People gain and maintain physical fitness through movement. There are differences between the movement of physical activity and exercise:
Physical activity – “any bodily movement produced by skeletal muscles that results in energy expenditure.”
Exercise – “a subset of physical activity that is planned, structured, and repetitive and has, as a final or an intermediate objective, the improvement or maintenance of physical fitness.’’
Exercise Screening
International Physical Activity Questionnaire (IPAQ)
- Initial screening of activity levels
- Useful for categorising low/moderate/high activity; not for detailed prescription
- Can be completed by patients directly
| Category | Criteria | Tiers of prehabilitation | Suggested Intervention |
| Low |
|
Targeted/possibly specialist depending on patients needs | Encourage initiation of physical activity; consider tailored motivational strategies |
| Moderate |
|
Universal | Support maintenance and progression; offer structured programs or goal-setting |
| High |
|
Universal | Reinforce current activity; monitor for overtraining or injury risk if applicable |
MET-Minute Calculation
MET-minutes/week are calculated by multiplying:
Minutes per day × Days per week × MET value
- Walking = 3.3 METs
- Moderate activity = 4.0 METs
- Vigorous activity = 8.0 METs
These categories help guide public health interventions, clinical advice, and individual goal-setting.
IPAQ is best used for population-level surveillance and initial screening, not for precise individualised plans.
Duke Activity Status Index (DASI)
- Identifies functional capacity estimation (METs)
- Supports risk stratification and exercise planning
- Can be completed by patients directly
| DASI Score | Interpretation | Tiers of prehabilitation | Suggested Intervention |
| < 16 | Very poor functional capacity (≈<5 METs) | Specialist | Consider urgent cardiopulmonary evaluation; may be unfit for major surgery or intensive rehab |
| 16–25 | Low to moderate capacity (≈5–7 METs) | Targeted | Tailored rehabilitation or exercise program; monitor for cardiovascular symptoms |
| 26–34 | Moderate to good capacity (≈7–9 METs) | Universal/targeted | Encourage continued physical activity; suitable for most non-strenuous procedures |
| >34 | Excellent capacity (≈>9 METs) | Universal | Likely fit for surgery and intensive physical activity; maintain current activity level |
Clinical Applications
- Preoperative assessment: a score >34 suggests low perioperative risk
- Heart failure and pulmonary hypertension: a cut-off of 33.8 has been used to stratify risk in patients with pulmonary arterial hypertension
- Cardiac rehabilitation: helps tailor exercise prescriptions and monitor progress
The international physical activity questionnaire (IPAQ)
- developed to measure health-related physical activity in populations
- used in the Manchester ‘Prehab4Cancer’ initiative
The Scottish Physical Activity Screening Questionnaire (Scot-PASQ)
- Provides a framework for meaningful physical activity conversations between health professionals and patients, enables description of activity levels and informs what physical activity support is needed
- Used as part of the Scottish National Physical Activity Pathway (NPAP), a set of steps a healthcare professional can take to encourage the people in their care to be more active
Godin Shephard Leisure Time Physical Activity Questionnaire (GSLTPAQ)
- Used to assess leisure time physical activity and exercise in oncology research
General practice physical activity questionnaire (GPPAQ)
- used in primary care to assess the physical activity levels of adults (16 to 74 years).
- provides a simple, 4 level physical activity index (PAI).
- helps practitioners decide when to offer interventions to increase physical activity
Physical activity stage of change assessment tool
- used to gauge how motivated a patient is to engage and adhere to a physical activity intervention
- provides those doing the screening with specific strategies and goals relative to the patient’s particular stage of change
- developed by Exercise is Medicine® Australia, empowering primary healthcare providers to effectively counsel patients about physical activity leading to sustained behaviour change
Wearable Technology Monitors
- are increasingly used to obtain objective measures of physical activity
- can help identify whether or not a person meets a specific threshold for physical activity
- potential for their use for screening and assessment of activity and exercise
Clinical Frailty Score – sometimes referred to as the ‘Rockwood Score’
- a self-reported measure
- summarises overall level of fitness/ frailty of an older adult after clinician evaluation
Exercise Assessment
Score interpretation and interventions
| Distance Walked | Interpretation | Tiers of prehabilitation | Suggested Intervention |
| < 300 meters | Severely reduced functional capacity | Specialist | Consider urgent cardiopulmonary evaluation; may indicate high risk for morbidity/mortality |
| 300–450 meters | Moderately reduced capacity | Targeted | Tailored rehabilitation, symptom management, and monitoring for decline |
| > 450 meters | Adequate to good capacity | Universal | Encourage maintenance or progression of physical activity; suitable for most procedures and rehab programs |
Additional Considerations
Normative values vary by age, sex, height, and weight. For example:
- Men aged 60–69: ~572 meters
- Women aged 70–79: ~471 meters
Minimal Clinically Important Difference (MCID): Often cited as 25–35 metres, depending on the population
Minimal Detectable Change (MDC): Varies by condition; used to confirm true change beyond measurement error
Clinical Applications
Heart failure: <300 meters often correlates with poor prognosis
Pulmonary hypertension: Used to monitor disease progression and treatment response
Stroke and neuro rehab: Helps assess fall risk and community ambulation potential
Assessment 30-second Chair Stand
Score interpretation
| Age Group | Below Average
Slightly below average = Targeted Far below average = Specialist |
Average Range = universal | Above Average = Universal | Suggested Intervention |
| 60–64 yrs | <14 stands | 14–19 stands | >19 stands | <14: Refer to strength training or falls prevention |
| 65–69 yrs | <12 stands | 12–18 stands | >18 stands | <12: Consider physiotherapy or mobility support |
| 70–74 yrs | <12 stands | 12–17 stands | >17 stands | <12: Tailored exercise programme; monitor for decline |
| 75–79 yrs | <11 stands | 11–16 stands | >16 stands | <11: Risk of functional limitation; initiate rehab |
| 80–84 yrs | <10 stands | 10–15 stands | >15 stands | <10: High fall risk; urgent strength and balance intervention |
| 85–89 yrs | <8 stands | 8–14 stands | >14 stands | <8: Consider assistive devices and home safety review |
Clinical notes
- Score of 0 (unable to rise without arms): Indicates severe impairment; urgent referral needed
- MCID (Minimal Clinically Important Difference): ~2 stands for older adults
- Use in Prehabilitation: Helps stratify patients for tailored physical activity plans, especially before surgery or cancer treatment
Cardiopulmonary exercise testing—a beginner’s guide to the nine-panel plot – PMC
CPET provides an objective assessment of integrated cardiovascular, pulmonary, and muscular function. In prehabilitation, the goal is not to exclude patients from surgery but instead to identify modifiable deficits and prescribe personalised training.
| CPET Variable | What it measures | Typical thresholds | Implication for prehabilitation |
| VO₂peak | Global aerobic capacity | >20 low risk; <15 high risk
>20 ml·kg⁻¹·min⁻¹ → Low risk, good functional reserve 15–20 ml·kg⁻¹·min⁻¹ → Moderate risk, likely to benefit from structured prehabilitation <15 ml·kg⁻¹·min⁻¹ → High risk, intensive prehabilitation recommended <10 ml·kg⁻¹·min⁻¹ → Very high risk, associated with increased postoperative complications |
Determines overall intensity; low values → high‑intensity aerobic training |
| Anaerobic Threshold (AT) | Sustainable aerobic metabolism | ≥11 low risk; <8 high risk
AT ≥11 ml·kg⁻¹·min⁻¹ → Low risk AT 8–11 ml·kg⁻¹·min⁻¹ → Intermediate risk AT <8 ml·kg⁻¹·min⁻¹ → High risk, associated with increased postoperative morbidity In prehabilitation, AT <11 typically triggers aerobic conditioning programmes. |
Sets aerobic training zone; low AT → endurance training focus |
| VE/VCO₂ slope | Ventilatory efficiency | <30 normal; >35 poor
<30 → Normal 30–35 → Mild inefficiency >35 → Significant inefficiency, often linked to cardiopulmonary disease and higher surgical risk |
Indicates need for respiratory training; may limit aerobic progression |
| O₂ pulse | Substitute for measuring stroke volume | Low values suggest cardiac limitation | Guides inclusion of interval training |
| Heart Rate response | Chronotropic competence | Blunted response indicates cardiac or autonomic issues | May require supervised training |
Incremental Shuttle Walk Test (ISWT)
- 10m course walked at increasing pace
- similar to the “bleep test”
- achieving >400m correlates to a VO2 peak of >15ml/kg/min
Timed Up and Go (TUG) Test: Uses, Procedure, Results