in 1957 and Ekman in 1958 led
Borg to develop a psychophysical category scale for ratings of
perceived exertion (RPE).3. 4 This scale is a 15-point, graded
scale with numbers ranging from 6 to 20. These numbers
follow the normal heart rate (HR) range closely (60-200 beats
per minute); in healthy middle-aged men, HR closely corresponds to 10 times the RPE value. Descriptive words are
included with every other number and range from very, very
light at 7 to very, very hard at 19 (Figure). Ratings of perceived
exertion have been reported to show linear correlations with
HR and work intensity with correlation coefficients between
.80 and .90.3-5 High correlations with other physiological
variables have also been found.6, 7 The Borg Scale has been
proven valid and reliable in repeated tests of increasing work
intensity with work loads either progressively or randomly
ordered.3 In a single motor performance, high correlations
have also been found between perceived exertion and pro-

Ms. O'Sullivan is Assistant Professor of Physical Therapy, Department of

Physical Therapy, Sargent College of Allied Health Professions, Boston University, Boston, MA 02215 (USA).
This article was submitted March 28, 1983; was with the author for revision
11 weeks; and was accepted October 24, 1983.

duced force.8 At constant intensities and low work loads, low

correlations from .20 to .50 between RPE and HR have been
found.59
PHYSIOLOGICAL FACTORS AND
PERCEIVED EXERTION
The development and widespread adoption of a perceptual
rating scale has facilitated the enormous growth of research
on the topic of perceived exertion in recent years. Numerous
studies have attempted to identify the physiological factors
that give rise to perception of exertion. These factors have
been divided into those that produce either local or more
generalized, central effects. Local signals include aches,
cramps, pain, or fatigue that arise from feelings of strain in
active muscles, tendons, and joints.7 The greater the feeling
of strain in the exercising muscles, the more intense the local
signals become.10 Lactate levels and oxygen debt associated
with anaerobic work of the exercising muscle appear to be
important factors in the generation of local signals.11,12 During
heavy work, the energy available from aerobic processes is
insufficient to meet the demands, producing an oxygen deficit
and causing the muscle to rely on anaerobic processes to
provide energy for contraction. During dynamic activities
involving large muscle mass (eg, cycling), the anaerobic
threshold may not be reached until 60 to 65 percent of

Response

Descriptors

6
7
8
9
10
11
12

Very, very light

Very light
Fairly light

13
14
15
16

Somewhat hard

17
18
19
20

Very hard

Hard

Very, very hard

Figure. The 15-point grade scale for ratings of perceived exertion,

the RPE scale.2

Volume 64 / Number 3, March 1984

Downloaded from http://ptjournal.apta.org/ by guest on October 24, 2012

343

maximal aerobic power (MAP).13 The anaerobic threshold

during arm exercise, which uses a smaller muscle mass, is
generally reached sooner.13, 14 A major end-product of anaerobic metabolism is lactic acid. Thus, lactate concentration is
a potent influence on perceived exertion. At high exercise
intensities, its influence is significant, but at low intensities,
its influence is minimal.15 The muscular discomfort of metabolic acidosis that results from high lactate levels is readily
perceived as a conscious sensation by the exercising individual.
Kinesthetic information arising from proprioceptive mechanisms (mechanoreceptor, Golgi tendon organ activity, and
sensations from muscle, ligament, joint, and skin) provides
another important source of local cues. In studies comparing
cycling with running, perceived exertion was found to be
higher for cycling than for treadmill running at constant
submaximal workloads.10 This higher level is not a surprising
finding when one considers that cycling involves more intense
work by fewer muscles than does running. At the same power
output, pedalling at a lower frequency (40 rpm) caused perceived exertion to be higher than at higher frequencies (60
rpm). Increased muscle tension at the lower frequencies was
again implicated in the more intense perceptual response.16. 17
Central factors reflect the circulatory, respiratory, and metabolic adjustment to aerobic work. Signals such as HR, catecholamine levels, pulmonary ventilation (VE), respiratory rate
(RR), overall feelings of exertional dyspnea, oxygen consumption (Vo2), and skin temperature all play a role in determining
the magnitude of the central response to physical work.2. 6
Mihevic notes that the term "central" in perceived exertion
literature takes on an entirely different meaning than that
traditionally accepted in the physiological literature (ie, the
central nervous system).15
The strong linear relationship between HR and perceived
exertion was originally suggested by Borg and has been upheld
in numerous studies in recent years.2 Correlation coefficients
from .80 and .90 have been found between HR and RPE in
a variety of work tasks (bike and treadmill and arm and leg
work) and under varying exercise conditions (from moderate
2.
6.18
to heavy intensity, continuous orintermittent).5.
The RPE-HR relationship can be altered under certain
conditions. When subjects are administered propranolol, a
beta-adrenergic receptor blocking agent, the HR remains low
while the RPE increases similarly to the results of control
studies.10, 19 When environmental heat is introduced into the
test environment, HR is significantly increased while the RPE
remains proportional to the levels of work intensity.20-22 These
and other studies in which HR was manipulated with either
pharmacological or environmental conditions lend support
to the concept that HR is not a major sensory cue for
perceived exertion. Robertson suggests this strong linear relationship is probably the result of other hemodynamic factors
such as cardiac output, stroke volume, or blood pressure.6
Studies on the effects of aging on perceived exertion reveal
that the HR necessary to produce a given RPE score declined
with age, roughly corresponding to the decline in maximal
HR.18. 23
Ventilatory signals that are readily monitored by the exercising individual include sensations of breathlessness and
dyspnea. Strong correlations exist between ventilatory function, respiratory rate, and perceived exertion (.61-.94).6, 15
These relationships are particularly true at high exercise in-

tensities where peak exercise intensities have been found to

coincide with peak ventilation.15 At low to moderate exercise
intensities (below 50% MAP), these signals appear to have
less of an impact as a cue for perceived exertion. When
pulmonary ventilation was manipulated by breathing a hypoxic gas mixture, RPE scores remained unaltered at low
levels of exercise, but at high levels of exercise (70% MAP),
both VE and RPE scores were significantly higher when compared with control scores.24 Hypnotic suggestion introduced
changes in both perceptual and metabolic responses to exercise following the direction of the suggestion. Although actual
workloads remained unchanged, VE and RPE scores closely
corresponded to hypnotic suggestions of light, moderate, or
heavy work.25 The results suggest that ventilation probably
provides an important central sensory cue for perceived exertion.
Perceived exertion has also been studied in relation to
aerobic power. When RPE is correlated with Vo2, strong
correlations ranging from .76 to .97 have been found.6. 26. 27 A
number of studies have investigated the perceptual differences
at absolute and relative levels of Vo2. Ratings of perceived
exertion values were, on the average, 2 to 3 units higher for
older subjects at absolute levels of Vo2, but no significant
differences were found when oxygen uptake was expressed as
a percentage of MAP.18 Similar effects were noted in studies
on sex differences. At controlled intensities of work and Vo2,
women experienced a higher rating of perceived exertion than
men. When oxygen uptake was expressed as a percentage of
MAP, however, scores were independent of sex.17 These studies indicate that the relationship of perceived exertion to Vo2
consumption is closely related to the proportion of maximum
working capacity required to perform a given work load
relative to Vo2max and not to an absolute work load.

PSYCHOLOGICAL FACTORS AND

PERCEIVED EXERTION
Morgan suggested that the unexplained variance between
perception of exertion and physiological variables may be
caused by the presence of psychological variables.25 He found
that anxious, depressed, or neurotic individuals consistently
interpret subjective sensations of physical work inaccurately
and postulated that this may be the result of their altered
states of autonomic arousal. Bartley suggested a similar model
in which homeostatic and comfort systems serve as a base for
understanding the perceptual systems.28 Morgan also found
that extroverted individuals perceive the same work load as
lighter than a group of introverted subjects.25 Robertson et al
found that individuals who consistently augment or magnify
the intensity of stimulation perceive the same work load as
more intense than individuals who reduce or attenuate the
intensity of their sensations.29 Because the physiological responses of the groups were similar at a given work load, this
study concluded that the contrasting styles of "stimulus intensity modulation appeared to have differentially influenced the
perceptual responses to muscular exertion."29 These findings
are supportive of Morgan's because individuals classified as
extroverts and reducers are known to have a high pain tolerance and more readily participate in athletics.30 Both
Morgan25 and Robertson et al29 note that perceptual responses
may be confounded by "state- versus trait-dependent" components. That is, individuals may characteristically function
PHYSICAL THERAPY

344
Downloaded from http://ptjournal.apta.org/ by guest on October 24, 2012

PRACTICE
in one way (trait-dependent), but under certain circumstances
(eg, extreme stress) may change the way they characteristically function, thereby becoming state-dependent. For example, trait augmenters may become reducers under extremely fatiguing endurance exercise or under the influence
of certain drugs, such as alcohol and aspirin. Highly anxious
subjects may reduce their state of anxiety by performing
strenuous physical exercise, but similar exercise may increase
the state of low anxious subjects. Thus, psychological components of state and trait may influence a subject's perceived
exertion and the interaction of the two may provide an
additional source for interpreting inconsistent findings in the
literature.
SENSORY INTEGRATION AND
PERCEIVED EXERTION
Borg originally proposed that during a short bout of work,
perceptions originated from the working muscles, whereas
during a prolonged bout of work, central signals from the
organs of circulation predominated.1. 2 This two-factor model
was further elaborated by Ekbloom and Goldbarg.10 Their
subjects were asked to rate separately local factors (muscle
and joint feeling) and central factors (breathing and HR).
Mihevic suggests that this is a simplistic approach to a complex psychobiological problem.15 Perception of exertion appears to be a generalized response resulting from the summation of many different sensations, each having a separate
perceptual weighting (Table).31-34 Although signals that are
more pronounced may dominate the sensory integration
mechanism, all signals are received. The particular conditions
of the exercise (such as type, mode, intensity, duration, and
conscious processing of the signals involved) determine the
perceptual responsiveness to work.6,7,15,35 As the load becomes
heavier, perceptual discrimination may increase.14 The exact
mechanism by which these physiological and psychological
signals are processed and integrated remains unclear. Although little research has been done to delineate the sensory
integration mechanisms, researchers are now beginning to
pursue this phase of investigation.
THERAPEUTIC IMPLICATIONS
Borg originally suggested that the most interesting application of perceived exertion ratings was in the area of exercise
prescription.3 Target HRs and training levels might be accurately regulated in some individuals by subjective ratings of
perceived exertion. Initial exercise training might be focused
on helping individuals accurately adjust the intensity of work
by feelings of how hard their body is working.
In a recent study of subjective regulation of work intensity
during treadmill exercise, Smutok et al noted a progressive
difference in HR at the same RPE between exercise stress
testing and subjectively rated exercise.9 Ratings of perceived
exertion were found to be reliable in determining conditioning
HR above 9 km per hour. Ratings of perceived exertion values
below these levels were inaccurate and unreliable in determining conditioning HR. Thus, reliability of subjective exercise
regulation seems to be related to the intensity of exercise.
They also noted a large range of intraindividual HR error
across all RPE values and suggested that some subjects are far
more accurate in regulating exercise intensity by RPE than
others. This variability may be more the result of the presence

TABLE
Subjective Symptoms of Prolonged Worka
Levels of
Perceptual
Processing
Low discomfort/intensity (movement
awareness)
Moderate
discomfort/
intensity
High discomfort/intensity

Subjective Symptoms
Local

General

Cardiopulmonary

muscle aches

muscle fatigue
legs aching,
heavy
muscle pain,
cramps
legs shaky,
tremors

feeling tired
perspiring

dyspnea
breathlessness

perspiring
feelings of
pain/task
aversion

difficulty with
breathing
heart pounding/chest
pain

Modified from Robertson6 and Pandolf.32

of psychological factors than the result of physiological ones.

Noble suggested that attempts to use "an estimation technique
(Borg Scale) for a production problem (training control)" may
be inappropriate.36 In a more recent study, Gutman et al had
patients with cardiac disease work at a tolerable level (selfselected intensities) and found that training HRs and RPEs
approximated those obtained during exercise stress testing.37
In an earlier study of patients with coronary heart disease,
RPEs were found to be higher in relation to HR than those
in a control group of healthy subjects working at similar work
loads.21 Squires et al found that cardiac patients on propranolol demonstrated a lower HR during submaximal and maximal exercise when compared with those not receiving propranolol, but RPE was the same for both groups at similar
work loads.19 Patients with arterial hypertension and vasoregulatory asthenia syndrome rated the perceived exertion as
less in relation to HR, especially at low-intensity exercise
levels. Because coronary patients have a relatively low, symptom-limited maximal HR, these findings are consistent with
those of Smutok et al.9 At low HRs and low exercise intensities, ratings of perceived exertion may not be a reliable indicator of HR. Patients who have angina pectoris do not appear
to have a high correlation between perceptions of angina and
perceptions of effort. As Noble reports, the angina scale
developed by Borg, Holmgren, and Ludblad may be a more
effective scale to monitor their responses.36
Therapeutic training regimens do not appear to alter the
relationship between HR and RPE.38 When both HR and
RPE are expressed as a percentage of MAP, differences are
not observed. This similarity is understandable because
Vo2max uptake or work capacity increases with training. The
relationship between training and RPE and HR was not
supported in a recent study of elderly subjects by Sidney and
Shephard.18 After a 34-week training period, HRs declined,
but ratings of perceived exertion remained unchanged or were
augmented. One explanation for this unpredicted finding is
that the habitual light mode of daily activity present before
the study was perceived as being of above average intensity.

Volume 64 / Number 3, March 1984

Downloaded from http://ptjournal.apta.org/ by guest on October 24, 2012

345

CONCLUSION
Ratings of perceived exertion appear to be a useful tool for
quantifying some of the perceptions we experience during
prolonged bouts of exercise. The RPE provides us with an
estimate of the subjective costs of physical activity that may
or may not be at variance with the actual physiological costs.
In young and healthy middle-aged subjects who exercised at
moderate to high intensities, RPE has been shown to be a
direct measure of physiological stress as well as an indirect
measure of physical work capacity. In elderly persons and
certain patient groups with cardiovascular or psychiatric problems and in certain environmental and drug situations, the
relationship between HR and RPE appears to be altered.
Research on perceived exertion has been largely focused in
the laboratory setting and needs to be applied more fully to
the clinical setting to evaluate its usefulness. For individuals
exercising at restricted HRs and in acute situations where
accuracy may mean the difference between life and death,
RPE is inappropriate to use alone as either an assessment or
prescriptive tool in measuring work capacity. Borg notes the

"perfect indicator of dangerous strain" involves a number of

important factors including HR, arrhythmias, ST segment
changes, blood pressure elevations, and energy costs.4 When
perceived exertion is used in conjunction with these indicators, it adds dimension to the assessment of response and
regulation of exercise in certain patients. Heightened perceptual awareness of the body's response to the stresses of prolonged work can provide valuable information to patients,
helping them to get "in tune" with and "listen" to their bodies.
In clinical or physical fitness settings, this increased awareness
may serve to prevent unnecessary strain or injury. Noble
recommends studying the usefulness of perceived exertion as
a predictor of physical fitness in school environments.36
Widespread use of the Borg scale has proven it to be a
useful tool for many clinicians and patients. Its misuse must
be guarded against, however, and the limitations of a psychophysical rating scale must be clearly understood. Borg suggests
that one perfect scale useful in all situations for perceptual
rating may not exist.4 What is clearly evident in published
research is an increased use of perceptual information as an
indicator of physical strain.

REFERENCES
1. Borg G: Physical Performance and Perceived Exertion. Lund, Sweden,
Gleerup, 1962, pp 10-11
2. Borg G: Perceived exertion. In Wilmore J (ed): Exercise and Sports Science
Reviews. New York, NY, Academic Press Inc, 1974, vol 2, p 131
3. Borg G: Perceived exertion: A note on history & methods. Med Sci Sports
5:90-93, 1973
4. Borg G: Psychophysical bases of perceived exertion. Med Sci Sports
Exerc 14:377-381,1982
5. Skinner J, Hutsler R, Bergstrinova V, et al: The validity and reliability of a
rating scale of perceived exertion. Med Sci Sports, 5:94-96,1973
6. Robertson R: Central signals of perceived exertion during dynamic exercise. Med Sci Sports Exerc 14:382-389,1982
7. Cafarelli E: Peripheral contributions to the perception of effort. Med Sci
Sports Exerc 14:382-389,1982
8. Cooper D, Grimby G, Jones D, et al: Perception of effort in isometric and
dynamic muscular contraction. Eur J Applied Physiol 41:173-180,1979
9. Smutok M, Skrinar G, Pandolf K: Exercise intensity: Subjective regulation
by perceived exertion. Arch Phys Med Rehabil 61:569-574,1980
10. Ekbloom B, Goldbarg A: The influence of training and other factors on the
subjective rating of perceived exertion. Acta Physiol Scand 83:399-406,
1971
11. Kay C, Shephard R: On muscle strength and the threshold of anaerobic
work. Int Z angew Physio 27:311-328,1969
12. Allen P, Pandolf K: Perceived exertion associated with breathing hyperoxic
mixtures during submaximal work. Med Sci Sports 9:122-127,1977
13. strand P, Rodahl K: Textbook of Work Physiology. New York, NY,
McGraw-Hill Inc, 1970, pp 279-318
14. Blitz P, VanMoorst A: Physical fatigue and the perception of differences in
load: A signal detection approach. Percept Mot Skills 46:779-790,1978
15. Mihevic P: Sensory cues for perceived exertion: A review. Med Sci Sports
Exerc 13:150-163,1981
16. Lollgen H, Graham T, Sjogaard G: Muscle metabolites, force and perceived
exertion bicycling at varying pedal rates. Med Sci Sports Exerc 14:345351,1980
17. Henrikson J, Knuttgen H, Binde-Peterson T: Perceived exertion during
exercise with concentric and eccentric muscle contractions. Ergonomics
15:537-544,1972
18. Sidney K, Shephard R: Perception of exertion in the elderly, effects of
aging, mode of exercise and physical training. Percept Mot Skills 44:9991010,1977
19. Squires R, Rod J, Pollock M, et al: Effect of propranolol on perceived
exertion soon after myocardial revascularization surgery. Med Sci Sports
Exerc 14:276-280,1982
20. Pandolf K, Carfarelli E, Noble B, et al: Perceptual responses during
prolonged work. Percept Mot Skills 35:975-985,1972

21. Skinner J, Hutsler R, Bergsteinova V, et al: Perception of effort during

different types of exercise and under different environmental conditions.
Med Sci Sports 5:104-109,1973
22. Noble B, Miltz K, Pandolf K, et al: Perceptual responses to exercise: A
multiple regression study. Med Sci Sports 5:104-109,1973
23. Borg G, Linderholm H: Perceived exertion and pulse rate during graded
exercise in various age groups. Acta Med Scand [Suppl] 472:194-206,
1967
24. Cafarelli E, Noble B: The effect of inspired carbon dioxide on subjective
estimates of exertion during exercise. Ergonomics 19:581-589,1976
25. Morgan W: Psychological factors influencing perceived exertion. Med Sci
Sports 5:97-103,1973
26. Noble B, Metz K, Pandolf K, et al: Perceived exertion during walking and
running. Med Sci Sports 5:116-120,1973
27. Horstman D, Morgan W, Cymerman A, et al: Perception of effort during
constant work to self-imposed exhaustion. Percept Mot Skills 48:11111126,1979
28. Bartley S: Homeostatic and comfort perceptual systems. J Psychol
75:157-162,1970
29. Robertson R, Gillespie R, Hiatt E, et al: Perceived exertion and stimulus
intensity modulation. Percept Mot Skills 45:211-218,1977
30. Morgan W, Costill D: Psychological characteristics of the marathon runner.
J Sports Med Phys Fitness 12:42-46,1972
31. Pandolf K, Buise R, Goldman R: Differentiated rating of perceived exertion
during conditioning of older individuals using leg-weight loading. Percept
Mot Skills 40:563-574,1975
32. Pandolf K: Differentiated ratings of perceived exertion during physical
exercise. Med Sci Sports Exerc 14:397-405,1982
33. Gillespie R, McCarthy J, Rose K: Differentiated perceptions of exertion:
Part 1, mode of integration of regional signals. Percept Mot Skills 49:683689,1979
34. Gillespie R, McCarthy J, Rose K: Differentiated perception of exertion: Part
2, relationship to focal and central physiological responses. Percept Mot
Skills 49:691-697,1979
35. Young A, Cymerman A, Pandolf K: Differentiated ratings of perceived
exertion are influenced by high altitude exposure. Med Sci Sports Exerc
14:223-228,1982
36. Noble B: Clinical applications of perceived exertion. Med Sci Sports Exerc
14:406-411,1982
37. Gutman M, Squires R, Pollack M, et al: Perceived exertion-heart rate
relationship during exercise testing and training in cardiac patients. Journal
of Cardiac Rehabilitation 1:52-59,1981
38. Docktor R, Sharkey B: Note on some physiological and subjective reactions
to exercise and training. Percept Mot Skills 32:233-234,1971

PHYSICAL THERAPY

346
Downloaded from http://ptjournal.apta.org/ by guest on October 24, 2012

Perceived Exertion : A Review

Susan B O'Sullivan
PHYS THER. 1984; 64:343-346.

This article has been cited by 1 HighWire-hosted articles:

Cited by

http://ptjournal.apta.org/content/64/3/343#otherarticles
http://ptjournal.apta.org/subscriptions/

Subscription
Information

Permissions and Reprints http://ptjournal.apta.org/site/misc/terms.xhtml

Information for Authors

http://ptjournal.apta.org/site/misc/ifora.xhtml

Downloaded from http://ptjournal.apta.org/ by guest on October 24, 2012