Medbridge Cancer Rehab Handout

Cancer Rehabilitation

By Anna Schwartz, Ph.D., FNP, FAAN

and Roger Campbell, M.S., CET, MFT-c

Course Material

This document contains the slides for the full course and

corresponding handouts relevant in Chapter 4.

Course Slides

Please refer to Course Slides as you are

viewing the presentation.

Cancer Rehabilitation Overview Module 1 Anna Schwartz, 1

Cancer Rehabilitation Overview

Anna L. Schwartz, PhD, FNP, FAAN

Rehabilitation Systems

University of Washington


Overview

• Incidence and prevalence

• Tumor Biology

• Staging

• Treatment of common cancers


Current State

• Over 1.5 million new cases cancer in 2011

• Over 12 million survivors alive in U.S. • Burden of cancer

– Morbidity

– Mortality

– Economic cost

– Lost work days

– Reduced quality of life

– Family burden

• Need for cancer rehabilitation


Burden of Suffering

• Inactivity associated with: – Coronary artery disease (CAD), hypertension, type II

diabetes, osteoporosis

• Leading cause of death is CAD – 1.5 million myocardial infarctions and 520,000 deaths

each year

• Type II Diabetes – Affects more than 6 million people – Risk factor for CAD, cerebrovascular disease, retinopathy

and hypertension

• Osteoporosis – Causes 1.3 million fractures/year – $7 Billion per year in direct and indirect costs


Cancer related Burden of Suffering

• Long-term and Late-effects – Increased risk of cardiac problems – arythmia, CHF, CAD, – Weight gain – increases risk for high cholesterol,

hypertension, DM – Diabetes Mellitus – Emotional/Psychological – Memory and thinking – Infertility – Recurrence – Fatigue – Development second cancers – Impacts QOL and financial wellbeing of:

• survivor, family and society


Exercise as Primary Prevention

• Coronary Artery Disease

• Hypertension

• Overweight and Obesity

• Diabetes (type II)

• Osteoporosis

• Psychological wellbeing

• Reduce cancer risk

• Weight control

• Improve QOL

• Improve Body composition

Prevention Health Promotion


Exercise as Tertiary Prevention

• Weight control

• Hypertension

• Cardiovascular risk

• Bone health

• Diabetes

• Goals: Improve quality of life by reducing disability, limiting or delaying complications and restoring function.


Cancer Incidence

• Leading cause of death of women 40-64

• Leading cause of death men 60-79

• 2nd to heart disease most common cause of death


Causes of Cancer Death

• Most common causes of cancer-related deaths in women: – Lung cancer 26%

– Breast cancer 15%

– Colorectal cancer 9%

• Most common causes of cancer-related deaths in men: – Lung cancer 29%

– Prostate cancer 11%

– Colorectal cancer 9%


Most common cancers

• Women – Breast cancer28% – Lung cancer 14% – Colorectal cancer 10%

• Men – Prostate cancer 28% – Lung cancer 15% – Colorectal cancer 10%

Jemal et al. Cancer Statistics, 2009.CA cancer J. Clin. 2009 Jul-Aug; 59(4):225-249.


Cancer Biology

• Abnormal cells division and proliferation

– Genetic abnormalities or mutations

– Mutations can cause oncogenes

– Mutations can cause inactivation of tumor suppressor genes

• Tumors can form new blood vessels (angiogensesis)


Metastasis

• Cancer spreads by

– Invasion of neighboring tissue

– Penetration into lymphatic or blood vessels


Cancer Categories

• Carcinoma – Arises in skin and tissues that line internal organs

• Sarcoma – Begins in supportive or connective tissues

• Muscle, bone, fat and blood vessels

• Leukemia – Develops in blood forming tissues

• Lymphoma and Myeloma – Originate in immune system cells


Staging Solid Tumors

• Solid Tumor Classification – TNM Classification

• Tumor size • Degree of Lymph Node(s) involved • Presence of distant Metastasis

• Stage 0: in situ or noninvasive • Stage I: disease confined to site of origin • Stage II: locoregional involvement • Stage III: larger tumor with lymph node

involvement • Stage IV: disease spread to distant sites


Lymphoid Tumor Classification

• REAL/WHO Classification

– Considers:

• Clinical

• Morphologic

• Immunophenotypic

• Genetic factors

• Ann Arbor Classification of staging

– Lymphomas

• Stage I-IV


Screening

• Purpose

– To detect cancer at early stage

• Early detection

– Can reduce morbidity, mortality and health care costs

• Screening effective if:

– Test can detect early disease

– Evidence that earlier treatment improves survival


Breast Cancer

• Diagnosed with:

– Mammogram, US, MRI, biopsy, surgery

• Local Therapy:

– Removal of tumor

– Surgical examination of lymph nodes with

• Sentinel lymph node biopsy

• Mastectomy, breast-conservation with lumpectomy

– Radiation


Breast Cancer continued

• Invasive breast cancer

– Sentinel lymph node biopsy

– Axillary lymph node dissection

• Lymph Node dissection = higher risk lymphedema

– 16-19% vs 3-5% with sentinel lymph node biopsy


Adjuvant Therapy Breast Cancer

• Treatment after surgery • May include:

– Radiation therapy – Chemotherapy – Hormonal therapy – Biologic therapy

• Necessity based on tumor characteristics – Size – Grade – Extent of lymph node involvement – Tumor marker expression


Breast Cancer and Radiation Therapy

• Duration

– 5 days/week x 5 – 6 weeks

• Indications

– Breast conservation

– Mastectomy with positive surgical margins

– Mastectomy with numerous lymph nodes


Breast Cancer Tumor Markers

• Tumor Markers – Hormone Receptors

• Estrogen and Progesterone Receptor

– HER2/neu • Protein that indicates aggressiveness of tumor • Herceptin is a monoclonal antibody used to

• Influence prognosis and treatment • Hormone receptor positive tumors

– Treated with anti-estrogen therapy usually at least 5-years – Exemestane (Aromasine) – Letrosole (Femara) – Anastrazole (Arimidex)

– Can reduce recurrence by at least 40%


Common Chemotherapies

• Drugs Used in Combination – Adriamycin

– Cyclophosphamide

– Paclitaxel

– Docetaxel

– Methotrexate

– 5-fluorouracil

• Given every 2-3 weeks for 12-24 weeks of treatment


Metastatic Breast Cancer

• Common metastatic sites: • Bone, liver, lung, brain

• Palliative treatment

• Supportive care to shrink disease, reduce pain and bone-targeted therapy – Zolendronic acid (Zometa)

– Denosumab (Xgeva)

– Chemotherapy and/or hormonal therapy

– Targeted radiation therapy


Prostate Cancer

• Mean age onset 68yo

• Most men die of CVD or other causes

• Diagnoses and Prognosis – PSA

– Transrectal prostate biopsy with US

– Gleason score of histologic grading

– Age

– Comorbid conditions

– Clinical stage


Localized Prostate Cancer

• Radical prostatectomy

– If in good health and tumor confined (Stage I or II)

– If pelvic lymph nodes involved prostatetomy usually not performed

• Increased risk recurrence with extraprosatitic disease

• Watchful-waiting


Stage I-III Prostate Cancer

• External beam Radiation – 75% with stage I disease alive at 10-years

– Less than 25% recurrence-free survival in Stage IV at 10-years

• Interstitial Brachytherapy • Permanently placed radioactive iodine implants

• May have lower risk impotence and other side effects

• Option for patient with: – Favorable tumor characteristics

» Low Gleason score

» T1 or T2 tumors


Medical Therapy

• Luteinizing-releasing hormone agonist (LHRH)

– Leuprolide (Lupron), goserelin (Zoladex)

– Usually given q 3 months

– Profound hypogonadal effect

• Antiandrogen therapy

– Flutamide (Eulexin), bicalutamide (Casodex), nulutamide (Nilandron)

– Usually taken daily


Metastatic Prostate Cancer

• Most common site • Bone, liver, brain

• Palliative therapy for control of disease and pain

• Hormonal therapy,

• Chemotherapy,

• Targeted radiotherapy

• Bone-targeted therapy • Zoledronic acid (Zometa)

• Denosumab (Xgeva)


Lung Cancer

• Leading cause of mortality in US

• 90% of cases related to smoking

• Dose response relationship

• Risk decreases with smoking cessation

• Screening not effective; does not decrease mortality


Diagnosis Lung Cancer

• Chest x-ray

• CT scan chest

• Bronchoscopy

• CT-guided needle biopsy or surgery in patients with pleural disease

• Imagery with CT, Positron Emission Testing (PET), brain MRI

• Pulmonary function testing


Prognosis & treatment

• 2 histologic categories

– Small cell lung cancer (SCLC)

– Non-small cell lung cancer (NSCLC)

• SCLC usually presents with advanced disease

• High risk brain metastasis

• Limited SCLC treatment includes:

• Surgery (lobectomy or pneumonectomy)

• Chemotherapy

• Thoracic radiation


SCLC Chemotherapy

• Cisplatin and etoposide

• Concurrent radiation therapy

• 3-week cycle x 4-6 cycles


NSCLC

• 80% of all lung cancers

• Operable tumors

– Lobectomy

– Pneumonectomy

• If margins are not clear chemotherapy or concurrent chemo-radiotherapy are recommended


Extensive Local Disease: NSCLC

• Treatment may include: • Surgery,

• Chemotherapy,

• Radiotherapy,

• Neoadjuvant chemotherapy, or

• Concurrent chemoradiotherapy


Metastatic Disease NSCLC

– Chemotherapy – Cisplatin – Carboplatin – Paclitaxel – Docitaxel – Etoposide

– Targeted therapy • Epidermal growth factor receptor inhibitors • Bevacizumab

– monoclonal antibody that blocks vascular endothelial growth

• Erlotinib – inhibits tyrosine kinase pathway – most effective if tumor is k-ras negative

• Cetuximab - most effective if tumor is k-ras negative


Colorectal Cancer

• Screening effective – Highly treatable and curable when confined to

bowel

• May be asymptomatic

• Initial workup – DRE

– Colonoscopy with biopsy suspicious lesions

– CT to determine extent disease

– CEA


Colorectal Cancer Management

• Hemicolectomy • If nodal involvement or tumors invading muscle

– Chemotherapy – 5-FU – Capecitabine – Oxaliplatin – Irinotecan – Bevacizumab – Cetuximab – particularly effective if no k-ras mutation

– Radiation therapy indicated if: – Muscle wall invasion – Perforated bowel wall – Positive surgical margins


Local recurrence Colorectal

• Usually happen at surgical site or adjacent lymph nodes

• Distant spread common to lung and liver

• If recurrence limited surgery may be curative

• Chemotherapy an option


Warning Signs Recurrence

• Generally related to site and extent of disease

• Risk of recurrence highest in the first several years following diagnosis and treatment

• Indolent cancers (e.g. prostate cancer and hormone receptor + breast cancer) recurrence can occur many years or even decades after diagnosis.

• Cancer survivors at risk for second primary cancers


Summary

• Cancer incidence and prevalence

• Tumor biology

• Staging of disease

• Overview of diagnosis and treatment

– Breast cancer

– Prostate cancer

– Lung cancer

– Colorectal cancer

Acute and Persistent Side Effects of Cancer Module 2 Anna Schwartz, 1

Acute and Persistent Side Effects of Cancer





Overview

• Common side effect and symptoms

• Major long-term side effects

• Lymphedema

• Cardiovascular risk factors

• Signs Recurrence


• Interventions directed to: – improve quality of life

– reduce depression, insomnia and fatigue

• Institute of Medicine recommends survivorship care plan – Livestrongcareplan.org

• Cancer therapies constantly changing – Need to keep up-to-date on new drugs and their

side effects and how they relate to rehabilitation


Most common side effects

• Fatigue

• Weakness

• Immune compromise

• Pain

• Peripheral neuropathy

• Lymphedema

• Depression

• Decreased quality of life


Fatigue

• Most common distress side effect • Reported in 70-100% survivors • Assessment

– Evaluate contributing factors • Pain • Sleep • Medication side effects • Hypothyroidism • Anemia

– Non-pharmacologic interventions • Exercise • Psychological interventions for stress anxiety • Nutrition counseling • Sleep therapy

– Pharmacologic Interventions • Anemia treatment • Psychostimulants


Weakness

• Muscle weakness

• Cardiopulmonary declines

• Causes:

– Inactivity

– Drugs (e.g. steroids)


Hematologic Effects

• Anemia

• Neutropenia

• Thrombocytopenia

• One study suggested hematologic benefit of exercise

– Has not been replicated


Pain

• Most common during and within 5-yrs post-treatment

• Etiology related to: – Nerve and tissue from tumor – Treatment related from chemotherapy, radiation, or

surgery • Osteoporosis • Androgen deprivation

• Mechanisms – Nociceptive – Neuropathic


Joint Pain/Arthralgia

• Drug related – Taxanes

– Cyclophosphamide

– Cisplatin

– Colony-stimulating factors

– Hormonal Therapies • E.g. Letrozole, exemestane, anastrozole

• Ibuprofen

• Moderate exercise


Cardiovascular

• Direct damage to CV system

• Indirect damage by increasing risk factors

• Treatment related effects

– Decreased ejection fraction, dyspnea, edema, weight gain

– Anthracyclines, taxanes and trastuzumab

– Dose dependent

– Increases with age


Trastuzumab (Herceptin)

• Used in HER2/neu + breast cancer

• Adjuvant setting

• Metastatic setting

• Given either QW or Q3weeks

• Major side effect – Cardiotoxicity – Monitor cardiac function by:

• Echocardiogram to evaluate ejection fraction

• Nuclear Scan

• Cardiopulmonary Exercise testing


• Radiation therapy

– Cardiotoxicity from inflammation

• Restrictive cardiomyopathy

• Decreased ability of heart to expand

• Fibrosis and scarring

• Can occur 10yrs post treatment

– Decreased ejection fraction

– Damages cardiac vasculature

• Increases risk for ischemia and myocardial infarction


Pulmonary Changes

• Occur in 20-50% of survivors

• SOB, decreased exercise tolerance

• Bleomycin – Pneumonitis

• <10% in germ cell tumors

• 30% Hodgkin’s lymphoma

• Radiation pneumonitis – Incidence is rare

– Pulmonary fibrosis • Decreased lung capacity leading to respiratory failure.


Neurological Changes

• Etiology – Tumor related – Treatment related

• Neuropathy – Associated with:

• Taxanes • Vinca alkaloids • Platinum agents • Thalidomide

– Symptoms related to dose and duration treatment • May or may not resolve after treatment • Pharmacologic management gabapentin, tricyclic antidepressants • Transcutaneous electrical nerve stimulation (TENS) • Physical Therapy


• Ototoxicity

– Related to cisplatin therapy

• Chemo-brain


Endocrine Changes

• Growth and development compromised • Usually specific to tumor and treatment area • Hypothyroidism • Infertility

– Alkylators (cychlophosphamide) – Premature ovarian failure

• Bone loss – Steroids – Endocrine therapy – Chemotherapy drugs


Musculoskeletal Changes

• Joint pain, stiffness

• Negative changes in body composition

• Inactivity related

• Treatment related

– Endocrine therapy

• Aromatase inhibitors

• Androgen deprivation therapy


Lymph Changes

• Lymphedema

• Limb heaviness, aching, numbness, chronic pain loss of function, increased risk infection

• Occurs in: breast, ovarian, colon, prostate and testicular cancers

• Most common in first 1-3 years

– May develop many years after surgery


Exercise and Lymphedema

• Exercise is important

• Start and progress slowly

• Progressive weight-lifting does not

– Increase incidence

– Severity

– Frequency


GI Changes

• Constipation related to pain management drugs • Radiation changes

– Strictures – Malabsorption – Adhesions – Diarrhea

• Surgical effects – Fecal incontinence – Urgency – Chronic diarrhea

• Chemotherapy


Renal Changes

• Nephrotoxicity – During treatment – electrolyte imbalances,

impaired renal function

– After treatment – hypertension, cardiovascular disease

• Associated drugs: – Platinum drugs

– Ifosfamide

– Methotrexate


Hepatic Changes

• Fibrosis

– Can cause cirrhosis

• Portal hypertension

• Hepatocellular carcinoma

• Iron overload from frequent transfusions

• Metastasis


Recurrence

• Concerning signs:

– Cough

– Low back pain

– Spinal cord compression

– New onset edema

– Weight loss

– Night sweats


Lifestyle Factors

• Body Weight – Overweight/obesity linked to increased incidence recurrence

and mortality from cancer – Mechanism

• Not fully understood • Related to:

– Sex hormones – Insulin Growth factor-1 – Adopokines (e.g. leptin)

– Increases risk for cancers of: • Breast • Colon • Endometrial • Kidney • Esophageal


Effects of Exercise

• Risk reduction in – Colon – Breast – Endometrial – Prostate cancer

• Dose-response effect with more exercise being protective – 30-60 minutes/day moderate – vigorous intensity

exercise reduces risk colon cancer – 4 hours/week moderate - vigorous intensity exercise

reduces breast cancer risk


Biologic Mechanism of Exercise

• Reduces body fat

• Decreases insulin and insulin growth factor-1

• Decreases leptin

• Increased adiponectin

• Decreases transit time through bowel

• Decreases sex hormones

• Decreases low-grade inflammation

• Improves immune function


Effect of Dietary Intake

• Inconclusive evidence regarding fat intake and cancer incidence

• Plant-based diet recommended for cancer prevention • Fiber may offer protection • Avoid red and processed meat

– Convincing evidence increases risk colorectal cancer – Cardinogenic N-nitroso compounds produced in gut during

metabolism

• Processed food - limit • Alcohol consumption - limit • Dietary Supplements


Summary

• Common side effect and symptoms

• Management of common side effects

• System approach to reviewing side effects

• Lifestyle factors

– Body mass

– Exercise

– Diet

Benefits of Exercise Module 3 Anna Schwartz, 1

Benefits of Exercise



University Washington


Overview of Module

• Benefits of exercise

– Physical

– Psychological

• Benefits by type of cancer

• American College of Sports Medicine Exercise Guidelines for Cancer Survivors


Time of Exercise

• During treatment

– Exercise is safe and effective

– Prevents declines observed in “usual care” survivors

– Exercise may improve tolerance for treatment

• High rates of completion chemotherapy observed in exercise

• Following treatment

– Bigger improvements in all outcomes

– Tailor program to time since treatment and side effects


Specificity of Training

• Target exercise program to needs of individual

– Increase strength in prostate cancer

– Focus on bone health in bone-wasting treatments

• Individualize rehabilitation program to weakness of survivor and their goals


Physical Effects

• Cardiorespiratory fitness

• Muscular endurance

• Muscular strength

• Flexibility

• Body composition

• Improved immune function

– Inverted J-shaped relationship with exercise


Cardiopulmonary Fitness

• Improvements seen during and following treatment

• Measured by peak oxygen consumption

• Functional tests (e.g. 6-minute walk)

• Exercise prescriptions in studies vary widely – Frequency: 2-5 x/week

– Intensity: 50-75% predicted maximum heart rate

• Type: walking or other aerobic activity Time: 10- 60 minutes – Duration: 2-26 weeks


Aerobic Capacity Breast Cancer

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Pre Post

Exerciser

Non-Exerciser

Feet


Aerobic Capacity - Breast Cancer

Change in walking distance by group: Aerobic exercisers: +20% (p<.05) Resistance exercisers: +3% Usual care group: -6%


Muscle Strength & Endurance

• Improvements seen during and following treatment

• Assess with 1-repetition maximum test (1-RM) • Exercise prescriptions in studies vary widely

– Frequency: 1-5 x/week – Exercises: varied and focused on large muscle groups – Sets: 1-3 – Repetitions: 8 – 15 – Intensity: 25 – 85% of 1RM – Duration: 3-52 weeks


Changes in Muscle Strength

• Aerobic exercisers have greatest benefit – 23%.

• Resistance exercisers benefit – 16%

• Usual care patients – decreased strength on average 25%


Changes in Leg Strength (leg press)


Changes in Arm Strength (overhead press)


Resistance Training Concerns

• Lymphedema

• Prostate cancer

• Bone metastasis


Flexibility

• Little research on the benefits of flexibility

• Assess range of motion at surgical site(s)


Weighty issues…


Body Composition

• Weight gain common during and following treatment

– Weight loss or maintenance important for long term health and survival

• Increases in body fat during treatment

• Declines in bone density

• Weight loss and cachexia

– Lung cancer and end stage disease


Changes in Lean Body Mass

% change in Lean Body Mass by group: AE 2.0% RE 5.4% CG -0.8%

% L

ean

Bo

dy

Mas

s (g

ram

s)


Bone Health

• Improvements observed with both aerobic and resistance exercise

• Improvements greater with aerobic exercise

– better adherence to interventions.


Changes in BMD @ L-spine

% change in BMD at L-spine by group: AE -2.3% RE -6.8% CG -7.9%.

L-Sp

ine


Psychological Effects

• Quality of life

• Depression

• Anxiety

• Self-esteem

• Body image

• Exercise may attenuate declines in quality of life


Fatigue

• Evidence Strong

• Aerobic and resistance exercise reduces fatigue

• Exercise mitigates increases in fatigue during treatment

• Modify exercise according to fatigue level


Fatigue

0

2

4

6

8

10

12

14

16

Pre Post

Exerciser

Non-Exercise


ACSM Roundtable & Guidelines

Round table and Consensus meeting International multidisciplinary team

Nursing Medicine Epidemiology Exercise physiology

Representation from Y-USA National Cancer Institute Lance Armstrong Foundation American Cancer Society


Review of Evidence

• National Health, Lung, & Blood Institute (1998)

• Category A: Overwhelming RCT data • Category B: Few RCTs, small in size

and results inconsistent • Category C: Uncontrolled/nonRCTs

and/or observational studies • Category D: Panel experts opinion

when evidence is insufficient Category


Breast Cancer During Treatment 26 Randomized Clinical Trials (RCTs) assessed safety efficacy Category A:

Safety: 25 RCTs no serious adverse evens (SAEs) Aerobic Capacity: 10 RCTs home-based to supervised

Category B: Fatigue: 5 RCTs showed decrease; 1 no change Body Composition: 5 RCTs 3 improved; 2 no change Quality of life: 3 RCTs improved QOL; several no effects (related

ceiling effect at baseline)

Other outcomes: incidence lymphedema decreased, physical function, muscle strength, bone density, psychological outcomes, side effects reduced


Prostate Cancer

12 studies Receiving androgen depravation therapy and radiation Category A:

Safety: 5 studies no SAEs 1 study myocardial infarction 15 minutes post exercise in 80yo

Category B: Fatigue Quality of life Body composition Prostate Specific Antigen Muscle strength Physical function


Colorectal Cancer

8 RCTs

Category A Safety – no SAEs

Body composition – 2 trials

Other outcomes: side effects, inflammation, oxidative stress, physical function, aerobic fitness and flexibility

Observations trials: exercise after CRC diagnosis may reduce risk for CRC-specific and overall mortality (Meyerhardt, et al 2005, 2006)


Consensus/ACSM Guidelines

Recommendations the same as for age appropriate guidelines from the US DHHS Physical Activity Guidelines for Americans 150 minutes/week moderate-intense aerobic exercise or

75 minutes/week of vigorous exercise Strength training 2-3 time/week, 8-10 exercises of 10-15

repetitions/set, with at least one set per session Avoid Inactivity!!!

Return to normal daily activities as quickly as possible Continue normal daily activities and exercise as much

as possible during and after non-surgical treatments


Avoid Inactivity!!!


How to Apply to Practice

• Provide clear instructions to exercise and avoid inactivity

• Reassure patient that exercise is safe • Instruct patient to exercise:

– At least every other day – Build up to 30 minutes – Start slowly and Progress slowly – Moderate intensity – Choose an activity they enjoy – Aerobic and resistance exercises


Program Implementation

• Develop leadership team with vision and experience

• Develop community connections

• Follow examples from successful programs

• Use evidence based guidelines

• Keep it simple.

• Be responsive to needs of survivors in your state and area.


Program Evaluation

• Use established, reliable and valid measures

• Use measures consistently

• Select outcome measures that are easy implement – Cost effective

– Time efficient

• Record changes – Motivating for participants

– Outcome data for program


Summary Points • Benefits of exercise • ACSM Guidelines

– Aerobic exercise • 150 minutes/wk moderate intensity • 75 minutes vigorous exercise/week

– Resistance Exercise • 2-3 days/week

– Avoid Inactivity

• Exercise for: – primary prevention, – health promotion and – tertiary prevention

• Applications to practice

Exercise Testing Overview Module 4 Roger Campbell, 1

Exercise Testing Overview

Roger Campbell, M.S., CET, MFT-c


[email protected]

www.rehabsys.com

mailto:[email protected]

http://www.rehabsys.com/


Body of Knowledge

American College of Sports Medicine

American Cancer Society

ACSM/ACS Certified Cancer Exercise Trainer

ACSM's Guidelines for Exercise Testing and Prescription (7th Edition)

Development of 21 Cancer Rehabilitation Programs – what works in the clinic


ACSM's Guidelines for Exercise Testing and Prescription (7th Edition)

• Purpose of Exercise Testing

• Pre-Exercise Testing & Evaluations

• Exercise Testing Types

• Exercise Interpretation


Purpose of Exercise Testing

• Educate participants about their present fitness status

• Provide data for the plan of care and exercise prescription

• Collect baseline and follow-up data that allow evaluation of progress and treatment justification

• Motivate participants by establishing reasonable, incremental goals

• Stratifying risk, identify precautions, limitations, and appropriateness for cancer rehabilitation


Pre-Exercise Testing & Evaluations

– To assure safety – To aid in the diagnosis of potential CV disease – To assess heart, lung, and muscle fitness – To provide a baseline from which to track progress – To develop early rapport with the participant

• Physicians Service for: • Medical History • Physical Evaluation • Lab Tests • Medical Clearance • Physicians Referral


Physician Directed Assessment

• Medical Diagnosis

• Previous physical examination

• History of Symptoms

• Recent Illness, hospitalization, surgeries.

• Orthopedic problems and limitations

• Medication use, drug allergies

• Habits, including caffeine, alcohol and tobacco use.

• Exercise History

• Family History of Disease

• Mental Status and ability to follow instructions


Laboratory Test Data Complete Blood Count (CBC)

• A complete blood count (CBC) gives important information about the type and number of cells in the blood, especially red blood cells, white blood cells and platelets.

• A CBC helps doctors and therapists check symptoms, such as weakness, fatigue, or bruising.

• A CBC also helps diagnose conditions, such as anemia, infection, and bleeding disorders.


Laboratory Test Data Check Hematocrit, Hemoglobin, WBC & Platelet Values.


Therapists Patient Evaluation

• Patient Information: Demographics – Insurance • Cancer Data: Type – Location • Presenting Symptoms: Cognitive – Osteoporosis – Nausea • Post surgery /Anti-Cancer Treatments: Type – Start/Finish • Allergies & Hospital History: Medication – Hospitalizations • Body Composition: Skin Fold • Sleep Hygiene: Disturbances • Activities of Daily Life: Functional Limitations • Dietary History: Malnutrition • Psychosocial Assessment: Temperament

• Medical History: Review of Systems • Physical Assessment: ROM - Strength • Functional Capacity Assessment: CPET – 6MWT • Patient Goal Setting: Functional Independence


Precautions • Surgical interventions may cause permanent loss and

disability

• Radiation and chemotherapy may cause permanent scar formation:

• Joints - fibrotic tissue development

• Lungs - pulmonary fibrosis

• Heart – cardiomyopathies

• Extremities - neuropathies

• However, cancer survivors typically benefit from exercise training through improvements in skeletal muscle and psychosocial status.


Terminating an Exercise Test • Absolute Indications

• A drop in systolic blood pressure (10 mm. Hg. from baseline despite increases in workload, when accompanied by indications of ischemia)

• Moderate to severe angina

• Increasing nervous system symptoms (i.e. ataxia, dizziness or near syncope) Signs of poor perfusion (cyanosis or pallor)

• Relative Indications

• Drop in diastolic blood pressure (10 mm. Hg.)

• Hypertensive response (Systolic > 250 mm. Hg., Diastolic > 115 mm. Hg.)

• Increasing chest pain

• Fatigue, shortness of breath, wheezing, or leg cramps

• Dizziness-Vertigo, Pallor, Syncope


Cardio Pulmonary Exercise Testing (CPET)

Functional, Objective, Measurable

• ‘Gold Standard' for evaluating functional capacity in sport and medicine

• CPET - measures ventricular function, respiratory function, cellular function and muscle work function


Tools for CPET


Functional Capacity by CPET

• Functional capacity is determining the maximal oxygen uptake (VO2 MAX) during incremental exercise

• Functional capacity in physiological terms is defined as the maximum ability of the heart and lungs to deliver oxygen and the ability of the muscles to extract it while doing work


Physiological Measurements from my CPET, 08.03.07

• Cardio Pulmonary Exercise Test (CPET) Values at Max Exercise

• VO2 Max: 34.9 mL/kg/min

• Heart Rate Max: 163

• Work Rate Max: Watts-181

• O2-Sat-SpO2: 91%

• RPE / SOBr: 9/9

• MET: 10 MET


V-volume, O2-oxygen, Max-maximum


(MET) - Metabolic Equivalent of Task.

• MET is a ratio of the metabolic rate of a person at rest, to the metabolic rate of a person performing some task

• MET is commonly used in sports medicine and rehabilitation to express intensity rates during activity

• One (1) MET: 3.5 ml O2/kg/min


Six-Minute Walk Test (6MWT)


Six-Minute Walk Test - Overview

• Is a simple test that requires a 100-ft hallway

• Measures the distance a patient can quickly walk on a flat, hard surface in 6 minutes

• Evaluates the integrated responses of all systems involved during exercise

• Will “Not” provide specific information on the function of each organ systems involved in exercise or the mechanism of exercise limitation, as is possible with - CPET


6-MWT Conversion MPH Ft PM 6MWT / Ft M E T kcal / min

1.5 132 792 2.14 10.7

1.6 140.8 844.8 2.22 11.1

1.7 149.6 897.6 2.3 11.5

1.8 158.4 950.4 2.37 11.85

1.9 167.2 1003.2 2.45 12.25

2 176 1056 2.52 12.6

2.1 184.8 1108.8 2.6 13

2.2 193.6 1161.6 2.68 13.4

2.3 202.4 1214.4 2.76 13.8

2.4 211.2 1267.2 2.83 14.15

2.5 220 1320 2.91 14.55

2.6 228.8 1372.8 2.99 14.95

2.7 237.6 1425.6 3.06 15.3

2.8 246.4 1478.4 3.14 15.7

2.9 255.2 1531.2 3.22 16.1

3 264 1584 3.29 16.45

3.1 272.8 1636.8 3.37 16.85

3.2 281.6 1689.6 3.45 17.25

3.3 290.4 1742.4 3.53 17.65

3.4 299.2 1795.2 3.6 18

3.5 308 1848 3.68 18.4

3.6 316.8 1900.8 3.75 18.75

3.7 325.6 1953.6 3.83 19.15

3.8 334.4 2006.4 3.9 19.5

3.9 343.2 2059.2 3.97 19.85

4 352 2112 4.04 20.2

MPH Ft PM 6MWT / Ft M E T kcal / min


6 MWT - Overview

• A self-paced 6MWT assesses the sub maximal level of functional capacity

• Patients choose the pace and are allowed to stop and rest during the test while the clock is running

• This is a symptom – limited test, e.g., Dizziness, Chest Pain, Pallor, Syncope

• Stop the test if these symptoms present and risk the patients safety


Tools for 6 MWT

• Clip Board / Pen

• Timer

• 6 MWT Form

• RPE Form

• DYSPNEA Form

• Pulse Oximeter

• Cones

http://mymicroproject.com/category.php?cid=11



6 MWT Measurements

• 6 Minute Walk Test.

• Distance

• Time

• HR

• RPE / SOBr

• 02-Sat - SPO2


Rating of Perceived Exertion (RPE)

• HOW HARD ARE YOU WORKING

• O. NO PHYSICAL EFFORT

• 1. MINIMAL EFFORT

• 2.

• 3. MODERATE EFFORT

• 4.

• 5. MEDIUM EFFORT

• 6.

• 7. HARD EFFORT

• 8.

• 9. VERY HARD EFFORT

• 10. MAXIMAL EFFORT


DYSPNEA SHORT OF BREATH (SOBr)

• HOW HARD ARE YOU BREATHING

• 0. NO (SOBr)

• 1. MINIMAL (SOBr)

• 2.

• 3. MODERATE (SOBr)

• 4.

• 5. MEDIUM (SOBr)

• 6.

• 7. QUITE (SOBr)

• 8.

• 9. VERY (SOBr)

• 10. MAXIMAL (SOBr)


ONE (1) Rep Max

• One (1) Rep Max is defined as the maximal weight that can be lifted once with good form

• Strength training progression may use a percentage of the 1RM based on the patients evaluated resiliency

• 50% 1 RM

• 60% 1 RM

• 70% 1 RM

• 80% 1 RM


Exercise Test Interpretation

• Identify what you believe to be the source of the patients exercise limitation

• Cardiac problems: Heart Rate / Rhythm / Chest Pain

• Ventilatory problems: RR / SOBr

• Pulmonary problems: Low Spo2 < 88%

• Neuromuscular problems: Pain, Muscle aches, Cramps

Plan of Care Module 5 Roger Campbell, 1

Plan of Care Exercise Prescription Overview



[email protected]

www.rehabsys.com




Plan of Care Objectives

• Preserve and possibly improve function

• Treatment must be individualized

– Tailor to level of patients function

– Accommodate for periods of increased fatigue

• Return to active healthy lifestyle

• Make exercise an integral part of everyday life

• Reduce long-term effects of cancer treatment


Medications & Cancer Therapies

– Glucocorticoids: may cause muscle weakness and wasting

– Growth factors: may cause bone pain

– Chemotherapy: may cause anemia, fatigue, and nausea; possibly myopathies and neuropathies

• e.g., Anthracyclines can cause cardiomyopathy and heart failure

– Radiation: may cause skin breakdown, muscle and joint constriction, and cardiopulmonary fibrosis


Cancer Treatments

• Cancer treatments along with Co-Morbidities can complicate exercise testing and prescription, e.g. pulmonary fibrosis development after radiation therapy

• Cancer patients may experience functional decline as a result of metastasis, osteoporosis, hematologic abnormalities, fatigue, chemo-induced peripheral neuropathy and treatment-induced cardiovascular and pulmonary toxicities


Cancer Late Effects

• Anti-cancer treatment can lead to further loss of function decades later

• Appropriately prescribed exercise can produce gains in aerobic fitness, muscular strength and quality of life

• Exercise may also prevent some types of cancer, reduce risk of cancer recurrence and cancer-related death


Exercise Prescription ACSM guidelines

• The American College of Sports Medicine (ACSM) recommends that an exercise prescription consist of these components: (FITT Principle)

• 1. Frequency of exercise

• 2. Intensity of exercise

• 3. Time or duration of exercise

• 4. Type or mode of exercise


Common Complications

• With bone metastasis, reduce intensity, duration, and mode of exercise to reduce skeletal fractures

• Infection risk is greater for those currently undergoing chemo or radiation therapy

• Patients with cardiac conditions may require increased supervision


Exercise Prescription

• The (FITT) components should be used to prescribe

health related exercise training for patients with cancer on or off treatment

• A patients present physical status and current phase of treatment or recovery must also be considered


Frequency

• In a deconditioned population such as cancer survivors, several shorter exercise sessions per day are generally better tolerated three times a week

• The ACSM recommends individuals to undertake two to three non-consecutive days per week of resistance training

• Flexibility training ranges from two to three days a week up to seven days a week.


Intensity

• The ‘Gold Standard” is direct measurement of intensity by cardiopulmonary exercise testing

• Heart Rate Max - Cardiovascular

• VO2 MAX – Pulmonary

• Watts-MPH – Skeletal muscle

• MET – Metabolic Equivalent of Task


Subjective Measure of Intensity Rating of Perceived Exertion (RPE)

• HOW HARD ARE YOU WORKING

• O. NO PHYSICAL EFFORT

• 1. MINIMAL EFFORT

• 2.

• 3. MODERATE EFFORT

• 4.

• 5. MEDIUM EFFORT

• 6.

• 7. HARD EFFORT

• 8.

• 9. VERY HARD EFFORT

• 10. MAXIMAL EFFORT


Type of Exercise

• The main health related types of exercise are:

• Aerobic

• Resistance

• Flexibility

• The best mode of exercise depends on the patients goals, health status, exercise history and cancer experience.


Aerobic Exercise Is

• “Any Activity” that uses large muscle groups, can be maintained continuously, and is rhythmic in nature.“

• It is a type of exercise that overloads the heart and lungs and causes them to work harder than at rest.


Resistance Training Is

• A method to maintain or improve muscular strength, endurance or power, which is performed against relatively high resistance and few repetitions

• Resistance exercise is a potent physiological intervention to increase muscle mass or reduce muscle wasting


Flexibility Training

• Flexibility refers to the total range of motion of a joint or a group of joints

• Radiation and chemotherapy may cause permanent scar formation in the joints, lungs, and the heart tissues

• Scare formation in joints result in range of motion limitations, thus requiring movement modifications


Time of Exercise

• The American College of Sports Medicine recommends that cancer survivors should exercise aerobically between 20-60 minutes

• Use the lower range (20 min) for less fit and older patients, also exercise duration increases according to fitness and age


Exercise Progression

• Frequency and duration should always be increased before intensity

• Progression should be slower and more gradual for the deconditioned patient and those who are experiencing severe side effects of treatment


Exercise Progression

• Progression is variable, cancer survivors will adapt differently to an exercise stimulus, thus the rate of adaptation dictates the rate of progression

• Cancer patient progression in less predictable, and often non-linear, because of multiple factors including the treatment schedule, fluctuating blood counts and varying symptom experiences


The Art & Science of undulatory

exercise progression is accomplished within an upward wave of increasing

function


The Training Effect

Increase in Fitness


Incremental Exercise Progression

• Is a step-wise approach to progression that is measured and sequential

• Step-wise increments of exercise typically produce progression with out fatigue hangovers


• Data collected from a 6 MWT:

• Work-Rest-Ratio, Method of Progression

• Your patient completes 3 Minutes on the 6 Minute Walk Test (6MWT)

• Lets see how the work-rest-ratio helps

Exercise Prescription Example


Exercise Prescription


Functional Independence MPH Ft PM 6MWT / Ft M E T kcal / min

1.5 132 792 2.14 10.7

1.6 140.8 844.8 2.22 11.1

1.7 149.6 897.6 2.3 11.5

1.8 158.4 950.4 2.37 11.85

1.9 167.2 1003.2 2.45 12.25

2 176 1056 2.52 12.6

2.1 184.8 1108.8 2.6 13

2.2 193.6 1161.6 2.68 13.4

2.3 202.4 1214.4 2.76 13.8

2.4 211.2 1267.2 2.83 14.15

2.5 220 1320 2.91 14.55

2.6 228.8 1372.8 2.99 14.95

2.7 237.6 1425.6 3.06 15.3

2.8 246.4 1478.4 3.14 15.7

2.9 255.2 1531.2 3.22 16.1

3 264 1584 3.29 16.45

3.1 272.8 1636.8 3.37 16.85

3.2 281.6 1689.6 3.45 17.25

3.3 290.4 1742.4 3.53 17.65

3.4 299.2 1795.2 3.6 18

3.5 308 1848 3.68 18.4

3.6 316.8 1900.8 3.75 18.75

3.7 325.6 1953.6 3.83 19.15

3.8 334.4 2006.4 3.9 19.5

3.9 343.2 2059.2 3.97 19.85

4 352 2112 4.04 20.2


Patient Education Overview Module 6 Roger Campbell, 1

Patient Education Overview



[email protected]

www.rehabsys.com




Cancer Patients Need Information

• Knowledge is power

• Patients with cancer want and benefit from information

• Education counts when making treatment decisions


Patient Education

• Improves compliance and medical outcomes

• Reduce medical errors

• Helps set realistic treatment expectations

• Enhances patient satisfaction

• Provides increased patient control over treatment

• Promotes healthy lifestyles


Key Elements

• Patient education is focused on skill building, responsibility, and motivation

• Patients need to know

• When

• How

• And Why they need to make a lifestyle change

• e.g., lifestyles such as, smoking, high-fat, refined-sugar diets, and physical inactivity, account for a majority of cancers


Coordinated Team Effort

• The cancer team’s coordination is just as important as any one persons delivery of education

• Each member of the patient’s health care team needs to be involved with education for optimal patient outcomes


The Big Question

Is the information evidence-based? • The best foundation for patient education is from

evidence-based clinical practice guidelines and reputable research findings

• Cancer Fitness by Dr. Anna Schwartz is an evidence-based patient education for cancer survivors

• Dr. Schwartz is a pioneer of cancer research • Schwartz, A.L. (2009). Fatigue in long term cancer survivors. Oncology Nurse.

• Schwartz, A.L., (2007). Exercise Regimen Reduces Fatigue. ONCOLOGY 21, 4, 37-39.

• Schwartz, A.L. Mortality, Accelerated Aging and Cardiopulmonary function in breast cancer survivorship, (2012) Journal of Clinical Oncology. Editorial.

• Schwartz, A.L. & Winters-Stone, KM(2009). Effects of 12-month Randomized controlled trial of Aerobic or Resistance Exercise During and Following Cancer Treatment in Women. Physician & Sports Medicine, 3, 1-6. PMID:…………………….


Cancer Rehab Patient Education

Cancer Fitness by: Anna L. Schwartz Ph.D., FNP, FAAN


CANCER FITNESS

• Is the Patient Education Manual for our Cancer Rehabilitation Programs www.rehabsys.com/clinic-map

• We present 1 to 2 lesson a week

• Cancer Rehabilitation is typically an 18 to 24 session program, 2-3 sessions a week

http://www.rehabsys.com/clinic-map




Cancer Fitness Lesson Outline


Lesson One: Managing You Side Effects

• Learn to manage your side effects early in your treatment

• If your management techniques are not working, develop a better plan

• Manage your side effects early before they get bad. This is especially true of pain and nausea.

• Ask for help if you aren’t feeling well

• If your side effects are not controlled, it is difficult to exercise.


Lesson Two: Cancer and Exercise: What Does the Science Show?

• Maintaining or increasing your physical fitness during cancer treatment can improve your quality of life

• Exercise does not need to be hard or cause discomfort

• Exercise done in short sessions, spaced out over the day, can decrease side effects from treatment

• The functional ability losses from inactivity and rest take a long time to rebuild


Lesson Three: The Basics of Exercise During Treatment.

• When and how to Start

• Exercise after Surgery

• Exercise during chemotherapy, immunotherapy, and radiotherapy.

• Exercise despite treatment-related limitations

• When to go easy and take a day off.

• Setting your limits.

• Exercise Precautions.


Lesson Four: Setting Goals for a Lifetime of Exercise.

• Starting an exercise program takes commitment and determination

• Examine your barriers and excuses to exercise, and make a plan to succeed

• Set your own goals that are reasonable and achievable


Lesson Five: Cancer Fitness Fundamentals

• Exercise is safe for cancer patients

• Exercise should be fun: not make you feel uncomfortable

• Exercise programs should be individually tailored to your ability and needs

• Use the rating of perceived exertion (RPE) scale to determine how hard you are exercising.


Lesson Six: Cancer Fitness Aerobic Exercise Program

• Frequency of activity

• Intensity of activity

• Type of Aerobic activity

• Time or Duration of activity

• Activity and Chemotherapy

• Exercise Logs

• Coming back to life


Lesson Seven: The Core of Resistance Exercise

• Don’t start resistance exercise until you are at least 4 weeks post surgery

• Start slowly and expect to progress slowly

• Notice any unusual changes in your body

• Do each exercise slowly, and work your muscles through a full range of motion


Lesson Eight

Realizing your potential

• Bringing our lives into balance and pursuing interests and activities that we enjoy fosters intensity, concentration, and enthusiasm.

• The pursuit of excellence does not happen with out commitment, passion, and a focused plan.

• These 8 Lessons motivate patients to achieve more


Cancer Health Behavior Change Turning the corner to better lifestyles

• Consists of two parts:

• First, Perceived susceptibility, a cancer diagnosis creates pause, and re-prioritizing

• Second, Perceived severity of cancer, can I beat this?


Perceived Susceptibility

• One's subjective perception of risk associated with a cancer diagnosis, indicates the need for re-prioritizing

– Perceived Severity, Q-Is this disease curable?

– Perceived Benefits, Q-How will rehab help me?

– Perceived Barriers, A-Fatigue, Pain, Time?

– Cues to Action, A-The survival rate is high!

– Self-Efficacy, A-I will focus my efforts to beat this!

– Self-Efficacy - One’s belief in their own competence


Readiness to Exercise - Questions

• Identify barriers to beginning and maintaining an exercise program

• Fatigue

• Pain

• Time

• Emotional distress

• Side effects of cancer treatments

• No history of exercise


Readiness to Exercise - Answers

• Stress benefit of exercise

• Council survivors on becoming more confident

• Provide cancer related education

• Reinforce the patient control over fitness

• Address issues of discomfort (both physical and environment)

• Acknowledge fear of injury, re-enforce safety protocols


Exercise Adherence

• Describe how to assist clients to develop their own strategy for motivation and adherence, e.g., what would you like to do again?

• Identify different behavior changes to encourage adherence to exercise, e.g., stop smoking

• Describe how to set short, medium and long term goals

Adopting Exercise for Cancer Survivors Module 7 Anna Schwartz, 1

Adapting Exercise for Cancer Survivors



University Washington


Overview

• Primary and Tertiary Prevention • Applying and adapting exercise rehabilitation to cancer

survivors • Cancer-specific concerns

– Lymphedema – Fatigue – Immune function – Fracture risk

• Osteoporosis • Bone metastasis

– Peripheral Neuropathy – Shoulder dysfunction


Exercise as Primary Prevention

• Coronary Artery Disease

• Hypertension

• Overweight and Obesity

• Diabetes (type II)

• Osteoporosis

• Psychological wellbeing

• Reduce cancer risk

• Weight control

• Improve Quality of Life

• Improve Body composition

Prevention Health Promotion


Exercise as Tertiary Prevention

• Weight control

• Hypertension

• Cardiovascular risk

• Bone health

• Diabetes

• Goals: Improve quality of life by reducing disability, limiting or delaying complications and restoring function.


How to Apply to Practice

• Provide clear instructions to exercise and avoid inactivity

• Reassure that exercise is safe • Basic exercise instructions:

– At least every other day – Build up to 30 minutes – Start slowly and Progress slowly – Moderate intensity – Choose an activity that is enjoyable – Aerobic and resistance exercises


Goals of Exercise Prescription Regain and improve physical function, aerobic capacity, strength and flexibility Improve quality of life Improve body composition and body image Improve cardiorespiratory, endocrine, neurological, muscular, cognitive and psychological outcomes Potentially reduce or delay recurrence or secondary primary cancer Reduce, attenuate and prevent long term and late effects of cancer treatment.


What to do?


Avoid Inactivity!!!


Basic Questions

• Previous exercise history

• Physical limitations

– Cancer-related

– Other limitations

• Goals and expectations

• Concerns of the survivor


Cancer-Specific Indications to Stop Exercise

• Breast: changes in arm/shoulder ROM, edema

• Prostate: None

• Colon: Hernia, ostomy-related systemic infection

• Gynecologic: Edema abdomen, groin, lower extremity

• Hematopoietic stem cell transplantations: None


General Injury Risks

• General Injury Risks – Osteoporosis – Peripheral neuropathy – Immune function

• Special Considerations Lymphedema Fracture risk Balance Sudden increase fatigue or

pain Cardiac compromise


Contraindications to Exercise

• Systemic infection

• Severe fatigue or ataxia

• Sudden onset pain

• Cardiac changes

– Dyspnea

– Shortness of breath

– Chest pain

– Arrhythmia


During Treatment

• Plan exercise around therapy

• Periodicity to plan optimal rehabilitation program

• Track side effect pattern and adapt schedule according to tolerance

• Adjust program based on new or developing side effects


Lines, Ports, Ostomy

• Lines – PICC lines – Port-a-Catheter – Indwelling catheter

• Lines in anticubital space may slide out with resistance exercise of biceps and elbow flexion/extension

• Use caution! • Consider another exercise!

• Ostomy – Risk of herniation at stoma

• Exercise should not overstrain muscles around stoma

– Risk of infection at stoma


Lymphedema

• Upper and lower limb lymphedema – 17-42% in breast cancer – 30% in melanoma, gynecological, bladder and testicular cancers

• Chronic, incurable side effect • Exercise may enhance alternative lymph pathways • Compression garments –

– Limited research – Clinically seems effective

• Range of motion • Resistance exercise decreases (Schmitz et al 2010)

– Number lymphedema flares/exacerbations • 14% vs controls 29%

– Number of medical interventions • 195 for controls vs 77 exercise group


Breast Reconstruction

• Implants

• Flaps

• Muscle changes

• Functional changes


Fatigue

• Slow progression

• Break into short bouts

• Monitor fatigue levels and adapt exercise to changes

• Reduce intensity and duration of exercise according to fatigue level


Immunity

• Inverted J-shaped relationship between intensity of exercise and immune function

– Reduction in immune function with overtraining, exhaustion

– Limited research in oncology setting

• Take care if immune compromised

– Avoid people with colds, coughs, etc

– Keep facility and equipment clean


Cardiovascular Concerns

• Be aware of treatments that compromise heart function

– Anthracyclines

– Biologic therapies

• Aerobic exercise may improve left ventricular remodeling in heart failure

• Similar effect not seen in breast cancer patients receiving adjuvant trastuzumab


Peripheral Neuropathy

• Brain Tumors • Brain Metastasis • Peripheral Neuropathy • No evidence exercise improves • Consider ability to hold free weights, manage

equipment • Consider balance • Adapt exercise with

• Stationary bicycle • Recumbent stepper • Spotter


Fracture Risk

• Treatment related

• Weakness, neuropathy related

• Disease specific

– Multiple myeloma

– Bone metastasis

– Long term effect = osteoporosis

• Adapt exercise to decrease risk of falls

• Monitor correct form with exercise


Shoulder Dysfunction

• Head and neck cancers after dissection surgery

• Range of Motion

• Strengthening

• Lymphedema


Amputations

• Adapt and focus on what can be done

• Focus on:

– Balance

– Range of motion

– Functional mobility

• Evaluate survivor’s goals and individualize program to reach those goals


Program Implementation

• Develop leadership team with vision and experience

• Develop community referral system

• Follow examples from successful programs

– E.g pulmonary or cardiac rehabilitation

• Use evidence based guidelines

• Keep it simple

• Be responsive to needs of survivors


Program Evaluation

• Use established, reliable and valid measures

• Use measures consistently

• Select outcome measures that are easy implement – Cost effective

– Time efficient

• Record changes over time – Motivating for participants

– Outcome data for program


Summary

• Exercise for prevention

• Risks and contraindications

• Specific concerns that require adaptation

• How to implement successful program

Today, cancer is about living

Functional Goals Overview Module 8 Roger Campbell, 1

Functional Goals Overview



[email protected]

www.rehabsys.com




Writing Cancer Patient Functional Goals

• Effective goal writing should relate to activities of daily living (ADL) and the patients desired functional independence

• Goal setting is a partnership, where therapists and patients work together to establish:

• 1. Functional short term goals

• 2. Functional long term goals.

• Goal setting starts during the initial evaluation


Plan of Treatment


Elements of Goals & Documentation

• Clearly defined, measurable, time-framed goals that relate to function

• Clearly stated plan of care defining what will be provided, at what frequency and duration

• Observations of movement, measurements, function gain – or loss, skill need, education of patient

• Factors that modify frequency, intensity, & progression


Report in Measurable, Objective, & Functional Terms

• e.g., Mr. Johnson will retrieve his mail, walking (1003 ft total), down 5 steps on his front porch, crossing the lawn to his mailbox, and going back to the house by 9/11/12 w/o assistance.

• MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT

• 2.45; walking; walking - 1.9 mph, slow pace


The Compendium of Physical Activities Tracking Guide

• The Compendium of Physical Activities was developed for use in epidemiologic studies world-wide, to standardize the assignment of MET intensities in physical activity to 600 functional task equivalents


Strengths / Weaknesses

• Strengths: It is a specific, measurable, validated translation between the metabolic cost of therapeutic exercise to 600 equivalent functional tasks

• Weaknesses: Translation validity is best achieved with functional adults. Functional limitations will increase the existing .3 standard error of estimation


Metabolic Equivalents of Task (MET)

• The validity of metabolic equivalents of task and it’s relationship to:

• Functional Capacity

• Physical Activity

• Activities of Daily Living

Are central to the Compendium


With Goals Established

• Therapist’s may “look up” the functional goal in the compendium

• Record a MET intensity required to perform a task

• Translate MET’s to Therapeutic Exercise

• e. g., “pt will care for home chores such as vacuum floors, fix meals, take the trash out, & make the bed w/o assistance by 9/18/12


Look the functional task up in the Compendium

MET Level / 600 Functional Tasks • MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT

• 3.5; home activities; vacuuming floors

• 2.5; home activities; cleaning, changing linen, taking out trash

• 2.3; home activities; wash dishes - standing

• 2.0; home activities; cooking or food preparation - general

• 2.5; home activities; feeding family pet, cat, dog, small animals

• 2.5; home activities; putting away groceries, carrying groceries

• 2.3; home activities; ironing

• 2.0; home activities; implied standing - laundry, fold or hang clothes

• 2.0; home activities; making bed

• 2.5; home activities; building a fire inside


The Patient’s Goal Requires a Functional Capacity of 3.5 MET

• At the time of evaluation, the patient walked 897 feet during a 6 MWT, a functional capacity of 2.3 MET

• The patient’s functional goals are to care for the home with vacuuming floors as the most demanding effort at 3.5 MET

• Therapists may design treatment justification to progress this patient from 2.3 MET to 3.5 MET


2.3 MET to 3.5 MET Incremental Treatment Justification


2.3 - 3.5 MET Functional Tasks


• 2.3; volunteer activities; standing - light work (filing)


• 2.3; home activities; food shopping with a grocery cart

• 3.5; home activities; mopping / vacuuming

• 3.5; home activities; standing - packing/unpacking boxes

• 3.5; home activities; standing - bathing dog and or cat


Cancer Rehab Goal Examples

• Pt to begin balance training to overcome the chemotherapy induced peripheral neuropathy, seeking a 41 on the Berg Balance Scale in order to independently walk on uneven surfaces at home by 6.29.12

• Pt will increase function to ambulate 600 feet to maintain the capacity of self care, driving to doctors appointments and cancer treatments by 6.29.12

• Pt seeks increased LE Strength from 3/5 to 4/5 to stand up from a seated position and walk down steps at home w/o assistance by 6.29.12


Cancer Rehab Goal Examples

• Pt to increase UE strength from 1/5 to 3/5 to enable hair dressing, an over the head strength restoration after breast cancer surgery by 6.29.12

• Pt to increase walking capacity from 1.5 MET to 3.0 MET for independence in self care, home care and community re-entry by 6.29.12

• Pt seeks increased function from 1.5 MET to 2.0 MET to recover self care tasks of bathing, & dressing by 5.29.12


Translation Procedure Functional Goals / Therapeutic Exercise


• 3.5; home activities; vacuuming

• 2.5; home activities; cleaning, changing linen, taking out trash


• 2.0; home activities; cooking or food preparation – general

• Recording peak (MPH/Ft PM/MET/Kcal.min), during therapeutic exercise provides therapists with an objective measurement of function for 600 tasks


Quick Translation Reference MPH Ft PM 6MWT / Ft M E T kcal / min

1.5 132 792 2.14 10.7

1.6 140.8 844.8 2.22 11.1

1.7 149.6 897.6 2.3 11.5

1.8 158.4 950.4 2.37 11.85

1.9 167.2 1003.2 2.45 12.25

2 176 1056 2.52 12.6

2.1 184.8 1108.8 2.6 13

2.2 193.6 1161.6 2.68 13.4

2.3 202.4 1214.4 2.76 13.8

2.4 211.2 1267.2 2.83 14.15

2.5 220 1320 2.91 14.55

2.6 228.8 1372.8 2.99 14.95

2.7 237.6 1425.6 3.06 15.3

2.8 246.4 1478.4 3.14 15.7

2.9 255.2 1531.2 3.22 16.1

3 264 1584 3.29 16.45

3.1 272.8 1636.8 3.37 16.85

3.2 281.6 1689.6 3.45 17.25

3.3 290.4 1742.4 3.53 17.65

3.4 299.2 1795.2 3.6 18

3.5 308 1848 3.68 18.4

3.6 316.8 1900.8 3.75 18.75

3.7 325.6 1953.6 3.83 19.15

3.8 334.4 2006.4 3.9 19.5

3.9 343.2 2059.2 3.97 19.85

4 352 2112 4.04 20.2



Exercise Equipment

• Aerobic exercise equipment includes an instrument panel for test, measurement and control

• Instrument panels are the source of (MPH/MET/Kcal.min) measurements during therapeutic exercise


Individual Therapeutic Session SOAP Note Format

• Subjective

• Objective

• Measurements

• Physiological Changes During Exercise

• Aerobic Exercise

• Resistance Exercise

• Patient Education

• Assessment

• Plan


Cancer Rehab SOAP Note Example


Specific Discharge Summary

• Comments on Training and Compliance

• Signs, Symptoms and Changes

• Patient Education

• Current Home Activity Guidelines


General Discharge Summary





For on-site program development, contact:

Anna L. Schwartz, Ph.D., FNP, FAAN Executive Medical Director, Educator, Author


[email protected]

www.rehabsys.com/about-us

Roger K. Campbell, M.S., CET, MFT-c Program and Business Development Consultant


[email protected]

www.rehabsys.com


http://www.rehabsys.com/about-us





Bone Health Module 9 Anna Schwartz, 1

Bone Health in the Cancer Setting





Overview

• Cancer treatment and bone health

• Impact adjuvant therapy

• Evaluating bone health

• Clinical guidelines for cancer treatment-induced bone loss

• Exercise for prevention


Treatment Effects on Bone

• Chemotherapy recognized as severe risk • Common drugs

– Glucocorticoids – Methotrexate – Aromatase inhibitors

• Effects of drugs – Alter bone modeling and remodeling – Bone resorption (osteoclasts) – Bone development (steocytes)

• Skeletal complications – Osteopenia – Osteoporosis – Osteonecrosis


Clinical consequences

• Hip fractures have greatest impact

– Morbidity

– Mortality

– Impaired quality of life

• Medical Cost in 2008: $22 Billion


Evaluating Bone Health

• DXA is gold standard – DXA precision error is low

– Doesn’t capture bone architecture • coefficient of variation <1.0%-1.5%

• Site specific monitoring – Hip

– Spine- highly sensitive to turnover

• FRAX scores (fracture risk index) – Measures 10-year probability of hip and major

osteoporotic fracture


Common Cancers Affected

• Breast cancer

• Prostate Cancer

• Lymphoma

• Leukemia (pediatric and adult)

• Gastric cancers

• Any cancer treated with glucocorticoids


Risk Factors

• Female • Low body weight • Advanced age • Family history of osteoporosis • Caucasian or Asian • Low estrogen • Corticosteroids • Smoking • Inactivity • Excessive alcohol use


Cancer Specific Risk Factors

• Adjuvant chemotherapy

• Chemotherapy-induced ovarian failure or suppression

• Tamoxifen (if premenopausal)

• Aromatase inhibitors

• Androgen depravation therapy


Breast Cancer Treatment

• AIs cause 2-3-fold higher risk of fractures compared to women on tamoxifen

• Tamoxifen

– Postmenopausal: reduce/prevent bone loss

– Premenopausal: accelerated bone loss

• Bone loss from aromatase inhibitors

– 3-4% bone loss at spine/year

– 1-2% bone loss at hip/year


Breast Cancer

• Zolendronic acid twice yearly

• Patients need

– Advice to exercise

– Calcium and Vitamin D supplements

– Baseline BMD

– Therapy if T score < -2.0

– If noncompliance or decreasing BMD after 1-2 years on oral bisphosphonates switch to iv


Arthralgias

• Common with aromatase inhibitor therapy

• Pain or stiffness in joins

• Unclear why aromatase inhibitors cause this

• Some chemotherapies contribute


Prostate cancer

• Androgen deprivation therapy mainstay of treatment

• Musculoskeletal side effects

– Increased risk osteoporosis

– Declines in quality of life

• Resistance Exercise

• Bisphosphonate therapy


Prostate Cancer Bone Loss

• 2-8% per year at lumbar spine

• 1.8-6.5% per year at hip

• Loss continues indefinitely while on treatment

• No recovery observed after treatment ends

• 19.4% of men surviving 5years have a fracture

– 1 fracture for every 28 men treated with androgen deprivation therapy


Prostate Cancer

• Vitamin D deficiency accelerates bone loss – Assess Vitamin D levels

• Treatment: bisphosphonates – Prevent bone loss – Increase BMD – Not shown to prevent fractures

• Exercise – Limited research – Increased muscle mass, strength, balance

• Combined aerobic and resistance exercise program N=57

– Several large RCT ongoing


ACSM Guidelines to preserve bone health

• Mode – Weight-bearing endurance activities – Activities that involve jumping – Resistance exercise targeting major muscle groups

• Intensity – Moderate to high for bone-loading forces

• Ground reaction forces >2 time body weight

• Duration – 30-60 minutes/day

• Frequency – Weight bearing endurance activities 3-5 days/week – Resistance exercise 2-3 times/week


Clinical Guidelines: ASCO

• BMD screening – all women >65 y – Women 60-64y w history of:

• Family history of fractures • Prior on traumatic fracture • Aromatase inhibitor use • Premature ovarian failure

• Assess – DXA • Treatment

– All women – Calcium 1200mg/d + Vitamin D 400-800IU/d – Physical activity – Smoking Cessation – Pharmacologic treatment if BMD T-score < -2.5

ASCO = American Society of Clinical Oncology


NCCN Guidelines

• BMD screening – Baseline BMD and FRAX algorithm if:

• Premature ovarian failure • Adjuvant hormone therapy that reduces estrogen or action • Glucocorticoids

• Assess – Annual DXA if accelerated bone loss suspected – Biannual DXA if treatment known to cause bone loss

• Treatment – Calcium 1200mg/d + Vitamin D 400-800IU/d – Physical activity – Smoking Cessation – Limit alcohol – Pharmacologic treatment if BMD T-score < -2.0

NCCN = National Comprehensive Cancer Network


FRAX algorithm

• Developed by World Health Organization to evaluate fracture risk

• Integrates clinical risk factors and BMD at femoral neck • Based on population-based cohorts from

– Europe – North America – Asia and Australia

• Algorithm gives 10-yr probability of fracture – Hip – Major osteoporotic fracture

• Spine • Forearm • Hip • Shoulder


Hadji et al (2011) Guidelines Post-menopausal women on AIs

• BMD screening and risk factor assessment for all women receiving aromatase inhibitors

• Assess – DXA and risk assessment very 1-2 year – Monitor individuals on oral bisphosphonate

• Treatment – Calcium 1200mg/d + Vitamin D 400-800IU/d – Physical activity – Pharmacologic treatment if BMD T-score < -2.0 or 2 risk factors:

• T-score < -1.5 • Age > 65y • Low BMD (<20kg.m2) • Family history hip fracture • Oral corticosteroids >6 months • Smoking (current or past)



Exercise

• No targeted prescription

• Bone-loading exercise

• Optimal safe and effective dose to prevent bone loss unknown

• How exercise compares to, or interacts bisphosphonates is unknown


Breast Cancer starting Chemotherapy

• N=66 Breast cancer with 6-month follow-up • Moderate intensity aerobic and resistance exercise

– Usual care lost 6.23% BMD at spine – Aerobic exercise maintained BMD (-0.76%) – Resistance exercise lost 4.92%

• Aerobic capacity – increased ~25% in Aerobic exercise group – Increased 4% Resistance exercise group – Decreased 10% in Usual care group

• Resistance exercise – Poor adherence – Insufficient bone loading to stimulate bone adaptation

• Weight bearing aerobic exercise attenuates BMD declines

Schwartz et al 2007


Changes in Leg Strength (leg press)

30

40

50

60

70

80

90

100

110

Start CT 6-months 12-months

Aerobic Exercise

Resistance Exercise

Ususal Care

N=101; Beginning chemotherapy with steroids; Mixed tumors: Breast (n=77), colon (n=13), Lymphoma (n=11); Stages I-III


Changes in Arm Strength (overhead press)

15

17.5

20

22.5

25

27.5

30

32.5

35

Start CT 6-months 12-months

Aerobic Exercise

Resistance Exercise

Ususal Care

Schwartz, 2009


Changes in BMD @ L-spine

0.7

0.9

1.1

Start CT 6-months

Aerobic Exercise

Resistance Exercise

Ususal Care

% change in BMD at L-spine by group: AE -2.3% RE -6.8% CG -7.9%.

L-Sp

ine

Schwartz, Winters-Stone 2009


Swenson et al, 2009

• Daily walking program in premenopausal and newly postmenopausal breast cancer survivors

– Did not prevent bone loss

• Low osteogenic potential of walking

• Inadequate stimulus for bone loading

– Did not slow bone turnover

– Oral bisphosphonates stabilized bone outcomes


Other RCT Outcomes

• 1-y mixed-mode exercise preserved total BMD in postmenopausal breast cancer survivor compared to usual care (-1.7%). – Irwin et al, 2009

• No effect in 3-mo home based walking program – Rogers et al, 2009

• Spine BMD preserved in 1y vigorous resistance and impact training compared to BMD loss (-2.1%) in control group – Breast cancer survivors 1-y post treatment. – Winters-Stone et al, 2011


RCT Outcomes

• Low to moderate intensity Resistance + bisphosphonate treatment (N=249)

– Increased hip and spine BMD

– Slightly reduced bone turnover

– Not significantly more than bisphosphonate alone

– Waltman et al, 2010


Summary of Exercise Studies

• Limited studies

• Moderate-intensity exercise may preserve bone health during and after cancer treatment

• Unclear benefits of exercise compared to bisphosphonate

• Aerobic, resistance and impact exercise necessary

• Fall prevention exercise programs


Adherence Success

• Feedback

• Support

• Specific instruction


Summary

• Effects of cancer treatment on bone health

• Clinical guidelines specific to cancer treatment-induced bone loss

• Exercise research and intervention

Course Handouts

Please refer to the Course Handouts

when starting

Chapter 4: Exercise Testing Overview

6‐MWT ConversionMPH Ft PM 6MWT / Ft M E T kcal / min

1.5 132 792 2.14 10.71.6 140.8 844.8 2.22 11.11.7 149.6 897.6 2.3 11.51.8 158.4 950.4 2.37 11.851.9 167.2 1003.2 2.45 12.25

2 176 1056 2.52 12.62.1 184.8 1108.8 2.6 132.2 193.6 1161.6 2.68 13.42.3 202.4 1214.4 2.76 13.82.4 211.2 1267.2 2.83 14.152.5 220 1320 2.91 14.552.6 228.8 1372.8 2.99 14.952.7 237.6 1425.6 3.06 15.32.8 246.4 1478.4 3.14 15.72.9 255.2 1531.2 3.22 16.1

3 264 1584 3.29 16.453.1 272.8 1636.8 3.37 16.853.2 281.6 1689.6 3.45 17.253.3 290.4 1742.4 3.53 17.653.4 299.2 1795.2 3.6 183.5 308 1848 3.68 18.43.6 316.8 1900.8 3.75 18.753.7 325.6 1953.6 3.83 19.153.8 334.4 2006.4 3.9 19.53.9 343.2 2059.2 3.97 19.85

4 352 2112 4.04 20.2MPH Ft PM 6MWT / Ft M E T kcal / min

American Thoracic Society

Am J Respir Crit Care Med Vol 166. pp 111–117, 2002DOI: 10.1164/rccm.166/1/111Internet address: www.atsjournals.org

ATS Statement: Guidelines for the Six-Minute Walk Test

T

HIS

O

FFICIAL

S

TATEMENT

OF

THE

A

MERICAN

T

HORACIC

S

OCIETY

WAS

APPROVED

BY

THE

ATS B

OARD

OF

D

IRECTORS

M

ARCH

2002

CONTENTS

Purpose and ScopeBackgroundIndications and LimitationsContraindicationsSafety IssuesTechnical Aspects of the 6

-

Minute Walk TestRequired EquipmentPatient PreparationMeasurementsQuality AssuranceInterpretationReferences

PURPOSE AND SCOPE

This statement provides practical guidelines for the 6-minutewalk test (6MWT). Specifically, it reviews indications, detailsfactors that influence results, presents a brief step-by-step pro-tocol, outlines safety measures, describes proper patient prep-aration and procedures, and offers guidelines for clinical inter-pretation of results. These recommendations are not intendedto limit the use of alternative protocols for research studies.We do not discuss the general topic of clinical exercise testing.

As with other American Thoracic Society statements onpulmonary function testing, these guidelines come out of aconsensus conference. Drafts were prepared by two members(P.L.E. and R.J.Z.) and were based on a comprehensive Med-line literature search from 1970 through 2001, augmented bysuggestions from other committee members. Each draft re-sponded to comments from the working committee. The guide-lines follow previously published methods as closely as possi-ble and provide a rationale for each specific recommendation.The final recommendations represent a consensus of the com-mittee. The committee recommends that these guidelines bereviewed in five years and in the meantime encourages furtherresearch in areas of controversy.

BACKGROUND

There are several modalities available for the objective evalu-ation of functional exercise capacity. Some provide a verycomplete assessment of all systems involved in exercise per-formance (high tech), whereas others provide basic informa-tion but are low tech and are simpler to perform. The modalityused should be chosen based on the clinical question to be ad-dressed and on available resources. The most popular clinicalexercise tests in order of increasing complexity are stair climb-ing, a 6MWT, a shuttle-walk test, detection of exercise-inducedasthma, a cardiac stress test (e.g., Bruce protocol), and a cardio-

pulmonary exercise test (1, 2). Other professional organiza-tions have published standards for cardiac stress testing (3, 4).

Assessment of functional capacity has traditionally beendone by merely asking patients the following: “How manyflights of stairs can you climb or how many blocks can youwalk?” However, patients vary in their recollection and mayreport overestimations or underestimations of their true func-tional capacity. Objective measurements are usually betterthan self-reports. In the early 1960s, Balke developed a simpletest to evaluate the functional capacity by measuring the dis-tance walked during a defined period of time (5). A 12-minutefield performance test was then developed to evaluate thelevel of physical fitness of healthy individuals (6). The walkingtest was also adapted to assess disability in patients withchronic bronchitis (7). In an attempt to accommodate patientswith respiratory disease for whom walking 12 minutes was tooexhausting, a 6-minute walk was found to perform as well asthe 12-minute walk (8). A recent review of functional walkingtests concluded that “the 6MWT is easy to administer, bettertolerated, and more reflective of activities of daily living thanthe other walk tests” (9).

The 6MWT is a practical simple test that requires a 100-fthallway but no exercise equipment or advanced training fortechnicians. Walking is an activity performed daily by all butthe most severely impaired patients. This test measures the dis-tance that a patient can quickly walk on a flat, hard surface in aperiod of 6 minutes (the 6MWD). It evaluates the global and in-tegrated responses of all the systems involved during exercise,including the pulmonary and cardiovascular systems, systemiccirculation, peripheral circulation, blood, neuromuscular units,and muscle metabolism. It does not provide specific informa-tion on the function of each of the different organs and systemsinvolved in exercise or the mechanism of exercise limitation, asis possible with maximal cardiopulmonary exercise testing. Theself-paced 6MWT assesses the submaximal level of functionalcapacity. Most patients do not achieve maximal exercise capac-ity during the 6MWT; instead, they choose their own intensityof exercise and are allowed to stop and rest during the test.However, because most activities of daily living are performedat submaximal levels of exertion, the 6MWD may better reflectthe functional exercise level for daily physical activities.

INDICATIONS AND LIMITATIONS

The strongest indication for the 6MWT is for measuring the re-sponse to medical interventions in patients with moderate tosevere heart or lung disease. The 6MWT has also been used asa one-time measure of functional status of patients, as well as apredictor of morbidity and mortality (

see

Table 1 for a list ofthese indications). The fact that investigators have used the6MWT in these settings does not prove that the test is clinicallyuseful (or the best test) for determining functional capacity orchanges in functional capacity due to an intervention in pa-tients with these diseases. Further studies are necessary to de-termine the utility of the 6MWT in various clinical situations.

112

AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 166 2002

Formal cardiopulmonary exercise testing provides a globalassessment of the exercise response, an objective determina-tion of functional capacity and impairment, determination ofthe appropriate intensity needed to perform prolonged exer-cise, quantification of factors limiting exercise, and a defini-tion of the underlying pathophysiologic mechanisms such asthe contribution of different organ systems involved in exer-cise. The 6MWT does not determine peak oxygen uptake, di-agnose the cause of dyspnea on exertion, or evaluate thecauses or mechanisms of exercise limitation (1, 2). The infor-mation provided by a 6MWT should be considered comple-mentary to cardiopulmonary exercise testing, not a replace-ment for it. Despite the difference between these two functionaltests, some good correlations between them have been re-ported. For example, a significant correlation (r

�

0.73) be-tween 6MWD and peak oxygen uptake has been reported forpatients with end-stage lung diseases (36, 37).

In some clinical situations, the 6MWT provides informa-tion that may be a better index of the patient’s ability to per-form daily activities than is peak oxygen uptake; for example,6MWD correlates better with formal measures of quality oflife (38). Changes in 6MWD after therapeutic interventionscorrelate with subjective improvement in dyspnea (39, 40).The reproducibility of the 6MWD (with a coefficient of varia-tion of approximately 8%) appears to be better than the re-producibility of 1-second forced expiratory volume in patientswith chronic obstructive pulmonary disease (COPD) (8, 41–43). Questionnaire indices of functional status have a largershort-term variability (22–33%) than does the 6MWD (37).

The shuttle-walking test is similar to the 6MWT, but it usesan audio signal from a tape cassette to direct the walking paceof the patient back and forth on a 10-m course (44–47). Thewalking speed is increased every minute, and the test ends whenthe patient cannot reach the turnaround point within the re-quired time. The exercise performed is similar to a symptom-limited, maximal, incremental treadmill test. An advantage ofthe shuttle walking test is that it has a better correlation withpeak oxygen uptake than the 6MWD. Disadvantages includeless validation, less widespread use, and more potential forcardiovascular problems.

CONTRAINDICATIONS

Absolute contraindications for the 6MWT include the follow-ing: unstable angina during the previous month and myocar-

dial infarction during the previous month. Relative contraindi-cations include a resting heart rate of more than 120, a systolicblood pressure of more than 180 mm Hg, and a diastolic bloodpressure of more than 100 mm Hg.

Patients with any of these findings should be referred to thephysician ordering or supervising the test for individual clini-cal assessment and a decision about the conduct of the test.The results from a resting electrocardiogram done during theprevious 6 months should also be reviewed before testing. Sta-ble exertional angina is not an absolute contraindication for a6MWT, but patients with these symptoms should perform thetest after using their antiangina medication, and rescue nitratemedication should be readily available.

Rationale

Patients with the previously mentioned risk factors may be atincreased risk for arrhythmias or cardiovascular collapse duringtesting. However, each patient determines the intensity of theirexercise, and the test (without electrocardiogram monitoring)has been performed in thousands of older persons (31, 48–50)and thousands of patients with heart failure or cardiomyopathy(32, 51, 52) without serious adverse events. The contraindica-tions listed previously here were used by study investigatorsbased on their impressions of the general safety of the 6MWTand their desire to be prudent, but it is unknown whether ad-verse events would occur if such patients performed a 6MWT;they are, therefore, listed as relative contraindications.

SAFETY ISSUES

1. Testing should be performed in a location where a rapid,appropriate response to an emergency is possible. The ap-propriate location of a crash cart should be determined bythe physician supervising the facility.

2. Supplies that must be available include oxygen, sublingualnitroglycerine, aspirin, and albuterol (metered dose inhaleror nebulizer). A telephone or other means should be inplace to enable a call for help.

3. The technician should be certified in cardiopulmonary re-suscitation with a minimum of Basic Life Support by anAmerican Health Association–approved cardiopulmonaryresuscitation course. Advanced cardiac life support certifi-cation is desirable. Training, experience, and certificationin related health care fields (registered nurse, registered re-spiratory therapist, certified pulmonary function techni-cian, etc.) are also desirable. A certified individual shouldbe readily available to respond if needed.

4. Physicians are not required to be present during all tests.The physician ordering the test or a supervising laboratoryphysician may decide whether physician attendance at aspecific test is required.

5. If a patient is on chronic oxygen therapy, oxygen should begiven at their standard rate or as directed by a physician ora protocol.

Reasons for immediately stopping a 6MWT include the follow-ing: (

1

) chest pain, (

2

) intolerable dyspnea, (

3

) leg cramps, (

4

)staggering, (

5

) diaphoresis, and (

6

) pale or ashen appearance.Technicians must be trained to recognize these problems

and the appropriate responses. If a test is stopped for any ofthese reasons, the patient should sit or lie supine as appropri-ate depending on the severity or the event and the technician’sassessment of the severity of the event and the risk of syncope.The following should be obtained based on the judgment ofthe technician: blood pressure, pulse rate, oxygen saturation,and a physician evaluation. Oxygen should be administered asappropriate.

TABLE 1. INDICATIONS FOR THE SIX-MINUTE WALK TEST

Pretreatment and posttreatment comparisonsLung transplantation (9, 10)Lung resection (11)Lung volume reduction surgery (12, 13)Pulmonary rehabilitation (14, 15)COPD (16–18)Pulmonary hypertensionHeart failure (19, 20)

Functional status (single measurement)COPD (21, 22)Cystic fibrosis (23, 24)Heart failure (25–27)Peripheral vascular disease (28, 29)Fibromyalgia (30)Older patients (31)

Predictor of morbidity and mortalityHeart failure (32, 33)COPD (34, 35)Primary pulmonary hypertension (10, 36)

Definition of abbreviation

: COPD

�

chronic obstructive pulmonary disease.

American Thoracic Society 113

TECHNICAL ASPECTS OF THE 6MWT

Location

The 6MWT should be performed indoors, along a long, flat,straight, enclosed corridor with a hard surface that is seldomtraveled. If the weather is comfortable, the test may be per-formed outdoors. The walking course must be 30 m in length.A 100-ft hallway is, therefore, required. The length of the cor-ridor should be marked every 3 m. The turnaround points shouldbe marked with a cone (such as an orange traffic cone). A start-ing line, which marks the beginning and end of each 60-m lap,should be marked on the floor using brightly colored tape.

Rationale.

A shorter corridor requires patients to take moretime to reverse directions more often, reducing the 6MWD.Most studies have used a 30-m corridor, but some have used20- or 50-m corridors (52–55). A recent multicenter studyfound no significant effect of the length of straight coursesranging from 50 to 164 ft, but patients walked farther on con-tinuous (oval) tracks (mean 92 ft farther) (54).

The use of a treadmill to determine the 6MWD might savespace and allow constant monitoring during the exercise, butthe use of a treadmill for 6-minute walk testing is not recom-mended. Patients are unable to pace themselves on a tread-mill. In one study of patients with severe lung disease, themean distance walked on the treadmill during 6 minutes (withthe speed adjusted by the patients) was shorter by a mean of14% when compared with the standard 6MWD using a 100-fthallway (57). The range of differences was wide, with patientswalking between 400–1,300 ft on the treadmill who walked1,200 ft in the hallway. Treadmill test results, therefore, arenot interchangeable with corridor tests.

REQUIRED EQUIPMENT

1. Countdown timer (or stopwatch)2. Mechanical lap counter3. Two small cones to mark the turnaround points4. A chair that can be easily moved along the walking course5. Worksheets on a clipboard6. A source of oxygen7. Sphygmomanometer8. Telephone9. Automated electronic defibrillator

PATIENT PREPARATION

1. Comfortable clothing should be worn.2. Appropriate shoes for walking should be worn.3. Patients should use their usual walking aids during the test

(cane, walker, etc.).4. The patient’s usual medical regimen should be continued.5. A light meal is acceptable before early morning or early af-

ternoon tests.6. Patients should not have exercised vigorously within 2 hours

of beginning the test.

MEASUREMENTS

1. Repeat testing should be performed about the same timeof day to minimize intraday variability.

2. A “warm-up” period before the test should not be performed.3. The patient should sit at rest in a chair, located near the

starting position, for at least 10 minutes before the teststarts. During this time, check for contraindications, mea-sure pulse and blood pressure, and make sure that cloth-ing and shoes are appropriate. Compete the first portionof the worksheet (

see

the A

PPENDIX

).

4. Pulse oximetry is optional. If it is performed, measure andrecord baseline heart rate and oxygen saturation (SpO

2

)and follow manufacturer’s instructions to maximize the sig-nal and to minimize motion artifact (56, 57). Make sure thereadings are stable before recording. Note pulse regularityand whether the oximeter signal quality is acceptable.

The rationale for measuring oxygen saturation is that al-though the distance is the primary outcome measure, im-provement during serial evaluations may be manifest eitherby an increased distance or by reduced symptoms with thesame distance walked (39). The SpO

2

should not be used forconstant monitoring during the exercise. The technicianmust not walk with the patient to observe the SpO

2

. If wornduring the walk, the pulse oximeter must be lightweight (lessthan 2 pounds), battery powered, and held in place (perhapsby a “fanny pack”) so that the patient does not have to holdor stabilize it and so that stride is not affected. Many pulseoximeters have considerable motion artifact that preventsaccurate readings during the walk. (57)

5. Have the patient stand and rate their baseline dyspneaand overall fatigue using the Borg scale (

see

Table 2 forthe Borg scale and instructions [58]).

6. Set the lap counter to zero and the timer to 6 minutes. As-semble all necessary equipment (lap counter, timer, clip-board, Borg Scale, worksheet) and move to the startingpoint.

7. Instruct the patient as follows:

“The object of this test is to walk as far as possible for 6minutes. You will walk back and forth in this hallway. Sixminutes is a long time to walk, so you will be exerting your-self. You will probably get out of breath or become ex-hausted. You are permitted to slow down, to stop, and torest as necessary. You may lean against the wall while rest-ing, but resume walking as soon as you are able.

You will be walking back and forth around the cones.You should pivot briskly around the cones and continueback the other way without hesitation. Now I’m going toshow you. Please watch the way I turn without hesitation.”

Demonstrate by walking one lap yourself. Walk andpivot around a cone briskly.

“Are you ready to do that? I am going to use thiscounter to keep track of the number of laps you complete. Iwill click it each time you turn around at this starting line.Remember that the object is to walk AS FAR AS POSSI-BLE for 6 minutes, but don’t run or jog.

Start now, or whenever you are ready.”

TABLE 2. THE BORG SCALE

0 Nothing at all0.5 Very, very slight (just noticeable)1 Very slight2 Slight (light)3 Moderate4 Somewhat severe5 Severe (heavy)67 Very severe8910 Very, very severe (maximal)

This Borg scale should be printed on heavy paper (11 inches high and perhaps lami-nated) in 20-point type size. At the beginning of the 6-minute exercise, show the scaleto the patient and ask the patient this: “Please grade your level of shortness of breathusing this scale.” Then ask this: “Please grade your level of fatigue using this scale.”

At the end of the exercise, remind the patient of the breathing number that theychose before the exercise and ask the patient to grade their breathing level again. Thenask the patient to grade their level of fatigue, after reminding them of their grade be-fore the exercise.

114


8. Position the patient at the starting line. You should alsostand near the starting line during the test. Do not walkwith the patient. As soon as the patient starts to walk,start the timer.

9. Do not talk to anyone during the walk. Use an even toneof voice when using the standard phrases of encourage-ment. Watch the patient. Do not get distracted and losecount of the laps. Each time the participant returns to thestarting line, click the lap counter once (or mark the lapon the worksheet). Let the participant see you do it. Ex-aggerate the click using body language, like using a stop-watch at a race.

After the first minute, tell the patient the following (ineven tones): “You are doing well. You have 5 minutes togo.”

When the timer shows 4 minutes remaining, tell the pa-tient the following: “Keep up the good work. You have 4minutes to go.”

When the timer shows 3 minutes remaining, tell the pa-tient the following: “You are doing well. You are halfwaydone.”

When the timer shows 2 minutes remaining, tell the pa-tient the following: “Keep up the good work. You have only2 minutes left.”

When the timer shows only 1 minute remaining, tell thepatient: “You are doing well. You have only 1 minute togo.”

Do not use other words of encouragement (or body lan-guage to speed up).

If the patient stops walking during the test and needs arest, say this: “You can lean against the wall if you wouldlike; then continue walking whenever you feel able.” Donot stop the timer. If the patient stops before the 6 minutesare up and refuses to continue (or you decide that theyshould not continue), wheel the chair over for the patient tosit on, discontinue the walk, and note on the worksheet thedistance, the time stopped, and the reason for stopping pre-maturely.

When the timer is 15 seconds from completion, say this:“In a moment I’m going to tell you to stop. When I do, juststop right where you are and I will come to you.”

When the timer rings (or buzzes), say this: “Stop!” Walkover to the patient. Consider taking the chair if they lookexhausted. Mark the spot where they stopped by placing abean bag or a piece of tape on the floor.

10. Post-test: Record the postwalk Borg dyspnea and fatiguelevels and ask this: “What, if anything, kept you from walk-ing farther?”

11. If using a pulse oximeter, measure SpO

2

and pulse ratefrom the oximeter and then remove the sensor.

12. Record the number of laps from the counter (or tick markson the worksheet).

13. Record the additional distance covered (the number of metersin the final partial lap) using the markers on the wall as dis-tance guides. Calculate the total distance walked, rounding tothe nearest meter, and record it on the worksheet.

14. Congratulate the patient on good effort and offer a drinkof water.

QUALITY ASSURANCE

Sources of Variability

There are many sources of 6MWD variability (

see

Table 3).The sources of variability caused by the test procedure itselfshould be controlled as much as possible. This is done by fol-

lowing the standards found in this document and by using aquality-assurance program.

Practice Tests

A practice test is not needed in most clinical settings butshould be considered. If a practice test is done, wait for at least1 hour before the second test and report the highest 6MWD asthe patient’s 6MWD baseline.

Rationale.

The 6MWD is only slightly higher for a second6MWT performed a day later. The mean reported increaseranges from 0 to 17% (23, 27, 40, 41, 54, 59). A multicenterstudy of 470 highly motivated patients with severe COPD per-formed two 6MWTs 1 day apart, and on average, the 6MWDwas only 66 ft (5.8%) higher on the second day (54).

Performance (without an intervention) usually reaches aplateau after two tests done within a week (8, 60). The trainingeffect may be due to improved coordination, finding optimalstride length, and overcoming anxiety. The possibility of apractice or training effect from tests repeated after more thana month has not been studied or reported; however, it is likelythat the effect of training wears off (does not persist) after afew weeks.

Technician Training and Experience

Technicians who perform 6MWTs should be trained using thestandard protocol and then supervised for several tests beforeperforming them alone. They should also have completed car-diopulmonary resuscitation training.

Rationale.

One multicenter study of older people foundthat after correction for many other factors, two of the techni-cians had mean 6MWDs that were approximately 7% lowerthan the other two sites (31).

Encouragement

Only the standardized phrases for encouragement (as speci-fied previously here) must be used during the test.

Rationale.

Encouragement significantly increases the dis-tance walked (42). Reproducibility for tests with and withoutencouragement is similar. Some studies have used encourage-ment every 30 seconds, every minute, or every 2 minutes. Wehave chosen every minute and standard phrases. Some studies(53) have instructed patients to walk as fast as possible. Al-though larger mean 6MWDs may be obtained thereby, we rec-ommend that such phrases not be used, as they emphasize ini-tial speed at the expense of earlier fatigue and possibleexcessive cardiac stress in some patients with heart disease.

TABLE 3. 6MWD SOURCES OF VARIABILITY

Factors reducing the 6MWDShorter heightOlder ageHigher body weightFemale sexImpaired cognitionA shorter corridor (more turns)Pulmonary disease (COPD, asthma, cystic fibrosis, interstitial lung disease)Cardiovascular disease (angina, MI, CHF, stroke, TIA, PVD, AAI)Musculoskeletal disorders (arthritis, ankle, knee, or hip injuries, muscle wasting, etc.)

Factors increasing the 6MWDTaller height (longer legs)Male sexHigh motivationA patient who has previously performed the testMedication for a disabling disease taken just before the testOxygen supplementation in patients with exercise-induced hypoxemia

Definition of abbreviations

: COPD

�

chronic obstructive pulmonary disease; 6MWD

�

6-minute walking distance.


Supplemental Oxygen

If oxygen supplementation is needed during the walks and se-rial tests are planned (after an intervention other than oxygentherapy), then during all walks by that patient oxygen shouldbe delivered in the same way with the same flow. If the flowmust be increased during subsequent visits due to worseninggas exchange, this should be noted on the worksheet and con-sidered during interpretation of the change noted in 6MWD.The type of oxygen delivery device should also be noted onthe report: for instance, the patient carried liquid oxygen orpushed or pulled an oxygen tank, the delivery was pulsed orcontinuous, or a technician walked behind the patient with theoxygen source (not recommended). Measurements of pulseand SpO

2

should be made after waiting at least 10 minutes af-ter any change in oxygen delivery.

Rationale.

For patients with COPD or interstitial lung dis-ease, oxygen supplementation increases the 6MWD (17, 59,61, 63). Carrying a portable gas container (but not using it forsupplemental oxygen) reduced the mean 6MWD by 14% inone study of patients with severe respiratory disability, but us-ing the container to deliver supplemental oxygen during theexercise increased the mean 6MWD by 20–35% (59).

Medications

The type of medication, dose, and number of hours taken be-fore the test should be noted.

Rationale.

Significant improvement in the distance walked,or the dyspnea scale, after administration of bronchodilatorshas been demonstrated in patients with COPD (62, 63), as wellas cardiovascular medications in patients with heart failure (19).

INTERPRETATION

Most 6MWTs will be done before and after intervention, andthe primary question to be answered after both tests havebeen completed is whether the patient has experienced a clini-cally significant improvement. With a good quality-assuranceprogram, with patients tested by the same technician, and af-ter one or two practice tests, short-term reproducibility of the6MWD is excellent (37). It is not known whether it is best forclinical purposes to express change in 6MWD as (

1

) an abso-lute value, (

2

) a percentage change, or (

3

) a change in the per-centage of predicted value. Until further research is available,we recommend that change in 6MWD be expressed as an ab-solute value (e.g., the patient walked 50 m farther).

A statistically significant mean increase in 6MWD in agroup of study participants is often much less than a clinicallysignificant increase in an individual patient. In one study of112 patients (half of them women) with stable, severe COPD,the smallest difference in 6MWD that was associated with anoticeable clinical difference in the patients’ perception of ex-ercise performance was a mean of 54 m (95% confidence in-terval, 37–71 m) (64). This study suggests that for individualpatients with COPD, an improvement of more than 70 m inthe 6MWD after an intervention is necessary to be 95% confi-dent that the improvement was significant. In an observationalstudy of 45 older patients with heart failure, the smallest dif-ference in 6MWD that was associated with a noticeable differ-ence in their global rating of worsening was a mean of 43 m(20). The 6MWD was more responsive to deterioration thanto improvement in heart failure symptoms.

Reported Mean Changes in 6MWD After Interventions

Supplemental oxygen (4 L/min) during exercise in patients withCOPD or interstitial lung disease increased mean 6MWD byapproximately 95 m (36%) in one study (59). Patients taking

an inhaled corticosteroid experienced a mean 33 m (8%) in-crease in 6MWD in an international COPD study (16). Pa-tients with COPD in a study of the effects of exercise and dia-phragmatic strength training experienced a mean increase in6MWD of 50 m (20%) (65). Lung volume reduction surgery inpatients with very severe COPD has been reported to increase6MWD by a mean of 55 m (20%) (13).

Cardiac rehabilitation in patients referred with various heartdiseases increased 6MWD by a mean of 170 m (15%) in a recentstudy (66). In 25 older patients with heart failure, an angiotensin-converting enzyme inhibitor medication (50 mg captopril perday) improved 6MWD a mean of 64 m (39%) compared with amean increase of only 8% in those receiving a placebo (19).

Interpreting Single Measurements of Functional Status

Optimal reference equations from healthy population-basedsamples using standardized 6MWT methods are not yet avail-able. In one study, the median 6MWD was approximately 580m for 117 healthy men and 500 m for 173 healthy women (50).A mean 6MWD of 630 m was reported by another study of 51healthy older adults (55). Differences in the population sam-pled, type and frequency of encouragement, corridor length,and number of practice tests may account for reported differ-ences in mean 6MWD in healthy persons. Age, height, weight,and sex independently affect the 6MWD in healthy adults;therefore, these factors should be taken into considerationwhen interpreting the results of single measurements made todetermine functional status. We encourage investigators to pub-lish reference equations for healthy persons using the previ-ously mentioned standardized procedures.

A low 6MWD is nonspecific and nondiagnostic. When the6MWD is reduced, a thorough search for the cause of the im-pairment is warranted. The following tests may then be help-ful: pulmonary function, cardiac function, ankle–arm index,muscle strength, nutritional status, orthopedic function, andcognitive function.

Conclusions

The 6MWT is a useful measure of functional capacity targetedat people with at least moderately severe impairment. The testhas been widely used for preoperative and postoperative eval-uation and for measuring the response to therapeutic inter-ventions for pulmonary and cardiac disease. These guidelinesprovide a standardized approach to performing the 6MWT.The committee hopes that these guidelines will encourage fur-ther research into the 6MWT and allow direct comparisonsamong different studies.

This statement was developed by the ATS Committee on Proficiency Stan-dards for Clinical Pulmonary Function Laboratories.Members of the committee are:

R

OBERT

O. C

RAPO

, M.D.,

Chair

*R

ICHARD

C

ASABURI

, P

H

.D, M.D.A

LLAN

L. C

OATES

, M.D.P

AUL

L. E

NRIGHT

, M.D.*N

EIL

R. M

AC

I

NTYRE

, M.D.R

OY

T. M

C

K

AY

, P

H

.D.D

OUGLAS

J

OHNSON

, M.D.J

ACK

S. W

ANGER

, M.S.R. J

ORGE

Z

EBALLOS

, M.D.*Ad Hoc Committee members are:

V

ERA

B

ITTNER

, M.D.C

ARL

M

OTTRAM

, R.R.T.*Writing Committee Members

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APPENDIX

The following elements should be present on the 6MWT worksheet and report:

Lap counter: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Patient name: ____________________ Patient ID# ___________

Walk # ______ Tech ID: _________ Date: __________

Gender: M F Age: ____ Race: ____ Height: ___ft ____in, ____ meters

Weight: ______ lbs, _____kg Blood pressure: _____ / _____

Medications taken before the test (dose and time): __________________

Supplemental oxygen during the test: No Yes, flow ______ L/min, type _____

Baseline End of Test

Time ___:___ ___:___

Heart Rate _____ _____

Dyspnea ____ ____ (Borg scale)

Fatigue ____ ____ (Borg scale)

SpO2 ____ % ____%

Stopped or paused before 6 minutes? No Yes, reason: _______________

Other symptoms at end of exercise: angina dizziness hip, leg, or calf pain

Number of laps: ____ (�60 meters) � final partial lap: _____ meters �

Total distance walked in 6 minutes: ______ meters

Predicted distance: _____ meters Percent predicted: _____%

Tech comments:

Interpretation (including comparison with a preintervention 6MWD):

be easo y

6 Minute Walk Test (6MWT)Name:________________________________Date:______________________

Blood Pressure befor and after 6MWT: ________________/________________

Resting Data

HRrest RPE Fatigue SOBr LPM W/O 02 %SP02 W/ 02 %SP02

6MWT HRate %SP02 RPE Fatigue SOBr LPM DISTANCE WALKED

1 MIN:

2 MIN:

3 MIN:

4 MIN:

5 MIN: feet from last lap

6 MIN: Checks: Feet:

Totals Total Feet: COMMENTS: i.e., signes and symptoms; angina, dizziness, Checkmarks = 100 feet stopped or paused befor 6 minutes, reason why…………...stopped o paused o 6 utes,

Tester Signature:___________________________Date:___________________

• Laboratory Test Data: Complete Blood Count (CBC)

• A complete blood count (CBC) gives important information about the type and number of cells in the blood, especially red blood cells, white blood cells and platelets.

• A CBC helps doctors and therapists check symptoms, such as weakness, fatigue, or bruising.

• A CBC also helps diagnose conditions, such as anemia, infection, and bleeding disorders.

( R P E ) Ratings of Perceived Exertion

HOW HARD ARE YOU WORKING O. NO PHYSICAL EFFORT 1. MINIMAL EFFORT 2. 3. MODERATE EFFORT 4. 5. MEDIUM EFFORT 6. 7. HARD EFFORT 8. 9. VERY HARD EFFORT 10. MAXIMAL EFFORT

(DYSPNEA) SHORTNESS OF BREATH (SOBr)

HOW HARD ARE YOU BREATHING 0. NO (SOBr) 1. MINIMAL (SOBr) 2. 3. MODERATE (SOBr) 4. 5. MEDIUM (SOBr) 6. 7. QUITE (SOBr) 8. 9. VERY (SOBr) 10. MAXIMAL (SOBr)

The Compendium of Physical Activities Tracking Guide

KEYBlue text = new activity was added to the descritipon of that specific compendium codeIf compcode and METS columns are blank under 1993 this means that the 2000 compcode and METS was added to the new addition to the compendiumIf compcode and METS columns are blank under 2000 this means that the 1993 compcode and METS was removed from the new addition of the compendium

1993 2000compcode METS compcode METS heading description

01009 8.5 01009 8.5 bicycling bicycling, BMX or mountain01010 4.0 01010 4.0 bicycling bicycling, <10 mph, leisure, to work or for pleasure (Taylor Code 115

01015 8.0 bicycling bicycling, general01020 6.0 01020 6.0 bicycling bicycling, 10-11.9 mph, leisure, slow, light effort01030 8.0 01030 8.0 bicycling bicycling, 12-13.9 mph, leisure, moderate effort 01040 10.0 01040 10.0 bicycling bicycling, 14-15.9 mph, racing or leisure, fast, vigorous effor01050 12.0 01050 12.0 bicycling bicycling, 16-19 mph, racing/not drafting or >19 mph drafting, very fast, racing genera01060 16.0 01060 16.0 bicycling bicycling, >20 mph, racing, not drafting01070 5.0 01070 5.0 bicycling unicycling02010 5.0 02010 7.0 conditioning exercise bicycling, stationary, general02011 3.0 02011 3.0 conditioning exercise bicycling, stationary, 50 watts, very light effor02012 5.5 02012 5.5 conditioning exercise bicycling, stationary, 100 watts, light effor02013 7.0 02013 7.0 conditioning exercise bicycling, stationary, 150 watts, moderate effor02014 10.5 02014 10.5 conditioning exercise bicycling, stationary, 200 watts, vigorous effor02015 12.5 02015 12.5 conditioning exercise bicycling, stationary, 250 watts, very vigorous effor02020 8.0 02020 8.0 conditioning exercise calisthenics (e.g. pushups, situps, pullups, jumping jacks), heavy, vigorous effort02030 4.5 02030 3.5 conditioning exercise calisthenics, home exercise, light or moderate effort, general (example: back exercises), going up & down from floor (Taylor Code 15002040 8.0 02040 8.0 conditioning exercise circuit training, including some aerobic movement with minimal rest, general02050 6.0 02050 6.0 conditioning exercise weight lifting (free weight, nautilus or universal-type), power lifting or body building, vigorous effort (Taylor Code 21002060 5.5 02060 5.5 conditioning exercise health club exercise, general (Taylor Code 16002065 6.0 02065 9.0 conditioning exercise stair-treadmill ergometer, general02070 9.5 02070 7.0 conditioning exercise rowing, stationary ergometer, genera02071 3.5 02071 3.5 conditioning exercise rowing, stationary, 50 watts, light effort02072 7.0 02072 7.0 conditioning exercise rowing, stationary, 100 watts, moderate effor02073 8.5 02073 8.5 conditioning exercise rowing, stationary, 150 watts, vigorous effor02074 12.0 02074 12.0 conditioning exercise rowing, stationary, 200 watts, very vigorous effor02080 9.5 02080 7.0 conditioning exercise ski machine, general02090 6.0 02090 6.0 conditioning exercise slimnastics, jazzercise 02100 4.0 02100 2.5 conditioning exercise stretching, hatha yoga

02101 2.5 conditioning exercise mild stretching02110 6.0 02110 6.0 conditioning exercise teaching aerobic exercise class02120 4.0 02120 4.0 conditioning exercise water aerobics, water calisthenics02130 3.0 02130 3.0 conditioning exercise weight lifting (free, nautilus or universal-type), light or moderate effort, light workout, genera02135 1.0 02135 1.0 conditioning exercise whirlpool, sitting03010 6.0 03010 4.8 dancing ballet or modern, twist, jazz, tap, jitterbug03015 6.0 03015 6.5 dancing aerobic, general

03016 8.5 dancing aerobic, step, with 6 – 8 inch step03017 10.0 dancing aerobic, step, with 10 – 12 inch step

03020 5.0 03020 5.0 dancing aerobic, low impact03021 7.0 03021 7.0 dancing aerobic, high impact03025 4.5 03025 4.5 dancing general, Greek, Middle Eastern, hula, flamenco, belly, and swing dancing03030 5.5 03030 5.5 dancing ballroom, dancing fast (Taylor Code 125)

03031 4.5 dancing ballroom, fast (disco, folk, square), line dancing, Irish step dancing, polka, contra, country03040 3.0 03040 3.0 dancing ballroom, slow (e.g. waltz, foxtrot, slow dancing), samba, tango, 19th C, mambo, chacha

03050 5.5 dancing Anishinaabe Jingle Dancing or other traditional American Indian dancing04001 4.0 04001 3.0 fishing and hunting fishing, general04010 4.0 04010 4.0 fishing and hunting digging worms, with shovel

Page 1 of 12


04020 5.0 04020 4.0 fishing and hunting fishing from river bank and walking04030 2.5 04030 2.5 fishing and hunting fishing from boat, sitting04040 3.5 04040 3.5 fishing and hunting fishing from river bank, standing (Taylor Code 660)04050 6.0 04050 6.0 fishing and hunting fishing in stream, in waders (Taylor Code 670)04060 2.0 04060 2.0 fishing and hunting fishing, ice, sitting04070 2.5 04070 2.5 fishing and hunting hunting, bow and arrow or crossbow04080 6.0 04080 6.0 fishing and hunting hunting, deer, elk, large game (Taylor Code 170)04090 2.5 04090 2.5 fishing and hunting hunting, duck, wading04100 5.0 04100 5.0 fishing and hunting hunting, general04110 6.0 04110 6.0 fishing and hunting hunting, pheasants or grouse (Taylor Code 68004120 5.0 04120 5.0 fishing and hunting hunting, rabbit, squirrel, prairie chick, raccoon, small game (Taylor Code 690)04130 2.5 04130 2.5 fishing and hunting pistol shooting or trap shooting, standing05010 2.5 05010 3.3 home activities carpet sweeping, sweeping floors05020 4.5 05020 3.0 home activities cleaning, heavy or major (e.g. wash car, wash windows, clean garage), vigorous effor

05021 3.5 home activities mopping05025 2.5 home activities multiple household tasks all at once, light effor05026 3.5 home activities multiple household tasks all at once, moderate effor05027 4.0 home activities multiple household tasks all at once, vigorous effor

05030 3.5 05030 3.0 home activities cleaning, house or cabin, genera05040 2.5 05040 2.5 home activities cleaning, light (dusting, straightening up, changing linen, carrying out trash05041 2.3 05041 2.3 home activities wash dishes - standing or in general (not broken into stand/walk components05042 2.3 05042 2.5 home activities wash dishes; clearing dishes from table – walking

05043 3.5 home activities vacuuming05045 6.0 home activities butchering animals

05050 2.5 05050 2.0 home activities cooking or food preparation - standing or sitting or in general (not broken into stand/walk components), manual appliance05051 2.5 05051 2.5 home activities serving food, setting table - implied walking or standing05052 2.5 05052 2.5 home activities cooking or food preparation - walking

05053 2.5 home activities feeding animals05055 2.5 05055 2.5 home activities putting away groceries (e.g. carrying groceries, shopping without a grocery cart), carrying packages05056 8.0 05056 7.5 home activities carrying groceries upstairs

05057 3.0 home activities cooking Indian bread on an outside stove05060 3.5 05060 2.3 home activities food shopping with or without a grocery cart, standing or walking05065 2.0 05065 2.3 home activities non-food shopping, standing or walking05066 2.3 home activities walking shopping (non-grocery shopping)05070 2.3 05070 2.3 home activities ironing05080 1.5 05080 1.5 home activities sitting - knitting, sewing, lt. wrapping (presents)05090 2.0 05090 2.0 home activities implied standing - laundry, fold or hang clothes, put clothes in washer or dryer, packing suitcase05095 2.3 05095 2.3 home activities implied walking - putting away clothes, gathering clothes to pack, putting away laundry05100 2.0 05100 2.0 home activities making bed05110 5.0 05110 5.0 home activities maple syruping/sugar bushing (including carrying buckets, carrying wood)05120 6.0 05120 6.0 home activities moving furniture, household items, carrying boxes05130 5.5 05130 3.8 home activities scrubbing floors, on hands and knees, scrubbing bathroom, bathtub05140 4.0 05140 4.0 home activities sweeping garage, sidewalk or outside of house05145 7.0 home activities moving household items, carrying boxes05146 3.5 05146 3.5 home activities standing - packing/unpacking boxes, occasional lifting of household items light - moderate effor05147 3.0 05147 3.0 home activities implied walking - putting away household items - moderate effort

05148 2.5 home activities watering plants05149 2.5 home activities building a fire inside

05150 9.0 05150 9.0 home activities moving household items upstairs, carrying boxes or furniture05160 2.5 05160 2.0 home activities standing - light (pump gas, change light bulb, etc.)05165 3.0 05165 3.0 home activities walking - light, non-cleaning (readying to leave, shut/lock doors, close windows, etc.05170 2.5 05170 2.5 home activities sitting - playing with child(ren) – light, only active periods 05171 2.8 05171 2.8 home activities standing - playing with child(ren) – light, only active periods 05175 4.0 05175 4.0 home activities walk/run - playing with child(ren) – moderate, only active periods 05180 5.0 05180 5.0 home activities walk/run - playing with child(ren) – vigorous, only active periods

05181 3.0 home activities carrying small children

Page 2 of 12


05185 3.0 05185 2.5 home activities child care: sitting/kneeling - dressing, bathing, grooming, feeding, occasional lifting of child-light effort, genera05186 3.5 05186 3.0 home activities child care: standing - dressing, bathing, grooming, feeding, occasional lifting of child-light effort

05187 4.0 home activities elder care, disabled adult, only active periods05188 1.5 home activities reclining with baby05190 2.5 home activities sit, play ing with animals, light, only active periods05191 2.8 home activities stand, playing with animals, light, only active periods05192 2.8 home activities walk/run, playing with animals, light, only active periods05193 4.0 home activities walk/run, playing with animals, moderate, only active periods05194 5.0 home activities walk/run, playing with animals, vigorous, only active periods05195 3.5 home activities standing - bathing dog

06010 3.0 06010 3.0 home repair airplane repair06020 4.5 06020 4.0 home repair automobile body work06030 3.0 06030 3.0 home repair automobile repair06040 3.0 06040 3.0 home repair carpentry, general, workshop (Taylor Code 620)06050 6.0 06050 6.0 home repair carpentry, outside house, installing rain gutters, building a fence, (Taylor Code 640)06060 4.5 06060 4.5 home repair carpentry, finishing or refinishing cabinets or furniture06070 7.5 06070 7.5 home repair carpentry, sawing hardwood06080 5.0 06080 5.0 home repair caulking, chinking log cabin06090 4.5 06090 4.5 home repair caulking, except log cabin06100 5.0 06100 5.0 home repair cleaning gutters06110 5.0 06110 5.0 home repair excavating garage06120 5.0 06120 5.0 home repair hanging storm windows06130 4.5 06130 4.5 home repair laying or removing carpet06140 4.5 06140 4.5 home repair laying tile or linoleum, repairing appliances06150 5.0 06150 5.0 home repair painting, outside home (Taylor Code 650)06160 4.5 06160 3.0 home repair painting, papering, plastering, scraping, inside house, hanging sheet rock, remodeling

06165 4.5 home repair painting, (Taylor Code 630)06170 3.0 06170 3.0 home repair put on and removal of tarp - sailboat06180 6.0 06180 6.0 home repair roofing06190 4.5 06190 4.5 home repair sanding floors with a power sander06200 4.5 06200 4.5 home repair scraping and painting sailboat or powerboat06210 5.0 06210 5.0 home repair spreading dirt with a shovel06220 4.5 06220 4.5 home repair washing and waxing hull of sailboat, car, powerboat, airplane06230 4.5 06230 4.5 home repair washing fence, painting fence06240 3.0 06240 3.0 home repair wiring, plumbing07010 0.9 07010 1.0 inactivity quiet lying quietly, watching television

07011 1.0 inactivity quiet lying quietly, doing nothing, lying in bed awake, listening to music (not talking or reading07020 1.0 07020 1.0 inactivity quiet sitting quietly and watching television

07021 1.0 inactivity quiet sitting quietly, sitting smoking, listening to music (not talking or reading), watching a movie in a theate07030 0.9 07030 0.9 inactivity quiet sleeping07040 1.2 07040 1.2 inactivity quiet standing quietly (standing in a line)07050 1.0 07050 1.0 inactivity light reclining - writing07060 1.0 07060 1.0 inactivity light reclining - talking or talking on phone07070 1.0 07070 1.0 inactivity light reclining - reading

07075 1.0 inactivity light meditating08010 5.0 08010 5.0 lawn and garden carrying, loading or stacking wood, loading/unloading or carrying lumber08020 6.0 08020 6.0 lawn and garden chopping wood, splitting logs08030 5.0 08030 5.0 lawn and garden clearing land, hauling branches, wheelbarrow chores08040 5.0 08040 5.0 lawn and garden digging sandbox08050 5.0 08050 5.0 lawn and garden digging, spading, filling garden, composting, (Taylor Code 590)08060 6.0 08060 6.0 lawn and garden gardening with heavy power tools, tilling a garden, chain saw08080 5.0 08080 5.0 lawn and garden laying crushed rock08090 5.0 08090 5.0 lawn and garden laying sod08095 5.5 08095 5.5 lawn and garden mowing lawn, general08100 2.5 08100 2.5 lawn and garden mowing lawn, riding mower (Taylor Code 550)08110 6.0 08110 6.0 lawn and garden mowing lawn, walk, hand mower (Taylor Code 570)

Page 3 of 12


08120 4.5 08120 5.5 lawn and garden mowing lawn, walk, power mower08125 4.5 lawn and garden mowing lawn, power mower (Taylor Code 590)

08130 4.5 08130 4.5 lawn and garden operating snow blower, walking08140 4.0 08140 4.5 lawn and garden planting seedlings, shrubs08150 4.5 08150 4.5 lawn and garden planting trees08160 4.0 08160 4.3 lawn and garden raking lawn

08165 4.0 lawn and garden raking lawn (Taylor Code 600)08170 4.0 08170 4.0 lawn and garden raking roof with snow rake08180 3.0 08180 3.0 lawn and garden riding snow blower08190 4.0 08190 4.0 lawn and garden sacking grass, leaves08200 6.0 08200 6.0 lawn and garden shoveling snow, by hand (Taylor Code 610)08210 4.5 08210 4.5 lawn and garden trimming shrubs or trees, manual cutter08215 3.5 08215 3.5 lawn and garden trimming shrubs or trees, power cutter, using leaf blower, edger08220 2.5 08220 2.5 lawn and garden walking, applying fertilizer or seeding a lawn08230 1.5 08230 1.5 lawn and garden watering lawn or garden, standing or walking08240 4.5 08240 4.5 lawn and garden weeding, cultivating garden (Taylor Code 580)08245 5.0 08245 4.0 lawn and garden gardening, general

08246 3.0 lawn and garden picking fruit off trees, picking fruits/vegetables, moderate effort08250 3.0 08250 3.0 lawn and garden implied walking/standing - picking up yard, light, picking flowers or vegetables

08251 3.0 lawn and garden walking, gathering gardening tools09010 1.5 09010 1.5 miscellaneous sitting - card playing, playing board games09020 2.0 09020 2.3 miscellaneous standing - drawing (writing), casino gambling, duplicating machine09030 1.3 09030 1.3 miscellaneous sitting - reading, book, newspaper, etc.09040 1.8 09040 1.8 miscellaneous sitting - writing, desk work, typing09050 1.8 09050 1.8 miscellaneous standing - talking or talking on the phone09055 1.5 09055 1.5 miscellaneous sitting - talking or talking on the phone09060 1.8 09060 1.8 miscellaneous sitting - studying, general, including reading and/or writing09065 1.8 09065 1.8 miscellaneous sitting - in class, general, including note-taking or class discussion09070 1.8 09070 1.8 miscellaneous standing - reading

09071 2.0 miscellaneous standing - miscellaneous09075 1.5 miscellaneous sitting - arts and crafts, light effort09080 2.0 miscellaneous sitting - arts and crafts, moderate effort09085 1.8 miscellaneous standing - arts and crafts, light effort09090 3.0 miscellaneous standing - arts and crafts, moderate effort09095 3.5 miscellaneous standing - arts and crafts, vigorous effort09100 1.5 miscellaneous retreat/family reunion activities involving sitting, relaxing, talking, eating09105 2.0 miscellaneous touring/traveling/vacation involving walking and riding09110 2.5 miscellaneous camping involving standing, walking, sitting, light-to-moderate effort09115 1.5 miscellaneous sitting at a sporting event, spectator

10010 1.8 10010 1.8 music playing accordion10020 2.0 10020 2.0 music playing cello10030 2.5 10030 2.5 music playing conducting10040 4.0 10040 4.0 music playing drums10050 2.0 10050 2.0 music playing flute (sitting)10060 2.0 10060 2.0 music playing horn10070 2.5 10070 2.5 music playing piano or organ10080 3.5 10080 3.5 music playing trombone10090 2.5 10090 2.5 music playing trumpet10100 2.5 10100 2.5 music playing violin10110 2.0 10110 2.0 music playing woodwind10120 2.0 10120 2.0 music playing guitar, classical, folk (sitting)10125 3.0 10125 3.0 music playing guitar, rock and roll band (standing)10130 4.0 10130 4.0 music playing marching band, playing an instrument, baton twirling (walking)10135 3.5 10135 3.5 music playing marching band, drum major (walking)11010 4.0 11010 4.0 occupation bakery, general, moderate effort

11015 2.5 occupation bakery, light effort

Page 4 of 12


11020 2.3 11020 2.3 occupation bookbinding11030 6.0 11030 6.0 occupation building road (including hauling debris, driving heavy machinery)11035 2.0 11035 2.0 occupation building road, directing traffic (standing)11040 3.5 11040 3.5 occupation carpentry, general11050 8.0 11050 8.0 occupation carrying heavy loads, such as bricks11060 8.0 11060 8.0 occupation carrying moderate loads up stairs, moving boxes (16-40 pounds)11070 2.5 11070 2.5 occupation chambermaid, making bed (nursing)11080 6.5 11080 6.5 occupation coal mining, drilling coal, rock11090 6.5 11090 6.5 occupation coal mining, erecting supports11100 6.0 11100 6.0 occupation coal mining, general11110 7.0 11110 7.0 occupation coal mining, shoveling coal11120 5.5 11120 5.5 occupation construction, outside, remodeling

11121 3.0 occupation custodial work - buffing the floor with electric buffer11122 2.5 occupation custodial work - cleaning sink and toilet, light effort11123 2.5 occupation custodial work - dusting, light effort11124 4.0 occupation custodial work – feathering arena floor, moderate effor11125 3.5 occupation custodial work - general cleaning, moderate effort11126 3.5 occupation custodial work - mopping, moderate effort11127 3.0 occupation custodial work - take out trash, moderate effor11128 2.5 occupation custodial work - vacuuming, light effort11129 3.0 occupation custodial work - vacuuming, moderate effort

11130 3.5 11130 3.5 occupation electrical work, plumbing11140 8.0 11140 8.0 occupation farming, baling hay, cleaning barn, poultry work, vigorous effort11150 3.5 11150 3.5 occupation farming, chasing cattle, non-strenuous (walking), moderate effort

11151 4.0 occupation farming, chasing cattle or other livestock on horseback, moderate effor11152 2.0 occupation farming, chasing cattle or other livestock, driving, light effort

11160 2.5 11160 2.5 occupation farming, driving harvester, cutting hay, irrigation work11170 2.5 11170 2.5 occupation farming, driving tractor11180 4.0 11180 4.0 occupation farming, feeding small animals11190 4.5 11190 4.5 occupation farming, feeding cattle, horses

11191 4.5 occupation farming, hauling water for animals, general hauling water11192 6.0 occupation farming, taking care of animals (grooming, brushing, shearing sheep, assisting with birthing, medical care, branding)

11200 8.0 11200 8.0 occupation farming, forking straw bales, cleaning corral or barn, vigorous effort11210 3.0 11210 3.0 occupation farming, milking by hand, moderate effort11220 1.5 11220 1.5 occupation farming, milking by machine, light effort11230 5.5 11230 5.5 occupation farming, shoveling grain, moderate effort11240 12.0 11240 12.0 occupation fire fighter, general11245 11.0 11245 11.0 occupation fire fighter, climbing ladder with full gear11246 8.0 11246 8.0 occupation fire fighter, hauling hoses on ground11250 17.0 11250 17.0 occupation forestry, ax chopping, fast11260 5.0 11260 5.0 occupation forestry, ax chopping, slow11270 7.0 11270 7.0 occupation forestry, barking trees11280 11.0 11280 11.0 occupation forestry, carrying logs11290 8.0 11290 8.0 occupation forestry, felling trees11300 8.0 11300 8.0 occupation forestry, general11310 5.0 11310 5.0 occupation forestry, hoeing11320 6.0 11320 6.0 occupation forestry, planting by hand11330 7.0 11330 7.0 occupation forestry, sawing by hand11340 4.5 11340 4.5 occupation forestry, sawing, power11350 9.0 11350 9.0 occupation forestry, trimming trees11360 4.0 11360 4.0 occupation forestry, weeding11370 4.5 11370 4.5 occupation furriery11380 6.0 11380 6.0 occupation horse grooming11390 8.0 11390 8.0 occupation horse racing, galloping11400 6.5 11400 6.5 occupation horse racing, trotting11410 2.6 11410 2.6 occupation horse racing, walking

Page 5 of 12


11420 3.5 11420 3.5 occupation locksmith11430 2.5 11430 2.5 occupation machine tooling, machining, working sheet meta11440 3.0 11440 3.0 occupation machine tooling, operating lathe11450 5.0 11450 5.0 occupation machine tooling, operating punch press11460 4.0 11460 4.0 occupation machine tooling, tapping and drilling11470 3.0 11470 3.0 occupation machine tooling, welding11480 7.0 11480 7.0 occupation masonry, concrete11485 4.0 11485 4.0 occupation masseur, masseuse (standing)11490 7.0 11490 7.5 occupation moving, pushing heavy objects, 75 lbs or more (desks, moving van work)

11495 12.0 occupation skindiving or SCUBA diving as a frogman (Navy Seal)11500 2.5 11500 2.5 occupation operating heavy duty equipment/automated, not driving11510 4.5 11510 4.5 occupation orange grove work11520 2.3 11520 2.3 occupation printing (standing)11525 2.5 11525 2.5 occupation police, directing traffic (standing)11526 2.0 11526 2.0 occupation police, driving a squad car (sitting)11527 1.3 11527 1.3 occupation police, riding in a squad car (sitting)11528 8.0 11528 4.0 occupation police, making an arrest (standing)11530 2.5 11530 2.5 occupation shoe repair, general11540 8.5 11540 8.5 occupation shoveling, digging ditches11550 9.0 11550 9.0 occupation shoveling, heavy (more than 16 pounds/minute11560 6.0 11560 6.0 occupation shoveling, light (less than 10 pounds/minute)11570 7.0 11570 7.0 occupation shoveling, moderate (10 to 15 pounds/minute)11580 1.5 11580 1.5 occupation

sitting - light office work, general (chemistry lab work, light use of hand tools, watch repair or micro-assembly, light assembly/repair), sitting, reading, driving at work11585 1.5 11585 1.5 occupation sitting meetings, general, and/or with talking involved, eatting at a business meeting11590 2.5 11590 2.5 occupation sitting; moderate (heavy levers, riding mower/forklift, crane operation) teaching stretching or yoga11600 2.5 11600 2.3 occupation standing; light (bartending, store clerk, assembling, filing, duplicating, putting up a Christmas tree), standing and talking at work, changing clothes when teaching

physical education 11610 3.0 11610 3.0 occupation standing; light/moderate (assemble/repair heavy parts, welding, stocking, auto repair, pack boxes for moving, etc.), patient care (as in nursing

11615 4.0 occupation lifting items continuously, 10 – 20 lbs, with limited walking or resting11620 3.5 11620 3.5 occupation standing; moderate (assembling at fast rate, intermittent, lifting 50 lbs, hitch/twisting ropes)11630 4.0 11630 4.0 occupation standing; moderate/heavy (lifting more than 50 lbs, masonry, painting, paper hanging11640 5.0 11640 5.0 occupation steel mill, fettling11650 5.5 11650 5.5 occupation steel mill, forging11660 8.0 11660 8.0 occupation steel mill, hand rolling11670 8.0 11670 8.0 occupation steel mill, merchant mill rolling11680 11.0 11680 11.0 occupation steel mill, removing slag11690 7.5 11690 7.5 occupation steel mill, tending furnace11700 5.5 11700 5.5 occupation steel mill, tipping molds11710 8.0 11710 8.0 occupation steel mill, working in general11720 2.5 11720 2.5 occupation tailoring, cutting11730 2.5 11730 2.5 occupation tailoring, general11740 2.0 11740 2.0 occupation tailoring, hand sewing11750 2.5 11750 2.5 occupation tailoring, machine sewing11760 4.0 11760 4.0 occupation tailoring, pressing

11765 3.5 occupation tailoring, weaving11766 6.5 11766 6.5 occupation truck driving, loading and unloading truck (standing)11770 1.5 11770 1.5 occupation typing, electric, manual or computer11780 6.0 11780 6.0 occupation using heavy power tools such as pneumatic tools (jackhammers, drills, etc.11790 8.0 11790 8.0 occupation using heavy tools (not power) such as shovel, pick, tunnel bar, spade11791 2.0 11791 2.0 occupation walking on job, less than 2.0 mph (in office or lab area), very slow11792 3.5 11792 3.3 occupation walking on job, 3.0 mph, in office, moderate speed, not carrying anything11793 4.0 11793 3.8 occupation walking on job, 3.5 mph, in office, brisk speed, not carrying anything11795 3.0 11795 3.0 occupation walking, 2.5 mph, slowly and carrying light objects less than 25 pounds

11796 3.0 occupation walking, gathering things at work, ready to leave11800 4.0 11800 4.0 occupation walking, 3.0 mph, moderately and carrying light objects less than 25 lbs

Page 6 of 12


11805 4.0 occupation walking, pushing a wheelchair11810 4.5 11810 4.5 occupation walking, 3.5 mph, briskly and carrying objects less than 25 pounds11820 5.0 11820 5.0 occupation walking or walk downstairs or standing, carrying objects about 25 to 49 pounds11830 6.5 11830 6.5 occupation walking or walk downstairs or standing, carrying objects about 50 to 74 pounds11840 7.5 11840 7.5 occupation walking or walk downstairs or standing, carrying objects about 75 to 99 pounds11850 8.5 11850 8.5 occupation walking or walk downstairs or standing, carrying objects about 100 pounds or ove11870 3.0 11870 3.0 occupation working in scene shop, theater actor, backstage employee

11875 4.0 occupation teach physical education, exercise, sports classes (non-sport play11876 6.5 occupation teach physical education, exercise, sports classes (participate in the class

12010 6.0 12010 6.0 running jog/walk combination (jogging component of less than 10 minutes) (Taylor Code 18012020 7.0 12020 7.0 running jogging, general

12025 8.0 running jogging, in place12027 4.5 running jogging on a mini-tramp

12030 8.0 12030 8.0 running running, 5 mph (12 min/mile)12040 9.0 12040 9.0 running running, 5.2 mph (11.5 min/mile)12050 10.0 12050 10.0 running running, 6 mph (10 min/mile)12060 11.0 12060 11.0 running running, 6.7 mph (9 min/mile)12070 11.5 12070 11.5 running running, 7 mph (8.5 min/mile)12080 12.5 12080 12.5 running running, 7.5 mph (8 min/mile)12090 13.5 12090 13.5 running running, 8 mph (7.5 min/mile)12100 14.0 12100 14.0 running running, 8.6 mph (7 min/mile)12110 15.0 12110 15.0 running running, 9 mph (6.5 min/mile)12120 16.0 12120 16.0 running running, 10 mph (6 min/mile)12130 18.0 12130 18.0 running running, 10.9 mph (5.5 min/mile)12140 9.0 12140 9.0 running running, cross country12150 8.0 12150 8.0 running running (Taylor Code 200)12160 8.0 running running, in place12170 15.0 12170 15.0 running running, stairs, up12180 10.0 12180 10.0 running running, on a track, team practice12190 8.0 12190 8.0 running running, training, pushing a wheelchair12195 3.0 running running, wheeling, general13000 2.5 13000 2.0 self care standing - getting ready for bed, in general13009 1.0 13009 1.0 self care sitting on toilet13010 2.0 13010 1.5 self care bathing (sitting)13020 2.5 13020 2.0 self care dressing, undressing (standing or sitting)13030 1.5 13030 1.5 self care eating (sitting)13035 2.0 13035 2.0 self care talking and eating or eating only (standing)

13036 1.0 self care taking medication, sitting or standing13040 2.5 13040 2.0 self care grooming (washing, shaving, brushing teeth, urinating, washing hands, putting on make-up), sitting or standing

13045 2.5 self care hairstyling13046 1.0 self care having hair or nails done by someone else, sitting

13050 4.0 13050 2.0 self care showering, toweling off (standing)14010 1.5 14010 1.5 sexual activity active, vigorous effort14020 1.3 14020 1.3 sexual activity general, moderate effort14030 1.0 14030 1.0 sexual activity passive, light effort, kissing, hugging15010 3.5 15010 3.5 sports archery (non-hunting)15020 7.0 15020 7.0 sports badminton, competitive (Taylor Code 450)15030 4.5 15030 4.5 sports badminton, social singles and doubles, general15040 8.0 15040 8.0 sports basketball, game (Taylor Code 490)15050 6.0 15050 6.0 sports basketball, non-game, general (Taylor Code 480)15060 7.0 15060 7.0 sports basketball, officiating (Taylor Code 500)15070 4.5 15070 4.5 sports basketball, shooting baskets15075 6.5 15075 6.5 sports basketball, wheelchair15080 2.5 15080 2.5 sports billiards15090 3.0 15090 3.0 sports bowling (Taylor Code 390)15100 12.0 15100 12.0 sports boxing, in ring, general

Page 7 of 12


15110 6.0 15110 6.0 sports boxing, punching bag15120 9.0 15120 9.0 sports boxing, sparring15130 7.0 15130 7.0 sports broomball15135 5.0 15135 5.0 sports children’s games (hopscotch, 4-square, dodge ball, playground apparatus, t-ball, tetherball, marbles, jacks, acrace games15140 4.0 15140 4.0 sports coaching: football, soccer, basketball, baseball, swimming, etc.15150 5.0 15150 5.0 sports cricket (batting, bowling)15160 2.5 15160 2.5 sports croquet15170 4.0 15170 4.0 sports curling15180 2.5 15180 2.5 sports darts, wall or lawn15190 6.0 15190 6.0 sports drag racing, pushing or driving a car15200 6.0 15200 6.0 sports fencing15210 9.0 15210 9.0 sports football, competitive15230 8.0 15230 8.0 sports football, touch, flag, general (Taylor Code 51015235 2.5 15235 2.5 sports football or baseball, playing catch15240 3.0 15240 3.0 sports frisbee playing, general15250 3.5 15250 8.0 sports frisbee, ultimate15255 4.5 15255 4.5 sports golf, general15260 5.5 sports golf carrying clubs

15265 4.5 sports golf, walking and carrying clubs (See footnote at end of the Compendium15270 3.0 15270 3.0 sports golf, miniature, driving range15280 5.0 sports golf, pulling clubs

15285 4.3 sports golf, walking and pulling clubs (See footnote at end of the Compendium15290 3.5 15290 3.5 sports golf, using power cart (Taylor Code 070)15300 4.0 15300 4.0 sports gymnastics, general15310 4.0 15310 4.0 sports hacky sack15320 12.0 15320 12.0 sports handball, general (Taylor Code 520)15330 8.0 15330 8.0 sports handball, team15340 3.5 15340 3.5 sports hand gliding15350 8.0 15350 8.0 sports hockey, field15360 8.0 15360 8.0 sports hockey, ice15370 4.0 15370 4.0 sports horseback riding, general15380 3.5 15380 3.5 sports horseback riding, saddling horse, grooming horse15390 6.5 15390 6.5 sports horseback riding, trotting15400 2.5 15400 2.5 sports horseback riding, walking15410 3.0 15410 3.0 sports horseshoe pitching, quoits15420 12.0 15420 12.0 sports jai alai15430 10.0 15430 10.0 sports judo, jujitsu, karate, kick boxing, tae kwan do15440 4.0 15440 4.0 sports juggling15450 7.0 15450 7.0 sports kickball15460 8.0 15460 8.0 sports lacrosse15470 4.0 15470 4.0 sports motor-cross15480 9.0 15480 9.0 sports orienteering15490 10.0 15490 10.0 sports paddleball, competitive15500 6.0 15500 6.0 sports paddleball, casual, general (Taylor Code 460)15510 8.0 15510 8.0 sports polo15520 10.0 15520 10.0 sports racquetball, competitive15530 7.0 15530 7.0 sports racquetball, casual, general (Taylor Code 470)15535 11.0 15535 11.0 sports rock climbing, ascending rock15540 8.0 15540 8.0 sports rock climbing, rappelling15550 12.0 15550 12.0 sports rope jumping, fast15551 10.0 15551 10.0 sports rope jumping, moderate, general15552 8.0 15552 8.0 sports rope jumping, slow15560 10.0 15560 10.0 sports rugby15570 3.0 15570 3.0 sports shuffleboard, lawn bowling15580 5.0 15580 5.0 sports skateboarding15590 7.0 15590 7.0 sports skating, roller (Taylor Code 360)

Page 8 of 12


15591 12.0 sports roller blading (in-line skating)15600 3.5 15600 3.5 sports sky diving15605 10.0 15605 10.0 sports soccer, competitive15610 7.0 15610 7.0 sports soccer, casual, general (Taylor Code 540)15620 5.0 15620 5.0 sports softball or baseball, fast or slow pitch, general (Taylor Code 440)15630 4.0 15630 4.0 sports softball, officiating15640 6.0 15640 6.0 sports softball, pitching15650 12.0 15650 12.0 sports squash (Taylor Code 530)15660 4.0 15660 4.0 sports table tennis, ping pong (Taylor Code 410)15670 4.0 15670 4.0 sports tai chi15675 7.0 15675 7.0 sports tennis, general15680 6.0 15680 6.0 sports tennis, doubles (Taylor Code 430)

15685 5.0 sports tennis, doubles15690 8.0 15690 8.0 sports tennis, singles (Taylor Code 420)15700 3.5 15700 3.5 sports trampoline15710 4.0 15710 4.0 sports volleyball (Taylor Code 400)

15711 8.0 sports volleyball, competitive, in gymnasium15720 3.0 15720 3.0 sports volleyball, non-competitive, 6 - 9 member team, genera15725 8.0 15725 8.0 sports volleyball, beach15730 6.0 15730 6.0 sports wrestling (one match = 5 minutes)15731 7.0 15731 7.0 sports wallyball, general

15732 4.0 sports track and field (shot, discus, hammer throw)15733 6.0 sports track and field (high jump, long jump, triple jump, javelin, pole vault)15734 10.0 sports track and field (steeplechase, hurdles)

16010 2.0 16010 2.0 transportation automobile or light truck (not a semi) driving16015 1.0 transportation riding in a car or truck16016 1.0 transportation riding in a bus

16020 2.0 16020 2.0 transportation flying airplane16030 2.5 16030 2.5 transportation motor scooter, motorcycle16040 6.0 16040 6.0 transportation pushing plane in and out of hangar16050 3.0 16050 3.0 transportation driving heavy truck, tractor, bus17010 7.0 17010 7.0 walking backpacking (Taylor Code 050)17020 3.5 17020 3.5 walking carrying infant or 15 pound load (e.g. suitcase), level ground or downstairs17025 9.0 17025 9.0 walking carrying load upstairs, general17026 5.0 17026 5.0 walking carrying 1 to 15 lb load, upstairs17027 6.0 17027 6.0 walking carrying 16 to 24 lb load, upstairs17028 8.0 17028 8.0 walking carrying 25 to 49 lb load, upstairs17029 10.0 17029 10.0 walking carrying 50 to 74 lb load, upstairs17030 12.0 17030 12.0 walking carrying 74+ lb load, upstairs

17031 3.0 walking loading /unloading a car17035 7.0 17035 7.0 walking climbing hills with 0 to 9 pound load17040 7.5 17040 7.5 walking climbing hills with 10 to 20 pound load17050 8.0 17050 8.0 walking climbing hills with 21 to 42 pound load17060 9.0 17060 9.0 walking climbing hills with 42+ pound load17070 3.0 17070 3.0 walking downstairs17080 6.0 17080 6.0 walking hiking, cross country (Taylor Code 040)

17085 2.5 walking bird watching17090 6.5 17090 6.5 walking marching, rapidly, military17100 2.5 17100 2.5 walking pushing or pulling stroller with child or walking with children

17105 4.0 walking pushing a wheelchair, non-occupational setting17110 6.5 17110 6.5 walking race walking17120 8.0 17120 8.0 walking rock or mountain climbing (Taylor Code 060)17130 8.0 17130 8.0 walking up stairs, using or climbing up ladder (Taylor Code 030)17140 4.0 17140 5.0 walking using crutches17150 2.0 17150 2.0 walking walking, household walking

17151 2.0 walking walking, less than 2.0 mph, level ground, strolling, very slow

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17152 2.5 walking walking, 2.0 mph, level, slow pace, firm surface17160 2.5 17160 3.5 walking walking for pleasure (Taylor Code 010)

17161 2.5 walking walking from house to car or bus, from car or bus to go places, from car or bus to and from the worksite17162 2.5 walking walking to neighbor’s house or family’s house for social reasons17165 3.0 walking walking the dog

17170 3.0 17170 3.0 walking walking, 2.5 mph, firm surface17180 3.0 17180 2.8 walking walking, 2.5 mph, downhill 17190 3.5 17190 3.3 walking walking, 3.0 mph, level, moderate pace, firm surface17200 4.0 17200 3.8 walking walking, 3.5 mph, level, brisk, firm surface, walking for exercise17210 6.0 17210 6.0 walking walking, 3.5 mph, uphill17220 4.0 17220 5.0 walking walking, 4.0 mph, level, firm surface, very brisk pace17230 4.5 17230 6.3 walking walking, 4.5 mph, level, firm surface, very, very brisk

17231 8.0 walking walking, 5.0 mph 17250 3.5 17250 3.5 walking walking, for pleasure, work break17260 5.0 17260 5.0 walking walking, grass track17270 4.0 17270 4.0 walking walking, to work or class (Taylor Code 015)

17280 2.5 walking walking to and from an outhouse18010 2.5 18010 2.5 water activities boating, power18020 4.0 18020 4.0 water activities canoeing, on camping trip (Taylor Code 270)

18025 3.3 water activities canoeing, harvesting wild rice, knocking rice off the stalks18030 7.0 18030 7.0 water activities canoeing, portaging18040 3.0 18040 3.0 water activities canoeing, rowing, 2.0-3.9 mph, light effort18050 7.0 18050 7.0 water activities canoeing, rowing, 4.0-5.9 mph, moderate effort18060 12.0 18060 12.0 water activities canoeing, rowing, >6 mph, vigorous effort18070 3.5 18070 3.5 water activities canoeing, rowing, for pleasure, general (Taylor Code 25018080 12.0 18080 12.0 water activities canoeing, rowing, in competition, or crew or sculling (Taylor Code 26018090 3.0 18090 3.0 water activities diving, springboard or platform18100 5.0 18100 5.0 water activities kayaking18110 4.0 18110 4.0 water activities paddle boat18120 3.0 18120 3.0 water activities sailing, boat and board sailing, windsurfing, ice sailing, general (Taylor Code 235)18130 5.0 18130 5.0 water activities sailing, in competition18140 3.0 18140 3.0 water activities sailing, Sunfish/Laser/Hobby Cat, Keel boats, ocean sailing, yachting18150 6.0 18150 6.0 water activities skiing, water (Taylor Code 220)18160 7.0 18160 7.0 water activities skimobiling18170 12.0 water activities18180 16.0 18180 16.0 water activities skindiving, fast18190 12.5 18190 12.5 water activities skindiving, moderate18200 7.0 18200 7.0 water activities skindiving, scuba diving, general (Taylor Code 310)18210 5.0 18210 5.0 water activities snorkeling (Taylor Code 320)18220 3.0 18220 3.0 water activities surfing, body or board18230 10.0 18230 10.0 water activities swimming laps, freestyle, fast, vigorous effort18240 8.0 18240 7.0 water activities swimming laps, freestyle, slow, moderate or light effort18250 8.0 18250 7.0 water activities swimming, backstroke, general18260 10.0 18260 10.0 water activities swimming, breaststroke, general18270 11.0 18270 11.0 water activities swimming, butterfly, general18280 11.0 18280 11.0 water activities swimming, crawl, fast (75 yards/minute), vigorous effort18290 8.0 18290 8.0 water activities swimming, crawl, slow (50 yards/minute), moderate or light effort18300 6.0 18300 6.0 water activities swimming, lake, ocean, river (Taylor Codes 280, 295)18310 6.0 18310 6.0 water activities swimming, leisurely, not lap swimming, general18320 8.0 18320 8.0 water activities swimming, sidestroke, general18330 8.0 18330 8.0 water activities swimming, synchronized18340 10.0 18340 10.0 water activities swimming, treading water, fast vigorous effort18350 4.0 18350 4.0 water activities swimming, treading water, moderate effort, general

18355 4.0 water activities water aerobics, water calisthenics18360 10.0 18360 10.0 water activities water polo18365 3.0 18365 3.0 water activities water volleyball

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18366 8.0 water activities water jogging18370 5.0 18370 5.0 water activities whitewater rafting, kayaking, or canoeing19010 6.0 19010 6.0 winter activities moving ice house (set up/drill holes, etc.)19020 5.5 19020 5.5 winter activities skating, ice, 9 mph or less19030 7.0 19030 7.0 winter activities skating, ice, general (Taylor Code 360)19040 9.0 19040 9.0 winter activities skating, ice, rapidly, more than 9 mph19050 15.0 19050 15.0 winter activities skating, speed, competitive19060 7.0 19060 7.0 winter activities ski jumping (climb up carrying skis)19075 7.0 19075 7.0 winter activities skiing, general19080 7.0 19080 7.0 winter activities skiing, cross country, 2.5 mph, slow or light effort, ski walking19090 8.0 19090 8.0 winter activities skiing, cross country, 4.0-4.9 mph, moderate speed and effort, genera19100 9.0 19100 9.0 winter activities skiing, cross country, 5.0-7.9 mph, brisk speed, vigorous effort19110 14.0 19110 14.0 winter activities skiing, cross country, >8.0 mph, racing19130 16.5 19130 16.5 winter activities skiing, cross country, hard snow, uphill, maximum, snow mountaineering19150 5.0 19150 5.0 winter activities skiing, downhill, light effort19160 6.0 19160 6.0 winter activities skiing, downhill, moderate effort, general19170 8.0 19170 8.0 winter activities skiing, downhill, vigorous effort, racing19180 7.0 19180 7.0 winter activities sledding, tobogganing, bobsledding, luge (Taylor Code 370)19190 8.0 19190 8.0 winter activities snow shoeing19200 3.5 19200 3.5 winter activities snowmobiling

20000 1.0 religious activities sitting in church, in service, attending a ceremony, sitting quietly20001 2.5 religious activities sitting, playing an instrument at church20005 1.5 religious activities sitting in church, talking or singing, attending a ceremony, sitting, active participation20010 1.3 religious activities sitting, reading religious materials at home20015 1.2 religious activities standing in church (quietly), attending a ceremony, standing quietly20020 2.0 religious activities standing, singing in church, attending a ceremony, standing, active participation20025 1.0 religious activities kneeling in church/at home (praying)20030 1.8 religious activities standing, talking in church20035 2.0 religious activities walking in church20036 2.0 religious activities walking, less than 2.0 mph - very slow20037 3.3 religious activities walking, 3.0 mph, moderate speed, not carrying anything20038 3.8 religious activities walking, 3.5 mph, brisk speed, not carrying anything20039 2.0 religious activities walk/stand combination for religious purposes, usher20040 5.0 religious activities praise with dance or run, spiritual dancing in church20045 2.5 religious activities serving food at church20046 2.0 religious activities preparing food at church20047 2.3 religious activities washing dishes/cleaning kitchen at church20050 1.5 religious activities eating at church20055 2.0 religious activities eating/talking at church or standing eating, American Indian Feast days20060 3.0 religious activities cleaning church20061 5.0 religious activities general yard work at church20065 2.5 religious activities standing - moderate (lifting 50 lbs., assembling at fast rate)20095 4.0 religious activities standing - moderate/heavy work20100 1.5 religious activities typing, electric, manual, or computer21000 1.5 volunteer activities sitting - meeting, general, and/or with talking involved21005 1.5 volunteer activities sitting - light office work, in general21010 2.5 volunteer activities sitting - moderate work21015 2.3 volunteer activities standing - light work (filing, talking, assembling)21016 2.5 volunteer activities sitting, child care, only active periods21017 3.0 volunteer activities standing, child care, only active periods21018 4.0 volunteer activities walk/run play with children, moderate, only active periods21019 5.0 volunteer activities walk/run play with children, vigorous, only active periods21020 3.0 volunteer activities standing - light/moderate work (pack boxes, assemble/repair, set up chairs/furniture)21025 3.5 volunteer activities standing - moderate (lifting 50 lbs., assembling at fast rate)21030 4.0 volunteer activities standing - moderate/heavy work21035 1.5 volunteer activities typing, electric, manual, or computer

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21040 2.0 volunteer activities walking, less than 2.0 mph, very slow21045 3.3 volunteer activities walking, 3.0 mph, moderate speed, not carrying anything21050 3.8 volunteer activities walking, 3.5 mph, brisk speed, not carrying anything21055 3.0 volunteer activities walking, 2.5 mph slowly and carrying objects less than 25 pounds21060 4.0 volunteer activities walking, 3.0 mph moderately and carrying objects less than 25 pounds, pushing something21065 4.5 volunteer activities walking, 3.5 mph, briskly and carrying objects less than 25 pounds21070 3.0 volunteer activities walk/stand combination, for volunteer purposes

Footnote: METS for certain golfing activities were revised downward from 1993 estimates based on measurement of the activity using indirect calorimetry.

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Medbridge Cancer Rehab Handout