1. CHF and COPD stream tools and outcome measures

2. Outcome Measures and tools used in CHF and COPD
Hospital Anxiety and Depression Scale (HADS)
6-Minute Walk Test
Modified BORG – Rate of Perceived Exertion (RPE)
Modified Reintegration to Normal Living Index (mRNLI)
MET levels
New York Heart Association (NYHA) classification
Montreal Cognition Assessment (MoCA)
Hospital Anxiety and Depression Scale (HADS)
6-Minute Walk Test
Modified BORG – Rate of Perceived Exertion (RPE)
Modified Reintegration to Normal Living Index (mRNLI)

3. Hospital Anxiety and Depression Scale (HADS)

4. What is HADS
The Hospital Anxiety and Depression Scale (HADS) is a self assessment used as a screening tool for identifying anxiety and depression.  
The HADS is composed of fourteen items or statements
Seven of the items relate to anxiety and seven relate to depression.

5. How do I perform the HADS?
Instruct the patient to read each statement with the four responses.
The patient should choose one response from the four given which currently describes their feelings over the past week as it relates to the statement.
Dissuade the patient from thinking too long about their answers, they should go with their first response.

6. Scoring the HADS
The questions relating to anxiety are marked "A", and to depression "D". 
Each response has a score ranging from 0-3
The responses are summed to provide a separate score for anxiety and depression.

7. Interpretation of the HADS
A higher score (usually >8) indicates a likelihood of depression or anxiety.

8. Pros of using HADS as an outcome measure
The questionnaire is completed by the patient and only takes 2-5 minutes for the clinician to interpret
Although originally designed to be used with hospital populations it has been found to perform well with non-hospital groups – therefore a good tool to compare across the continuum of care.
No training required to administer tool
The HADS is a validated tool.

9. Cons of HADS as an outcome measure

10. References http://www.rehabmeasures.org/default.aspx

11. References
The tool can be obtained through the National Foundation for Education Research or
They will supply the scale, the chart for recording the scores and a manual with instructions and interpretations.

12. 6 Minute Walk Test

13. What is the 6 minute walk test?
The 6 Minute Walk Test is a test of aerobic capacity/endurance.
It assesses the distance walked over a 6 minute period.
It is a self-paced test and assesses the patient’s sub maximal level of functional capacity. Most ADL are performed at sub maximal levels of exertion; the 6 minute walk test can therefore be considered a fair reflection on a patient’s functional exercise level for daily physical activities.

14. How do I perform the 6 minute walk test?
Prepare the area by applying markers for the endpoints and at 3m intervals
Place traffic cones at the center of the turn points
Materials required
Stopwatch/timer
Worksheet for counting laps
Oximeter
Borg breathlessness and exertion scales
An easily movable chair

15. How do I perform the 6 minute walk test?
Participants should use their usual walking aids during the test and be dressed in comfortable clothing and walking shoes
Prior to the test, the participant should sit in a chair located near the starting point for at least 10 minutes
Assess pulse, SpO2, and BP (if not taken within the last 4 hours). Do not proceed with the test if:
Systolic BP is >200 mmHg or <60 mmHg
Diastolic BP is >100 mmHg
Resting HR is >120 or <50 bpm
Resting SpO2 is <88% (except for pts on long term oxygen therapy)

16. How do I perform the 6 minute walk test?
Explain the use of the modified BORG for assessing breathlessness.
Explain the use of the modified BORG rating for perceived exertion

17. How do I perform the 6 minute walk test?
Read the following instructions to the patient:
“The object of the test is to walk as far as possible for 6 minutes. You will walk back and forth in this hallway. Six minutes is a long time to walk, so you will be exerting yourself. You will probably get out of breath or become exhausted. You are permitted to slow down, to stop, and to rest as necessary. You may lean against the wall while resting, 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 continue back the other way without hesitation. Now I’m going to show you.”
Demonstrate by walking one lap yourself.
To begin the test say to the patient:
“Are you ready to do that? I am going to use this counter to keep track of the number of laps you complete. I will click it each time you turn around at this starting line. Remember that the object is to walk AS FAR AS POSSIBLE for 6 minutes, but don’t run or jog. Start now, or whenever you are ready.”

18. How do I perform the 6 minute walk test?
Standardized encouragement read in a steady voice
After the 1st minute: “You are doing well. You have 5 minutes to go.”
When the time shows 4 minutes remaining: “Keep up the good work. You have 4 minutes to go”
When the time shows 3 minutes remaining: “You are doing well. You are halfway done”
When the time shows 2 minutes remaining: “Keep up the good work. You have 2 minutes left”
When the time shows 1 minute remaining: “You are doing well. You only have 1 minute to go”
With 15 seconds to go: “In a moment I’m going to tell you to stop. When I do, just stop right where you are and I will come to you.”
At 6 minutes: “Stop”
Do not use any other words of encouragement to influence the patient’s walking speed

19. How do I score the 6 minute walk test?
Immediately following the 6 MW record the following;
SpO2
Pulse
Breathlessness (mBORG scale for breathlessness)
Exertion – patient’s response from the mBORG RPE
Record the number of completed laps
Record the distance walked, with the final partial lap in meters
Record if the patient stopped before 6 minutes
Record the reason for stopping

20. How do I interpret the 6 minute walk test?
The higher the distance the patient can achieve the more fit they are, and consequently the more functional or independent may be!
As an outcome draw comparisons for the distance walk, the RPE for breathlessness and the RPE for exertion.

21. Pros for using the 6 Minute Walk Test
It takes approximately 6 to 30 minutes to administer
It is a simple test that requires a 100 ft long hallway, no exercise equipment or advanced training for the technicians
It is self-paced and assesses the sub maximal level of functional capacity. Patient’s choose their own intensity of exercise and are allowed to stop and rest during the test.

22. Cons of 6 Minute Walk Test
Space limitations to set up the test walking track

23. References http://en.wikipedia.org/wiki/Metabolic_equivalent
Accessed May 14, 2013
Clin. Cardiol. 13, (1990). Metabolic Equivalents (METS) in Exercise Testing, Exercise Prescription, and Evaluation of Functional Capacity. M. JETTE.

24. Modified BORG (mBORG)

25. What is the Modified BORG scale (mBORG)?
The Borg Rating of Perceived Exertion (RPE) Scale and Borg Rating of Breathlessness are used as indicators to monitor and guide exercise or activity intensity.
The original scale introduced by Gunnar Borg rated exertion on a scale of More commonly used today is the revised modified scale from 0-10.

26. How do I perform the mBORG?
It is easy to use, however clinicians must take time to educate the patient and ensure appropriate understanding prior to use.

27. How do I use the mBORG for exertion? (mBORG RPE)
An example of instructions to the patient:
“While you are exercising try to estimate how hard you are exerting yourself using this scale. It starts at number 0 where it feels easy or like nothing at all and progresses through to number 10 where you feel like you are working at your maximum. Think of the total amount of exertion and physical fatigue you are feeling. How much exertion are you feeling right now?”
Modified BORG Rating Perceived Exertion Scale
Nothing at all
0.5
Very, very weak (just noticeable) 1
Very weak 2
Weak (light) 3
Moderate 4
Somewhat strong 5
Strong (heavy) 6 - 7
Very Strong 8 9 10
Maximal

28. How do I use the mBORG for Breathlessness?
An example of instructions to the patient:
“This is a scale that asks you to rate the difficulty of your breathing. It starts at number 0 where you breathing is causing you no difficulty at all and progresses through to number 10 where your breathing difficulty is maximal. How much difficulty is your breathing causing you right now?”
Modified Borg Rating Scale for Perceived Breathlessness
Nothing at all
0.5
Very, very slight shortness of breath 1
Very mild shortness of breath 2
Mild shortness of breath 3
Moderate shortness of breath or breathing difficulty 4
Somewhat severe 5
Strong or hard breathing 6 - 7
Severe shortness of breath or very hard breathing 8 9
Extremely severe 10
Shortness of breath so severe you need to stop

29. Scoring and Interpretation of the mBORG
The score is the rate the patient assigns for a given activity in relation to the activity outcomes.
When interpreting the scores, the practitioner takes into consideration the activity. The score is the patient’s subjective response to that activity. IE: a patient may have the same mRPE score pre and post treatment, yet achieve a greater distance on the 6 minute walk test with less breathlessness and less exertion.

30. Pros of using the mBORG
Using the BORG scale does not require any special skills or equipment
It is motivational demonstrating improvement in ability with certain activities over time.
The RPE can be used as a guide for exercise intensity. Exercising at moderate levels will help increase endurance and improve lung function. Knowing what “zone” they should exercise in, will help the patient recognize when they are exerting themselves to a level where they may be putting themselves at risk.

31. Cons of using the mBORG
It is a subjective measure rating the patient’s level of exertion or breathlessness

32. References www.acsm.org/docs/current-comments/perceivedexertion.pdf

33. Modified Reintegration to Normal Living Index (mRNLI)

34. What is the modified Reintegration to Normal Living Index (mRNLI)?
The mRNLI is a quality of life index.
The Reintegration to Normal Living Index (RNLI) was developed to assess, quantitatively, the degree to which individuals who have experienced traumatic or incapacitating illness achieve reintegration into normal social activities.
The modified version introduced changes to phrasing, the rating scale and subscales. Research showed the mRNLI improved in validity over the original RNLI for a mixed rehabilitation, community-dwelling population.

35. How do I use the mRNLI? Instructions to the patient:
Does not describe me or my situation
Sometimes describes me or my situation
Mostly describes me or my situation
Fully describes me or my situation
1. I move around my house as I need to
2. I move around my community as I need to.
3. I am able to make longer trips as I need to.
4. I am comfortable with how my self-care needs are met (dressing, feeding toileting bathing).
5. I spend most of my days occupied in work activity that is necessary or important to me (such as paid or voluntary work, housework, or studying etc.).
6. I am able to participate in recreational activities as I want to (hobbies, crafts, sports, reading, television, games, computers etc.).
7. I socialize with friends, family and/or business acquaintances as I want to or is necessary.
8. I have a role in my family which meets my needs and those of my family members. (Family means people with whom you live and/or relatives with whom you don’t live but see on a regular basis.)
9. In general, I am comfortable with my personal relationships.
10. In general, I am comfortable with myself when I am in the company of others.
11. I feel that I can deal with life events as they happen.
Instructions to the patient:
“For each of the following statements, please indicate how well each statement describes you and/or your situation by placing a mark in a box. Please mark only one box per question.”

36. How do I score the mRNLI?
There are three different scoring algorithms for this measure.  There is a
visual analog scale ranging from 0 to 10 (used in the original RNLI, not for the mRNLI)
a three-point scoring system; and
a four-point scoring system.
Regardless of the scoring system used, higher scores represent higher levels of reintegration or participation.

37. Example score using 0-3 scale Example score using 1-4 scale
How do I score the mRNLI?
Scoring examples
Total score interpretation
The total score = SUM(points for all 11 items)
The adjusted score = (total score) / 110 * 100
minimum adjusted score: 0
maximum adjusted score: 100
Statement
Does not describe me or my situation
Sometimes describes me or my situation
Mostly describes me or my situation
Fully describes me or my situation
Example score using 0-3 scale 1 2 3
Example score using 1-4 scale 4

38. mRNLI interpretation
The higher the score the better the patient’s perceived reintegration.

39. Pros of the mRNLI Self administered Ease of scoring and interpretation
Can be used in conjunction with goal setting, encouraging the patient to consider how their current state impacts their life, and what goals they would like to work towards to achieve improved quality of life

40. Cons of the mRNLI
Patients sometimes have difficulty relating to the statements

41. References

42. Understanding MET levels

43. What is a MET level
METs are a way of expressing rate of oxygen utilization. One MET is the rate of oxygen utilization at rest (when your body is sitting quietly) and is equivalent to 3.5 ml oxygen/kg body weight/min. An activity that uses oxygen at twice the resting rate is equal to a 2 MET level.
MET levels are based on the intensity of the work, not the length of time that someone performs the work
METs describe the functional capacity or exercise tolerance of an individual.

44. Why you may want to know about METs?
Certain activities may be too intense for some people. All activities have an energy requirement or a “metabolic cost”. This is expressed as a metabolic equivalent or METs.
Sometimes physicians refer to METs during patient assessments. It can be seen as an indicator of how “functional” a patient is.
Knowing someone’s MET level or range may provide you with some insight as to their current level of activity or level of independence.

45. Examples of MET level requirements
Physical activity
MET
Light intensity activities
< 3
sleeping
0.9
watching television
1.0
walking, 1.7 mph (2.7 km/h), level ground, strolling, very slow
2.3
walking, 2.5 mph (4 km/h)
2.9
Moderate intensity activities
3 to 6
bicycling, stationary, 50 watts, very light effort
3.0
walking 3.0 mph (4.8 km/h)
3.3
calisthenics, home exercise, light or moderate effort, general
3.5
walking 3.4 mph (5.5 km/h)
3.6
bicycling, <10 mph (16 km/h), leisure, to work or for pleasure
4.0
bicycling, stationary, 100 watts, light effort
5.5
Vigorous intensity activities
> 6
jogging, general
7.0
calisthenics (e.g. pushups, sit-ups, pullups,jumping jacks), heavy, vigorous effort
8.0
running jogging, in place
rope jumping
10.0
Activities of Daily Living
MET
Light activities
Bathing in tub/eating
1-2
writing, desk work, typing
1.8
Light housework 2
Warm shower - sitting
2-3
Fixing meals
2.5
Moderate activities
Washing floors
3.3
Warm shower standing
3-4
Grocery shopping/vaccuming
Mowing lawn - riding
Gardening – weeding and raking
3.5
Gardening - digging
4.4
Snow shoveling
5.1
Vigorous intensity activities
Mowing lawn - walking
7.0
Chopping wood
8.0
Carpentry work
5-7

46. How do I use MET levels in practice?
METS can be used as an intensity guide for patients when they exercise
As a general rule, 4–6 METs is considered moderate intensity. When exercising patients should strive for at least 30–45 minutes of moderately intense activity on most days of the week.
Knowing the range of METs at which they should be exercising makes it easier to choose appropriate activities.

47. What do MET levels mean as an outcome?
The higher the MET level the patient can achieve the more fit they are, and consequently the more functional or independent they are!
Physical conditioning lowers a persons RPE for a given MET level, (more about RPE to come!)

48. Pros of using MET levels as an outcome measure
When used in conjunction with RPE it provides feedback to patients re progress
Accuracy when obtained via exercise stress treadmill test

49. Cons of MET levels as an outcome measure
Requires patients to participate in an exercise stress test
Defining an exercise prescription through use of MET levels requires specialized training

50. References http://en.wikipedia.org/wiki/Metabolic_equivalent
Accessed May 14, 2013
Clin. Cardiol. 13, (1990). Metabolic Equivalents (METS) in Exercise Testing, Exercise Prescription, and Evaluation of Functional Capacity. M. JETTE.

51. Understanding NYHA classification

52. NYHA Functional Classification
A simple way of classifying the extent of heart failure.
There are 4 categories, based on how much a patient is limited during physical activity.
NYHA Class
Symptoms I
Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc. II
Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
III
Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m). Comfortable only at rest. IV
Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

53. Why you may want to know about NYHA
Doctors usually classify patients' heart failure according to the severity of their symptoms.
It may help you define your plan of care and determine your exercise prescription

54. References

55. Montreal Cognition Assessment (MoCA)

56. What is the MoCA?
The Montreal cognitive Assessment (MoCA) was designed as a rapid screening tool for mild cognitive dysfunction.
It assesses:
Attention and concentration
Executive functions
Memory
Language
Visuoconstructional skills
Conceptual thinking
Calculations
orientation

57. How do I perform the MoCA?
The test may be administered by anyone who understands and follows the instructions
Test instructions are specific and may be repeated once with the exception of items tested on the list of words, list of digits, list of letters, subtraction answers and phrases to repeat, these may not be repeated.
For complete instructions and scoring access the website There are detailed instructions which should be followed

58. How do I perform the MoCA? (one example)
Instructions to the subject:
"Please draw a line, going from a number to a letter in ascending order. Begin here [point to (1)] and draw a line from 1 then to A then to 2 and so on. End here [point to (E)].“
Scoring:
Allocate one point if the subject successfully draws the following pattern: 1 −A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not immediately self-corrected earns a score of 0.

59. MoCA interpretation?
The score is a summation of the 11 tests. The total possible score is 30 points; a score of 26 or above is considered normal.
18-26 = mild cognitive impairment,
10-17= moderate cognitive impairment
less than 10= severe cognitive impairment
Only a health professional with expertise in the cognitive field may interpret the results.

60. Pros of using the MoCA
At this time no special training is required to administer the test.

61. Cons of using the MoCA
The test administrator must follow the written script in providing the patient instructions for the test
Interpretation of the results should be completed by health care providers who are experts in cognition

62. References

63. The Cardiopulmonary Rehab Stream of Care
Thank you to the following organizations for their collaborative efforts which led to the development of the COPD and CHF care paths, patient education material and Care-giver resources.
Cambridge Cardiac Care
Cambridge Memorial Hospital
Grand River Hospital
Groves Memorial Hospital
Guelph General Hospital
Mount Forest Family Health Team
St. Joseph’s Health Care, Guelph
St. Mary’s General Hospital
Upper Grand Family Health Team
Waterloo Wellington Community Care Access Center
The Cardiopulmonary Rehab Stream of Care