Why physical capacity assessment is important
Deconditioning is a potentially modifiable risk factor that impacts postoperative recovery.
Who can assess
Exercise assessment should be completed by a qualified physiotherapist or exercise physiologist.
Who should receive an exercise assessment
Individuals with cancer who are deemed moderate or high risk following screening should be referred to an exercise service for comprehensive assessment.
There is currently no strong evidence to warrant automatic referrals for exercise assessment for any specific cancer populations or surgical procedures, however each health service should consider their target population to identify complex surgeries where physical function may be reduced. Those awaiting upper gastrointestinal surgery and complex abdominal surgeries are shown to be at higher risk of deconditioning; for example, oesophagectomy and whipples.
What and how to assess
Subjective assessment
A thorough subjective assessment will allow the clinician to align exercise recommendations with consideration of lifestyle, pre-existing physical limitations and available support networks to enhance compliance with exercise intervention.
- Social History; support network, home environment, hobbies, employment and identification of social deprivation (income, education qualifications, English proficiency, low skill occupation etc)
- Exercise habits, available equipment and/or access to facilities
- Falls history
- Previous injuries or chronic musculoskeletal conditions
- Impact and control of comorbidities (e.g. respiratory, cardiac, endocrine, neurological conditions).
Objective
Objective assessment allows clinicians to not only risk stratify patients but to establish a baseline of the patient’s physical capacity using formal outcome measures that can be re-measured to review progress.
An example of an assessment form can be found here.
Exercise assessment measures
Further information of tool, standardised instructions and normative values can be accessed by clicking the link under the tool listed below.
Find further information on CPET here Cardiopulmonary exercise testing
The 6MWT is a submaximal test of functional exercise capacity, distance walked is the primary outcome.
It is a self-paced test and for reproducibility should be conducted according to standardised guidelines1.
The 6MWT is demonstrated to have learning effects and 2 tests are recommended. However, in a real-world clinical setting using 1 test is considered reasonable. There is emerging evidence of a moderate relationship between 6MWT and CPET variables. Note that published cut offs vary and note references used for those provided.
| Number of items | Time to complete | Cut offs for risk stratification | Minimum clinically important difference (MCID)* | Can be completed by any clinician? | Is patient reported | Can be completed remotely? | Freely available^? | Resources |
| n/a | Mean time to perform one test is 10mins | Low risk >510m Moderate risk 435-510m High risk <435m2 | Lung Cancer: 22-42m3 Chronic respiratory population 30m1, coronary artery disease 25m4 | Yes – if they have completed training to standardise assessment | No | No as difficult to standardise | Yes | 30m walkway Stopwatch Borg scale Pulse oximetry |
The incremental shuttle walk test measures functional exercise capacity, the primary outcome is distance walked to the nearest 10m.
It is an externally paced incremental test and paced according to incremental speed audio recording –a beep test. It is reported to correlate well with a CPET V02 peak and is easy to prescribe targeted exercise based on results. Tests need to be completed 30 minutes apart.
| Number of items | Time to complete | Cut offs for risk stratification | Minimum clinically important difference (MCID)* | Can be completed by any clinician? | Is patient reported | Can be completed remotely? | Freely available^? | Resources |
| n/a | The mean time required to perform one test is 14.7 +/- 3.7 minutes | A cutoff distance of 250 m is a reliable predictor of postoperative morbidity in patients undergoing colorectal cancer surgery5, 11 | 70 m in patients with cardiac disease and 48 m in patients with COPD (no evidence recorded for cancer population) | Yes – if they have completed training to standardise assessment | No | No | No – Purchase of ISWT CD/USB recording | 10m walkway Floor markers/cones ISWT CD/USB recording |
Complete as many full stands as possible in 30 seconds from a standardised chair.
Can be used to assess leg strength, function and endurance.
Was developed to overcome the floor effect of the 5 repetition sit to stand test in older adults.
Valid measure of leg strength in older community-based adult.
Excellent test-retest reliability and interrater reliability.
| Number of items | Time to complete | Cut offs for risk stratification | Minimum clinically important difference (MCID)* | Can be completed by any clinician? | Is patient reported | Can be completed remotely? | Freely available^? | Resources |
| n/a | 2-3mins | High risk <12 (females), <14 (males) For age 60-64* *varies with age: see referenced link to table of normative values12 | Improvement of 2 or more | Yes – if they have completed training to standardise assessment | No | 30sec STS is feasible via telehealth6
| Yes | Standardised chair with arm rests (ideally 44-48 cm) but any chair is possible as long as you record height variation and use for all retesting Stopwatch |
To determine falls risk and measure the progress of balance, sit to stand and walking.
Simple screening test that measure probability for falls among older adults.
See link for normative values for older adults.
Test re-test user error can be high.
| Number of items | Time to complete | Cut offs for risk stratification | Minimum clinically important difference (MCID)* | Can be completed by any clinician? | Is patient reported | Can be completed remotely? | Freely available^? | Resources |
| n/a | 2-5mins | An older adult who takes ≥12 seconds to complete the TUG is at risk for falling Wide range in cancer surgery population but ≥15-20sec in surgical population is at higher risk of major complications7,8 | Reductions ≥ 0.8-1.4 seconds older adults with hip OA | Yes – if they have completed training to standardise assessment | No | No | Yes | Standardised armchair 5m walkway with floor marking/cone Stopwatch |
A series of physical tests encompassing balance, gait speed and sit to stand to assess lower leg function and mobility. The SPPB total score ranges from 0 (worst performance) to 12 points (best performance) and categorically evaluates performance in the tests using three or four classes of scores:
Three classes:
- 0–6 points (poor performance)
- 7–9 points (moderate performance)
- 10–12 points (good performance).
Four classes:
- 0–3 points (disability/very poor performance)
- 4–6 points (poor performance)
- 7–9 points (moderate performance)
- 10–12 points (good performance).
| Number of items | Time to complete | Cut offs for risk stratification | Minimum clinically important difference (MCID)* | Can be completed by any clinician? | Is patient reported | Can be completed remotely? | Freely available^? | Resources |
| 3-7 | 5-10mins | <109 | 110 | Yes – if they have completed training to standardise assessment | No | No | Yes | Stop watch Walkway with 3m or 4m marker Standardised arm chair |
Grip strength is a measure of muscular strength or the maximum force/tension generated by one’s forearm muscles.
It can be used as a screening tool for the measurement of upper body strength and overall strength. It is most useful when multiple measurements are taken over time to track performance.
| Number of items | Time to complete | Cut offs for risk stratification | Minimum clinically important difference (MCID)* | Can be completed by any clinician? | Is patient reported | Can be completed remotely? | Freely available^? | Resources |
| n/a | 5mins | Normative data for gender and age established. Research indicates that grip strength in midlife can predict physical disability in senior years and help evaluate a patient’s overall health. | 6.5kg | Yes – if they have completed training to standardise assessment | No | No | Yes | Jamar dynamometer |
Self reported questionnaire used for identification and assessment of severity or bother of various pelvic floor symptoms.
| Number of items | Time to complete | Cut offs for risk stratification | Minimum clinically important difference (MCID)* | Can be completed by any clinician? | Is patient reported | Can be completed remotely? | Freely available^? | Resources |
| 9 | 5mins | ≥”somewhat” should trigger education and pelvic floor exercises or referral onto continence therapist/women’s health physiotherapist | Nil reported | Yes | Yes | Yes | Yes | n/a |
If frailty tools have not been applied in previous screening (some frailty tools cannot be completed over the phone/remotely), consider completing relevant tool during assessment.
Please see Exercise screening and Frailty for further details
Other strength and physical assessment tools which have been utilised in prehabilitation studies and can be considered for use include:
- Gait speed
- Quadricep muscle strength with dynamometer.
^Correct at time of publication
*At time of publishing, MCID has not been established for general cancer populations. Listed are the reported MCID in specific populations that can may assist the interpretation of the measure.
- Holland AE, Spruit MA, Troosters T, Puhan MA, Pepin V, Saey D, et al. An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respir J. 2014;44(6):1428-46.
- Shulman MA, Cuthbertson BH, Wijeysundera DN et al. Using the 6-minute walk test to predict disability-free survival after major surgery. British Journal of Anaesthesia. 2019;122(1):111-119.
- Granger CL, Holland AE, Gordon IR, Denehy L. Minimal important difference of the 6-minute walk distance in lung cancer. Chron Respir Dis. 2015;12(2):146-154.
- Shoemaker MJ, Curtis AB, Vangsnes E, & Dickinson MG. Clinically meaningful change estimates for the six-minute walk test and daily activity in individuals with chronic heart failure. Cardiopulm Phys Ther J. 2013;Sep;24(3):21-29.
- Soumya CN, Thomas M, Ravindran S, Jagathnath Krishna KM. Preoperative incremental shuttle walk test for morbidity and mortality prediction in elective major colorectal surgery. Indian J Anaesth. 2022;66(Suppl 5):S250-S256.
- Bowman A, et al. Feasibility and Safety of the 30‐second Sit‐to‐stand Test Delivered via Telehealth: An Observational Study. PM & R. 2023;15(1):31–40.
- Huisman MG, van Leeuwen BL, Ugolini G, Montroni I, Spiliotis J, Stabilini C, de’Liguori Carino N, Farinella E, de Bock GH, Audisio RA. “Timed Up & Go”: a screening tool for predicting 30-day morbidity in onco-geriatric surgical patients? A multicenter cohort study. PLoS One. 2014 Jan 24;9(1):e86863. Erratum in: PLoS One. 2014;9(7):e103907. de’Liguori Carino, Nicola [corrected to Carino, Nicola de’Liguori]. Erratum in: PLoS One. 2016;11(1):e0147993. PMID: 24475186; PMCID: PMC3901725.
- Robinson TN, Wu DS, Sauaia A, Dunn CL, Stevens-Lapsley JE, Moss M, Stiegmann GV, Gajdos Csaba, Cleveland JC Jr, Inouye SK. Slower Walking Speed Forecasts Increased Postoperative Morbidity and 1-Year Mortality across Surgical Specialties. Annals of Surgery. 2013; Oct;258(4):582-590.
- Silva, Caroline & Ohara, Daniela & Pena Matos, Areolino & Pinto, Ana Carolina & Sousa Pegorari, Maycon. Short Physical Performance Battery as a Measure of Physical Performance and Mortality Predictor in Older Adults: A Comprehensive Literature Review. International Journal of Environmental Research and Public Health. 2021;18:1-15.
- Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc. 2006 May;54(5):743-9.
- Lee CHA, Kong JC, Ismail H et al. Systematic review and meta-analysis of objective assessment of physical fitness in patients undergoing colorectal cancer surgery. Dis Colon Rectum. 2018;61:400–409.
- Centers for Disease Control and Prevention: National Center for Injury Prevention and Control – Assessment: 30-Second Chair Stand (https://www.cdc.gov/steadi/media/pdfs/STEADI-Assessment-30Sec-508.pdf