ROL METS.pptx

METs in exercise prescription

1. Review of Literature PRESENTED BY- N Praneetha MPT FIRST YEAR CVTS PHYSIOTHERAPY 13-05-2022 Metabolic Equivalents 1

2. METABOLIC EQUIVALENT 13-05-2022 Metabolic Equivalents 2

3. CONTENTS Introduction Definition Clinical importance Intensity Levels Classification of activities Conversion of MET METs and Functional capacity Functional c lassification based on METs MET in Exercise prescription Estimating activity MET from Heart Rate MET in Cardiac rehabilitation Limitations 13-05-2022 Metabolic Equivalents 3

4. Introduction Resting metabolic rate is defined as the energy expended by the body in a resting condition. Typically 20-30% of the total body energy needs is accounted for by physical activity, which may vary depending on the type of activity. A physical activity is defined as any body movement resulting in energy expenditure higher than the resting. 13-05-2022 Metabolic Equivalents 4

5. Definition MET is defined as the amount of oxygen consumed when in a resting condition. It is calculated per mass of 1kg body weight and time. An average of 3.5ml O2 /kg/min has been determined as the oxygen consumption at the BMR. 13-05-2022 Metabolic Equivalents 5

6. Clinical Importance MET’s are simple, practical and an easily understood procedure to quantify the energy cost of activities. Often used to describe the functional capacity or aerobic power of an individual. Indicate intensity level and help to be more specific when prescribing exercise by providing the patient with subjective yet specific as to the desired intensity of participation. 13-05-2022 Metabolic Equivalents 6

7. Intensity Levels Depending on the metabolic equivalent of a task, reference thresholds of absolute intensities are classified into- Light- < 3.0 METs Moderate- 3.0-5.9 METs Vigorous- ≥ 6.0 METs MET and VO2 Max\Capture 1.PNG 13-05-2022 Metabolic Equivalents 7

8. Classification of activities McArdle et. al, gave a classification based on the difficulty of sustained physical activity in terms of intensity. In addition to MET’s the intensity of an activity is expressed in VO2 and Watts. For men, Light- up to 4 MET’s Heavy – up to 6-8 MET’s Unduly heavy work- > 10 MET’s 13-05-2022 Metabolic Equivalents 8

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10. Conversion of METs METs can also be expressed as Kcal/Min. 1.0 Kcal/Kg/h = 1 MET Formula- METs = (1KCal/Kg/H) Body mass in Kg/60 13-05-2022 Metabolic Equivalents 10

11. METs and Functional capacity The intensity of exercises is directly dependent on the speed of the movement, resistance or the mass lifted. MET and VO2 Max\Horizontal and uphill running.PNG In exercise testing, the ergometer presents the patient with a defined quantity of work. The exercise intensity is gradually increased from stage to stage in either a continuous mode or at intervals. At each stage observations of the patients vitals and any signs or symptoms are noted. In healthy individuals usually 1-2 METs or more is increased per stage, while in case of individuals with disease, as small as ½ or 1 MET is increased . 13-05-2022 Metabolic Equivalents 11

12. The exercise intensity equivalents in terms of METS and milliliters of oxygen for various testing protocols. MET and VO2 Max\Exercise testing protocols.PNG 13-05-2022 Metabolic Equivalents 12

13. Functional Classification Based on METs Class Description Class 1 Patient can perform to completion an activity requiring ≥7 metabolic equivalents Class 2 Patient can perform to completion any activity requiring ≥5 metabolic equivalents but cannot or does not perform to completion activities requiring ≥7 metabolic equivalents Class 3 Patient can perform to completion any activity requiring ≥2 metabolic equivalents but cannot or does not perform to completion any activities requiring ≥5 metabolic equivalents Class 4 Patient cannot or does not perform to completion activities requiring ≥2 metabolic equivalents Source: Goldman et al., 1981, Circulation 64, 1227, American Heart Association, Inc. 13-05-2022 Metabolic Equivalents 13

14. METs in Exercise Prescription For aerobic training, the intensity/dosage of exercise can vary from 40% of maximum MET for poorly conditioned or symptomatic individuals to about 80% of maximum MET for well-conditioned individuals or athletes. The Sliding scale for prescribing a training intensity- The exercise prescription can be accompanied by a recommended or target HR corresponding to the determined MET that is determined during progressive exercise testing.   13-05-2022 Metabolic Equivalents 14

15. Patients with functional capacity less than 3 METs are usually encouraged to exercise several times a day with sessions lasting for only 5 minutes. Individuals with functional capacity of 3-5 METs may exercise once or twice daily. Individuals with functional capacity from 5-8 METs may exercise on alternate days, 3 Times a week. 13-05-2022 Metabolic Equivalents 15

16. Estimating Activity METs from Heart Rate Naughton suggested that in sedentary subjects, each 10 bpm increase in heart rate is approximately equal to 1 MET increase in the energy expenditure. It can be estimated based on the resting and exercising heart rate as follows- Where, HR index is the ratio of the exercising heart rate to the exercising heart rate.   13-05-2022 Metabolic Equivalents 16

17. MET in Cardiac rehabilitation CCU- Essentially Bed rest Level 1 – 1-1.5 METs Evaluation and patient education Arms supported for meals and activities of daily living (ADL) Bed exercises and dangle with feet supported (if CK levels have peaked and patient has no complications) Introduction to inpatient cardiac rehab and role of physical therapy Monitored progression of activity Education: Home exercise/activity guidelines/outpatient cardiac rehab 13-05-2022 Metabolic Equivalents 17

18. Sitting- limited room ambulation Level 2 - 1.5–2 METs Sitting 15–30 min, 2–4 times/day Leg exercises Commode privileges Reclining upright chair Limited ADL Electric razor Limited supervised room ambulation for small uncomplicated MI Education: Identification of CAD risk factors; Concept of “healing interval” and need to pace activities 13-05-2022 Metabolic Equivalents 18

19. Room – limited hall ambulation Level 3 - 2–2.5 METs Room or hall ambulation up to 5 min as tolerated 3–4 times/day Standing leg exercises optional* Sit on side of bed or in bathroom to wash (per discretion nurse/physical therapist [PT]) Manual shave Bathroom privileges Independent or assisted ambulation in room or hall as advised by PT Education: Size of infarct and how it relates to the need for gradual resumption of activities; Impact of exercise on reducing the patient’s risk factors; Teach use of Borg’s Scale for Rating of Perceived Exertion and appropriate parameters with activity 13-05-2022 Metabolic Equivalents 19

20. Progressive hall ambulation Level 4 - 2.5–3 METs Hall ambulation 5–7 min as tolerated 3–4 times/day Standing trunk exercises optional* Independent or assisted ambulation in hall as advised by PT Education: Teach pulse taking and appropriate parameters with activity; Reinforce benefits of outpatient cardiac rehabilitation 13-05-2022 Metabolic Equivalents 20

21. Progressive hall ambulation Level 5 - 3–4 METs Hall ambulation 8–10 min as tolerated Arm exercises optional* Standing shower Independent hall ambulation as advised by PT Education: Written home exercise/activity guidelines reviewed; Patient given written information on outpatient cardiac rehab 13-05-2022 Metabolic Equivalents 21

22. Stair climbing Level 6 - 4–5 METs Progressive hall ambulation as tolerated Full flight of stairs (or as required at home) up and down one step at a time Education: Answer patient’s questions; Check for understanding of activity guidelines 13-05-2022 Metabolic Equivalents 22

23. Limitation of MET First is the assumption that 1 MET = 3.5 mL/Kg/min. Another limitation is that MET values represent the average energy expenditure of specific physical activity, which can vary considerably among individuals, depending on age, body habitus, fitness, musculoskeletal integrity and whether the activity is performed in a competitive environment. Finally, the oxygen costs or MET requirements listed in the compendium of physical activities were derived from continuous steady-state work, whereas activates of daily living are often performed intermittently, rather than continuously. 13-05-2022 Metabolic Equivalents 23

24. Irrespective of the limitations, the MET concept is a simple, practical and easily understood procedure for expressing the energy costs of physical activities as a multiple of the R esting Metabolic Rate. 13-05-2022 Metabolic Equivalents 24

25. 13-05-2022 Metabolic Equivalents 25 Title Methods Conclusion Metabolic equivalent of task (METs) threshold as an indicator of physical activity intensity Marcio de Almedia Mendes, Inacio da Silva, Virgilio Ramires , Felipe Reichert, Rafaela Martins, Rodrigo Ferreira, Elaine Tomasi 2018 A total of 112 participants were recruited using convenience sampling method. All participants carried out an incremental maximal cycle ergometer test and were asked to perform 9 free-living activities. The oxygen uptake was analysed using the VO2000 gas analyser through all the tests. Receiver Operator Characteristic (ROC) was used to analyse the intensity thresholds, having relative intensity categories as criterion measure. A total of 103 participants attended 2 visits. Among 54 men and 39 women, the mean age was 36.1±11.1 and 33.9 ±10.6 years, respectively. The use of the proposed thresholds in this study aims to improve the quality of physical activity measures, minimize errors in evaluation of physical activity intensities. Moreover, these parameters presented relatively high accuracy, including when specifically applied to groups of sex, age, nutritional status and physical fitness. Therefore, the overall thresholds, as well as those related specifically to men and women, might be an important alternative to minimize physical activity intensity misclassification.

26. 13-05-2022 Metabolic Equivalents 26 Title Method Conclusion Sex-Based Differences in Metabolic Equivalents (METs) After Cardiac Rehabilitation: A Systematic Review Neel A Duggal, David A Scalzitti , Samuel Watkins, Oliver Hecht, Stephanie J Johnson, Joshua G Woolstenhulme 2021 Four databases were systematically searched through August 2020. Search terms related to cardiac rehabilitation, treatment outcomes, and gender differences were used. Papers were considered relevant if they compared outcomes in cardiac rehabilitation between men and women. Information from the studies was extracted by two independent authors. Risk of bias was assessed using the Downs and Black instrument. Both men and women improve functional capacity from CR. The majority of studies reported that there were more men participating in CR programs than women. Given the underrepresentation of women in these studies, it is difficult to speculate if any differences in MET levels reported in these studies are a true representation of sex differences with respect to peak MET levels. Nonetheless, the statistically significant improvement in METs in both sexes suggests that women experience clinical benefit from CR and that efforts should be made for greater referral of women to CR programs.

27. 13-05-2022 Metabolic Equivalents 27 Title Method Conclusion Exercise training workloads in cardiac rehabilitation are associated with clinical outcomes in patients with heart failure Steven J. Keteyian , Dennis J. Kerrigan, Barry Lewis, Jonathan K. Ehrman , Clinton A. Brawner 2018 Patients with Heart Failure (HF) who participated in an early outpatient Cardiac Rehabilitation (CR) program were used in this retrospective analysis. Exercise workloads upon entry and completion of CR were converted to METs. The primary outcome was all-cause mortality and the secondary outcome was HF hospitalization. Cox regression analysis was used to assess the adjusted risk between MET levels in CR and clinical outcomes In a diverse cohort of patients with chronic HF our data suggests that an easily accessible measure of exercise capacity (i.e., METs) that is collected during CR is independently associated with the adjusted risk for both all-cause mortality and HF-specific hospitalization

28. Title Method Conclusion Effect of Early ≤ 3 Mets (Metabolic Equivalent of Tasks) of Physical Activity on Patient's Outcome after Cardiac Surgery Tariq MI, Khan AA, Khalid Z, Farheen H, Siddiqi FA, Amjad I 2017 A randomized controlled trial was conducted on 174 CABG and valvular heart disease patients undergoing cardiac surgical procedures. After selection of sample via non-probability purposive sampling, they were randomly allocated into interventional group (n=87) and control group (n=87). Treatment protocol for experimental group was ≤3 Mets of physical activity, i.e. chest physiotherapy, sitting over edge of bed, standing and sitting on chair at bedside, on zero postoperative day but the control group was treated with conventional treatment on first postoperative day. Pre- and post-treatment assessment was done in control and interventional groups on both zero and first postoperative days. Data was analyzed on SPSS version 21. Early physical activity (≤3 METS) post-cardiac surgeries prevent respiratory complications through improvement in dyspnea, respiratory rate, and oxygen saturation. 13-05-2022 Metabolic Equivalents 28

29. Title Method Conclusion Appropriateness of the metabolic equivalent (MET) as an estimate of exercise intensity for post-myocardial infarction patients Woolf-May K, Meadows S 2016 15 male phase-IV post-MIs (64.4±6.5 years) and 16 apparently healthy males (63.0±6.4 years) participated. Participants performed a graded cycle ergometer test (CET) of 50, 75 and 100 W, followed by 10 min active recovery (at 50 W) and 22 min seated recovery. Participants’ heart rate (HR, bpm), expired air parameters and ratings of perceived exertion (exercise only) were measured. Since METs take no consideration of any anaerobic component, they failed to reflect the significantly greater anaerobic contribution during exercise per MET for phase-IV post-MI patients. Given the anaerobic component will be greater for those with more severe forms of cardiac disease, current METs should be used with caution when determining exercise intensity in any patient with cardiac disease. 13-05-2022 Metabolic Equivalents 29

30. 13-05-2022 Metabolic Equivalents 30 Title Method Conclusion Sedentary Behavior Is an Independent Predictor of Mortality in Subjects With COPD Karina C Furlanetto , Leila Dona´ria , Lorena P Schneider, Jose´ R Lopes, Marcos Ribeiro, Karen BP Fernandes , Nidia A Hernandes , Fabio Pitta In this retrospective cohort study, sedentary behavior was assessed with 2 activity monitors ( DynaPort and Sensewear armband) in 101 subjects with COPD from 2006 to 2011. Vital status was then ascertained in 2015. The following 6 variables of sedentary behavior were analyzed: average of metabolic equivalent of task (MET)/d (reflecting intensity); time spent/d lying, sitting, and lying sitting (reflecting duration of sedentary postures); and time spent/d in activities requiring<1.5 MET and <2 MET (reflecting intensity and duration of sedentary time). Cutoff points for sedentarism and their respective prognostic values were investigated for each variable Sedentary behavior was an independent predictor of mortality in subjects with COPD, even adjusting for moderate-to-vigorous physical activity and a number of other variables. Mortality was higher in subjects with COPD who spend >8.5 h/d in activities requiring <1.5 MET. These finding may open new room for future studies aiming at decreasing sedentary time as a promising strategy to reduce mortality risk in subjects with COPD

31. Title Method Conclusion Physical activity in COPD patients: patterns and bouts David Donaire - Gonzalez, Elena Gimeno -Santos, Eva Balcells et al. 2013 177 patients(94% male, mean±SD age 71±8 years and forced expiratory volume in 1 s 52±16% predicted) wore the SenseWear Pro2 Armband accelerometer for eight consecutive days physical activity bouts were defined as periods of ≥ 10min above 1.5 metabolic equivalent tasks and classified according to their median intensity. Patients engaged in activity a median of 153 min/day and 57% of that time was spent in bouts. Median frequencies of bout per day were four to three for all and moderate-to-vigorous intensities, respectively. With increasing COPD severity, time in physical activity, proportion of time in bouts and frequency of bouts decreased. 61% of patients fulfilled the recommended physical activity guidelines. COPD patients of all spirometric severity stages engage in physical bouts of moderate-to-vigorous intensities. Patients with severe and very severe COPD perform their daily activities in fewer and shorter bouts than those in mild and moderate stages. 13-05-2022 Metabolic Equivalents 31

32. 13-05-2022 Metabolic Equivalents 32 Title Method Conclusion Basal energy expenditure, resting energy expenditure and one metabolic equivalent (1 MET) values for young Chinese adults with different body weights Wu J, Mao D, Zhang Y, Chen X, Hong P, Piao J, Zhuo Q, Yang X 2019 A total of 251 young Chinese adults were divided into three groups: the normal weight group, the overweight group and the obese group. Their BEE, REE and 1 MET values were measured by Cortex Metamax 3B (MM3B). Multiple linear regressions and correlation analysis were used to examine factors that influence EE in Chinese population. BEE and REE were significantly different for different body weights while these differences disappeared after adjustment for FFM, and people with different body weights may have different 1 MET values. Further studies should be conducted to obtain more accurate daily energy requirement and 1MET value for specific Chinese populations.

33. References Jetté M, Sidney K, Blümchen G. Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity. Clinical cardiology. 1990 Aug;13(8):555-65 . American College of Sports Medicine. ACSM's guidelines for exercise testing and prescription,10 th edition, Chapter 1: Benefits and risks associated with physical activity. Mathias Steinach , Hanns -Christian Gunga , Chapter 3 - Exercise Physiology, Editor(s ): Hanns -Christian Gunga , Human Physiology in Extreme Environments, Academic Press, 2015, Pages 77-116. https://doi.org/10.1016/B978-0-12-386947-0.00003-4 . Susan B. O’Sullivan, Thomas J. Schmitz, George D. Fulk . Physical Rehabilitation. 6 th edition. 2014. Chapter 13: Heart disease: p523-576 Franklin BA, Brinks J, Berra K, Lavie CJ, Gordon NF, Sperling LS. Using metabolic equivalents in clinical practice. The American journal of cardiology. 2018 Feb 1;121(3):382-7 . Victor L. Katch , Willian D. McArdel , Frank I. Katch . Essentials of Exercise Physiology. 4th edition, Chap 8: Energy Expenditure During Rest and Physical Activity, Pg 244. 13-05-2022 Metabolic Equivalents 33

34. Tariq MI, Khan AA, Khalid Z, Farheen H, Siddiqi FA, Amjad I. Effect of Early</= 3 Mets (Metabolic Equivalent of Tasks) of Physical Activity on Patient’s Outcome after Cardiac Surgery. J Coll Physicians Surg Pak. 2017 Aug 1;27(8):490-4. David Donaire - Gonzalez, Elena Gimeno -Santos, Eva Balcells et al. Physical activity in COPD patients: patterns and bouts. 2013 Keteyian SJ, Kerrigan DJ, Lewis B, Ehrman JK, Brawner CA. Exercise training workloads in cardiac rehabilitation are associated with clinical outcomes in patients with heart failure. American heart journal. 2018 Oct 1;204:76-82 . Duggal NA, Scalzitti DA, Watkins S, Hecht O, Johnson SJ. Sex-Based Differences in Metabolic Equivalents (METs) After Cardiac Rehabilitation: A Systematic Review. J Card Pulm Rehabil . 2021;5(143):2. Mendes MD, Da Silva I, Ramires V, Reichert F, Martins R, Ferreira R, Tomasi E. Metabolic equivalent of task (METs) thresholds as an indicator of physical activity intensity. PLoS One. 2018 Jul 19;13(7):e0200701. 13-05-2022 Metabolic Equivalents 34

35. Thank You ! 13-05-2022 Metabolic Equivalents 35