ROL METS.pptx

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

METABOLIC EQUIVALENT
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CONTENTS
 Introduction
 Definition
 Clinical importance
 Intensity Levels
 Classification of activities
 Conversion of MET
 METs and Functional capacity
 Functional classification based on METs
 MET in Exercise prescription
 Estimating activity MET from Heart Rate
 MET in Cardiac rehabilitation
 Limitations
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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.
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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.
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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.
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Intensity Levels
• Depending on the metabolic equivalent of a task, reference thresholds of absolute intensities
are classified into-
1) Light- < 3.0 METs
2) Moderate- 3.0-5.9 METs
3) Vigorous- ≥ 6.0 METs
MET and VO2 MaxCapture 1.PNG
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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,
1. Light- up to 4 MET’s
2. Heavy – up to 6-8 MET’s
3. Unduly heavy work- > 10 MET’s
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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
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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 MaxHorizontal 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.
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• The exercise intensity equivalents in terms of METS and milliliters of oxygen for various
testing protocols.
• MET and VO2 MaxExercise testing protocols.PNG
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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.
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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-
𝑇𝑟𝑎𝑖𝑛𝑖𝑛𝑔 𝐼𝑛𝑡𝑒𝑛𝑠𝑖𝑡𝑦 =
60+𝑀𝑎𝑥 𝑀𝐸𝑇
100
∗ 𝑀𝑎𝑥 𝑀𝐸𝑇
• The exercise prescription can be accompanied by a recommended or target HR
corresponding to the determined MET that is determined during progressive exercise testing.
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• 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.
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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-
𝑀𝐸𝑇 = 6 ∗ 𝐻𝑅 𝐼𝑛𝑑𝑒𝑥 − 5
Where, HR index is the ratio of the exercising heart rate to the exercising heart rate.
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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
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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
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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
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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
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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
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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
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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.
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• 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 Resting
Metabolic Rate.
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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.

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Title Method Conclusion
Sex-Based Differences in
(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.

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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

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.
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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.
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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

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.
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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.

References
1. 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.
2. American College of Sports Medicine. ACSM's guidelines for exercise testing and prescription,10th edition,
Chapter 1: Benefits and risks associated with physical activity.
3. 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.
4. Susan B. O’Sullivan, Thomas J. Schmitz, George D. Fulk. Physical Rehabilitation. 6th edition. 2014. Chapter
13: Heart disease: p523-576
5. 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.
6. 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.
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7. 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.
8. David Donaire- Gonzalez, Elena Gimeno-Santos, Eva Balcells et al. Physical activity in COPD patients:
patterns and bouts. 2013
9. 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.
10. 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.
11. 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.
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Thank You !
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