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MET Levels and Cardiac Rehabilitation

The Metabolic Equivalent of Task, or MET level, is the approximate amount of energy a person uses during physical activity. These levels are used as a reference point during cardiac rehabilitation. Patients who have had a heart attack or who have undergone open heart surgery are assisted to gradually return to normal activity levels, using MET levels as a guide to insure that activity does not exceed what the patient’s heart can tolerate. Following are some guides to help you learn the stages of cardiac rehabilitation, as guided by MET levels.

Functional Classification of Heart FailureNew York Heart Association

This system is used to classify heart disease according to the activity level that patients can tolerate.

Class Patient Symptoms Approximate MET Level Tolerated
I No limitations. Patients do not experience heart palpitations, shortness of breath, or extreme fatigue during normal physical activity. 4.5 and over
II Slight limitations of physical activity. Patients are comfortable at rest. Ordinary physical activity results in palpitations, shortness of breath, or fatigue. Up to 4.5
III Significant limitations of physical activity. Patients are comfortable at rest. Light to moderate activity causes palpitations, shortness of breath and fatigue. Up to 3.0
IV Unable to tolerate physical activity. Patients experience palpitations, shortness of breath and fatigue even at rest. Physical activity increases the severity of symptoms. Up to 1.5


Stages of Activity

These are the stages used during cardiac rehabilitation to present activities to patients.
MET levels are used to ensure that the activities do not exceed the patient’s activity tolerance.

Stage MET Level Range ADL Restrictions Recreational Restrictions Exercise Restrictions Pictures
I 1.0 – 1.4 Sitting up is allowed for short periods. Self-feeding, washing hands and face, bed mobility, transfers. Sitting: Reading, radio, non-competitive table games, light handwork. Can exercise all extremities in supine (10-15x, at a time). Can only sit to exercise neck and lower extremities.
II 1.4 – 2.0 Sitting up is allowed as tolerated – no limitations to sitting.
Sitting: Self-bathing, shaving, dressing, grooming.
Sitting: Crafts, painting, knitting, sewing, mosaics, embroidery. May exercise all extremities but NO ISOMETRICS or strengthening exercises are allowed. AROM to all extremities, progressively increasing number of repetitions.

Walking at slow pace in room, as tolerated

III 2.0 – 3.0 Sitting: Showering in warm water.

Sitting: Ironing, housekeeping tasks with brief standing periods to transfer light items.

Sitting: card playing, crafts, piano, machine sewing, typing. Sitting: wheelchair mobility limited distances
Standing: AROM exercises to all extremities, progressively increasing number of reps.
May include: balance exercises, light mat work with no resistance
Walking on a zero gradient and comfortable pace is allowed.
IV 3.0 – 3.5 Standing: showering in warm water, self, dressing, shaving, grooming,

Light housekeeping tasks while standing, using energy conservation – light vacuuming, dusting, sweeping, washing light clothing.

 Bowling, slow canoeing, golf putting, light gardening -planting, driving. Standing: all previous exercise, progressively increasing number of reps and speed. May include balance and mat exercises with light resistance.

Walking: unlimited, zero gradient, progressing speed/duration for up to 15-20 min or target HR reached. May begin walking on a treadmill at 1 to 1.5 mph, at a 1-2% grade.

Stairs: May begin slow stair climbing up to 2 flights.

Cycling: up to 5 mph with no resistance.

V 3.5 – 4.0 Standing: washing dishes, washing clothes, ironing, hanging light clothes, making beds. Slow swimming, light carpentry, golfing, light home repairs.
Sitting: More resistance may be added to exercises completed while sitting, up to 10 lbs.

Standing: continue with previous exercises, progressively increasing number of reps and speed.

Walking: Unlimited, increasing speed up to 2.5mph, on level surfaces.

Stairs: Increase tolerance.

Cycling: up to 8 mph with no resistance.

VI 4.0 and above Standing: showering in hot water, hanging/wringing clothes, mopping, stripping and making beds, raking. Swimming-no advanced strokes, slow dancing, slow  ice or roller skating, volleyball, badminton, table tennis, light calisthenics. Sitting: Exercising upper and lower extremities, up to 10-15 lbs.

Walking: increase speed to 3.5 mph.

Cycling up to 10 mph, no resistance.



Phases of Cardiac Rehabilitation

These phases are used as a basic protocol when providing cardiac rehabilitation services to patients.

Phase I: This phase begins during the patient’s inpatient hospital stay. It usually continues for up to 14 days after the patient’s initial procedure or cardiac event.

MET Level Precautions Activities Monitoring
Begins at MET level 1-2
Target MET level 3.5
No isometric exercises or muscle strengthening work

No overhead or lateral upper body activity
No exercise if person has the following conditions: unstable angina, uncontrolled arrhythmia, acute myocardial infarction (heart attack), deep vein thrombosis (DVT), or severe aortic stenosis

Patient education in the following areas:
● Energy conservation
● Work simplification
● Risk factors
● Smoking cessation
Light activity if regular pulse is 100 bpm or less
Take vital signs (blood pressure, pulse, respiration) at the beginning of each activity, at the peak of each activity, at the end of each activity, and 4-5 minutes after each activity.

May use a perceived exertion scale to monitor the patient’s perception of effort. (example – BORG scale for exertion)

Phase II: This phase begins when a patient is able to tolerate an activity level at 3.5 MET. It is completed through outpatient rehabilitation and can last up to 12 to 18 weeks after the patient’s initial cardiac event.

MET Level Precautions Activities Monitoring
Begins at MET level 4-5

Target MET level 5-6

Build up activity tolerance gradually

May start graded weight training 2-4 weeks after the initial cardiac event

Continued patient education as in Phase I

Practice work simplification and energy conservation techniques

Gradual graded exercise

Gradual graded weight training

Home evaluation

Work site evaluation if applicable

May be referred to a work hardening program if needed

Continued monitoring of vital signs during and after activity

May use perceived exertion scale. Target for BORG scale 11-15.

Phase III: This phase of cardiac rehabilitation involves maintenance of the gains made in phases I and II. It may begin as early as 4 weeks after the initial cardiac event, depending on the patient.
Phase III cardiac rehabilitation programs are usually provided in community exercise facilities, such as the YMCA. A physician must refer a patient to a Phase III cardiac rehabilitation program. Since these programs are community based, insurance may not cover the cost.

MET Level Precautions Activities Monitoring
Begins at MET level 5-6 Patient is educated in precautions and self monitors during activity. Maintenance gym exercise program

Weight training

Cardiovascular exercise

Patient usually undergoes a stress test prior to participating in the program.







Reference: https://www.bronsonhealth.com/app/files/public/744/BronsonCardiaRehabHomeExerciseBook.pdf

           2011 Compendium of Physical Activities

The Compendium of Physical Activities was developed to enhance the comparability of results across studies using self-report physical activity (PA) and is used to quantify the energy cost of a wide variety of PA. The 2011 Compendium retains the previous coding scheme to identify the major category headings and specific PA by their rate of energy expenditure in MET values. The Compendium is used globally to quantify the energy cost of PA in adults for surveillance activities, research studies, and, in clinical settings, to write PA recommendations and to assess energy expenditure in individuals. The 2011 Compendium is an update of a system for quantifying the energy cost of adult human PA and is a living document that is moving in the direction of being 100% evidence based.

Follow this link to download/view the compendium.


Normal Vital signs

Infant 0-12 months Child 1-11 years Teen to Adult Over age 12
Blood pressure 65-90/45-65 0-6 months, 80-100/55-65 6-12 months 90-110/55-75 110-135/65-85
Pulse (beats per minute) 100-160 bpm 70-120 bpm 60-100 bpm
Respiration 30-60
breaths/minute 0-6 months; 24-30 breaths/minute 6-12 months
breaths/minute 1-5 years; 12-20 breaths/minute 6-12 years


Borg Scale of Perceived Exertion

Rating of perceived exertion (RPE) is a widely used and reliable indicator to monitor and guide exercise intensity. The scale allows individuals to subjectively rate their level of exertion during exercise or exercise testing. Developed by Gunnar Borg, it is also referred to as the Borg Scale.There are two RPE scales which are commonly are commonly used:
1. The original Borg scale or category scale (6 to 20 scale)
2. The Revised category-ratio scale (0 to 10 scale).Both the 6-20 and 0-10 scales are used in clinical practice to measure perceived exertion; no current recommendations exist regarding use of one scale in preference to another. Despite being a subjective measure of exercise intensity, RPE scales provide valuable information when used correctly.http://www.heartonline.org.au/media/DRL/Rating_of_perceived_exertion_-_Borg_scale.pdf

The Original Borg Scale
Patient’s description of exertion Borg rating Example of activity
None 6 Reading, watching TV
Very, very light 7-8 Tying shoes, writing
Very light 9-10 Folding laundry
Fairly light 11-12 Walking, shopping
Somewhat hard 13-14 Brisk walking, vacuuming or cleaning
Hard 15-16 Swimming, bicycling
Very hard 17-18 Highest level of sustainable activity
Very, very hard 19-20 A burst of activity that cannot be sustained for a long time.