Episode 80: ‘Mow’ your limits

An episode about mowing, MET levels, and knowing your (your patient’s) limitations. Have you ever been asked, “Can I get back to….?”  How do you help your patients make these decisions? Do you consider MET levels, HR response, or overall aerobic capacity?

Using MET levels for a specific activity can be a great way to help educate patients on their current abilities or to assist in creating meaningful goals for future activities. It can be a great starting point to help determine the “it depends” answer. It provides objective information to help gauge the overall energy expenditure to complete a specific activity. 

So, how do we determine METs for mowing or any other activity? Check out this episode as we discuss the heart rate and blood pressure response to MET levels and incorporate the physical activity compendium to your toolbox.

In this episode:

• Define a MET
• HR and BP response to 1 MET activity
• Use of the physical activity compendium

 Resources:

2024 Adult / Older Adult Compendium: https://pacompendium.com/

Youth Compendium: https://www.nccor.org/tools-youthcompendium/


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Chapters

• 0:04 Physical Activity Levels and Energy Expenditure
• 17:06 Physical Activity Assessment Criteria
• 20:17 Optimizing Activity Levels for Success

Transcript

Rachele Burriesci: 0:04

Welcome to Talking All Things Cardiopulm. I am your host, r Rachel Barisi, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopalm to the forefront of conversation. Thanks for joining me today, and let's get after it.

Rachele Burriesci: 0:36

Today's episode is sponsored by Jane. You might already be familiar with the name, but if it's new to you, jane is a HIPAA compliant clinic management software and EMR Chasing down patients for important information isn't anyone's idea of a good time, especially when there are forms to be filled, payments to be processed and consents to be collected. That's why Jane has designed user-friendly online intake forms so you can gather all the information you need prior to the appointment, whether that's health history, insurance details or a credit card on file. Jane will even send a friendly reminder 24 hours before a patient's appointment if they haven't completed their intake forms yet, saving you from having to manually follow up. To see Jane in action, head to the show notes. Click that link to book a personalized demo, and if you're ready to get started, you can use the code CARDIALPALM1MO at the time of sign up for a one month grace period applied to your new account. Thanks again, jane.

Rachele Burriesci: 1:30

All right, Happy October 1st. I'm going to be a broken record. I'm going to say it again I can't believe it's October. This is actually one of the first years where it's starting to feel like fall in an appropriate sort of way, where it's like a gradual out of summer into fall, versus like you have summer and then you have winter. With that being said, we just had a relatively warm week and we're going to have a relatively warm next week, but today, on October 1st, it is 70 and cool. Actually, it was like really chilly this morning. I actually got some mowing done, which spurred this topic today, and it was just actually a really enjoyable time outside. So I've spoken about this, I think, in reels on Instagram, and I actually think I was more focused on snow shoveling in this same sort of regard. But I wanted to talk about the energy expenditure for doing activities like mowing and besides having to mow this morning myself and like physically doing these things and thinking about like the level of activity that is required to do it, I had a patient this past weekend who had a recent iliac to femoral bypass and arthrectomy for actually an occluded stent that had previously been placed and he had really severe intermittent claudication at the lateral thigh and buttocks, more than the lower leg, and he was actually a really active guy and he's been down for pretty much the whole summer and his wife has taken over the mowing because he physically couldn't do it.

Rachele Burriesci: 3:24

So now he's been down for pretty much the whole summer and his wife has taken over the mowing because he physically couldn't do it. So now he's post-surgery and one of the first questions he asked is can I go back to mowing? And the answer is always it depends, right? So on a broad question, you have a patient and the question is can they mow their lawn? It depends, and this is where your skill and knowledge base comes in, because no two patients are the same. No two comorbidities list is the same. No two VO2 maxes for that specific person is the same and no two lawns are the same. No two mowers are the same. Right Like there are so many moving variables in this picture. You have the same. No two mowers are the same. Right Like there are so many moving variables in this picture. You have the person, you have their VO2 capacity, you have their physical activity level at this moment.

Rachele Burriesci: 4:18

You have to think about symptoms and then you need to consider what's happening when they're mowing. Do they have a push mower? Do they have a ride mower? Do they have a flat lawn? Do they have an uphill? You know front yard, and I'm literally describing my own place right now Do you have a small patch of grass that's going to take you five minutes to mow, or do you have a good amount of space that might take you an hour or two, right? So time also is a variable that you have to think about. How long can you sustain said energy expenditure? So I'm not going to go into the real nitty gritty of met levels, although I consider doing that, but that will be a much longer, more detailed conversation. But I think it might be worth doing because when we're thinking about activity levels, we can use met levels to sort of help determine if a person is capable of doing said activity.

Rachele Burriesci: 5:25

Now, mets aren't perfect, because one MET has a standardized number and in real life there's going to be variability to that based on age, sex, weight, height, body temp. There's a number of different things that sort of weigh into your resting metabolic rate. With that being said, we can use the standardized number to give us a quick and dirty answer and for the most part it's at least a good starting point. It's at least a good conversation starter, right, can I mow? Well, can you perform X number of mets?

Rachele Burriesci: 6:09

So before I go any further, I want to give you a resource and I actually love doing these podcasts because I just learned that this resource has just been updated in 2024. So the resource is called Physical Activity Compendium. This is a living working document that was created I believe I think it was officially in production in 1993, but was started in 89. And it literally lists out the level of met levels expected for a certain activity. So you can look at anything from like gardening, to mowing, to skiing or, you know, playing something like pickleball. Actually, I should check to see if pickleball is on there, because that is a like hot sport right now and a very common sport in the older generation. Learn that in Michigan. Do not mess with the older pickleball generation. They will crush you, just for warning. But this is a really great document that literally goes through all sorts of activities that you can think of and it can at least put you in the ballpark of information I just got out of the screen. Let me see if I go here. I'll give you just some overall titles so you can go from bicycling, conditioning exercises, dancing, fishing and hunting.

Rachele Burriesci: 7:40

Home activities would include things like vacuuming versus maybe standing and doing the dishes. They typically give different met levels for like sitting or standing. They also include things like minimal, moderate, vigorous effort, which is great, self-care, sexual activity, different types of sports, transportation. They even had, like um, riding an e-bike, which you know was surprised about that. They've added new ones, actually in the 2024 update. Um, video games is actually one of the new categories that they added, and rightfully so, because actually I'm going to open that one, because why not? Um? They break it down between seated video games, which is a met level of 1.3, to video game with a handheld controller, with light effort, 1.5. And then it goes all the way up to conditioning exercise, virtual reality, fitness, which is a met level of 9.8. So, again, no, two things are the same, and this is actually a conversation I've had with gardening.

Rachele Burriesci: 8:53

If you have a patient that tells you that they garden, ask follow-up questions, because gardening can be low-level activity, like I have a planter box and I'm watering that planter box and that's as high level as it gets. Or your patient has a garden that they are upkeeping, which includes things like weeding and possibly turning dirt and being able to bend down and stand up carrying bags of dirt right. The variability is high. So you have to ask good questions. Let me talk about the lawn range for a second. So mowing the lawn can range from 2.5 to 6. 2.5 being the lowest level, which is a riding mower, and 6 would be a hand mower with vigorous effort. What most people are sitting at is that there's a 5 and a 5.5, and there's very, there's not a lot of differentiation between the two.

Rachele Burriesci: 10:03

Mowing the lawn, general walking with a power mower. So a lot of patients will tell you that like it's a power mower, you know it has an, you know auto go, so you're not pushing the full weight of the mower. If you don't have a power mower, you need to consider the weight of that mower as well. But five, 5.5 METs is about average for mowing the lawn. So what does that mean? It means a lot of things. So just first base information how does one MET level of activity affect the person? So again, averages, guesstimates, well-known averages. One MET level of activity is equivalent to 10 to 12 beats per minute for heart rate and an increase in 8 to 12 millimeters of mercury for blood pressure. So we know that as we exercise, heart rate and blood pressure are going to increase. Heart rate is more linear than blood pressure, but they both tend to increase gradually in a linear sort of manner until you surpass sub-max exercise and start moving into max exercise and then you have a more and start moving into max exercise and then you have a more steep incline. But average, for one met level of activity, you can expect to have an increase in your heart rate by 10 to 12 beats and an increase in your blood pressure between 8 and 12 millimeters mercury. So 10 is a good guesstimate, right? For every one met level of activity, you expect your heart rate to increase by 10 and your blood pressure to increase by 10. Keep it simple, okay. So then what does that mean for that person?

Rachele Burriesci: 11:49

Lots of questions have to come in here. Where does your patient rest? What's their resting heart rate? What's their resting blood pressure? What's their typical physical activity's their resting blood pressure? What's their typical physical activity? Do they have a history of angina? That's a big one for me, right? So if they have a cardiac history, do they have stable angina? Do they have they had a recent stent placed? Have they had surgery? Right, that's a. We're going to kind of keep that one off to the side because that has different implications.

Rachele Burriesci: 12:19

But if your person has angina and the question is, can I mow, then you need to know where that threshold is. You need to know at what RPP rate pressure product does that angina start. Because you want to maintain at least 10 under that heart rate, blood pressure rate. You don't want to trigger that response. My next question would be have they done a six minute walk test? Have they done a modified or regular Bruce protocol? If you have that information, this is a very simple yes, no answer. What was their max heart rate they were able to achieve? What was the max met level they were able to achieve? And if you want to know it, then you can do a six minute walk test, use a predictive equation which is quite long, so I'm not going to read it to you and figure out what their met level that they achieved.

Rachele Burriesci: 13:19

If they only can achieve two mets, then I would say no, you should not mow the lawn right, because mowing the lawn is five, unless they have a right on mower. And then you have to ask more questions Do they have the physical capability of climbing onto the mower, getting into it safely? Right From more balance, strength, perspective. So there are lots of different factors to answer this very simple question Can I mow the lawn? You want to know if it's a push mower. You want to know if it has, you know, power control that it's going to automatically propel itself. You want to know how big of a yard they're mowing. Do they have any assistance? Do they have the ability to sit and rest, or are they going to be out in the middle of nowhere doing this? I have a neighbor. I'll tell you neighbors, I should say the best people, first of all and second of all, they mow as a team and it's fantastic.

Rachele Burriesci: 14:24

So, like I have them in my mind sometimes in this regard. Right, if the husband was like hey, can I mow? This is how we do it. This would be a great way to interval mow, yeah, you mow. They literally do like one strip up and down and then swap. That allows for rest breaks, time to sit, time for heart rate recovery, staying away from angina threshold. You know, maybe if there is an incline in the yard, the other person takes the incline. So lots of different variables that can come in with such a simple task. But you can ask this question for anything right, can I snowblow? Can I go skiing? Can I ride a bike? There's so many follow-up questions, but you can really use this compendium to get a starting conversation and if the answer is no right now, well, maybe this is a goal to work towards.

Rachele Burriesci: 15:24

I kept the surgical patient off to the side because it's not just about the heart rate, blood pressure, met level, response, it's also about precautions. So if you had a patient who had a sternotomy, well, you're going to have lifting restrictions. Put no push, pull, lift greater than five to 10 pounds for about three months, right, so five, 10, 15 at its tightest, 10, 15, 20 at its. You know more liberal for typical precautions. Know more liberal for typical precautions. No, push, pull mowings out, even if you're not necessarily pushing greater than 10 pounds, like if you're on level ground. It's a propel mower. I don't know how much that forces, even when it's kind of helping you along, assisting you, but it gets dicey.

Rachele Burriesci: 16:23

And I had this conversation as I was mowing today because there is a change in the yard pitch. You have to go around a tree and all of a sudden you're holding a mower on an angle out. I would say sternotomy, just wait. Wait for your full restrictions to be up Now. My guy from the weekend he was a peripheral vascular surgery, so they still have a 10 pound lifting restriction. They don't necessarily have a push pull. Same thing. They probably could do some of the level ground short bouts.

Rachele Burriesci: 17:06

But what happens if you have to navigate around the tree and you're holding the mower sideways and obviously doing more than 10 pounds work? Is it worth it? Right, for him, it's only so many weeks left in the season. Just, I would let it be. At the end of the day, your patients are adults and they can make their own decisions, and that is something that you have to consider too. But from an education perspective, it's probably not worth it. I had a couple of notes here, yeah, so lots of different things you need to consider.

Rachele Burriesci: 17:45

When asked a specific question, I know everyone hates the it depends answer, but to be very honest with you, it almost always is it depends, because it depends on you. It depends on your patient, right? Everyone is different, so most things aren't black and white and you have to be able to say well, you're at this physical capacity, this is your current aerobic capacity and this is the level of activity that you're hoping to do. If it's way off, then it's a clear cut. You're not there yet, but it can be a goal for the future. I'm going to include this compendium link in the show notes. If you ever have this come across. You know, question-wise, can I do this activity? They have all kinds of things on there, like hunting, seeding, planting seeds in a sitting position, in a stooped position, lots of different, very specific items, which is awesome.

Rachele Burriesci: 18:47

Something else that's new in the 2024 update is they broke it down by age group, so it used to just be. The prior one was done in 2011. It was a 2011 compendium and it was just broad. It didn't have specific age groups. So now they broke it down into greater than 60 years old, which is the older adult category, and I believe it's 19 to 59. So you have this range of age that you can look at, and it's really nice that they did a transition at that 60-year-old mark, because as you age, your resting metabolic rate is also going to change, so it's going to be a different effect, and all of these numbers are based on prior research of physical activity and comparison to VO2 max or MET levels or MET per minute, and they've done the conversion to get it to a specific number minute, and they've done the conversion to get it to a specific number. They also, in 2017, made a pediatric I think they called it a young adult compendium so now there are a number of different things that a number of different categories you can look at for different age groups, which is phenomenal, because now it's not just this really gross guesstimate, it's getting closer, so it's a living document.

Rachele Burriesci: 20:15

It gets updated every so often.

Rachele Burriesci: 20:17

I honestly didn't know it got updated until I was looking for this link to include into the show notes today, so I'll include that and I'll include the article that's attached to it, because this is super helpful and you can actually help your patients understand why an activity is safe or not safe, or they're capable of doing it, or your concerns related to it and, more importantly, create goals that are specific to something that they want to do and gradually get there which I think is a wonderful part of what we do and help really optimize your person and let them be successful in their life, right? All right, do I have anything else? We talked about met levels. We talked about heart rate and blood pressure adjustment for each met. We need to consider that when we're thinking about activity right, if they're resting at 100 and they're doing an activity like mowing the lawn, which is five met levels, you can expect a 50 beat per minute-ish increase with that activity. Now you're at 150 beats. What does 150 beats look like in comparison to their max heart rate? What percentage are they working at? And this, again, is where time comes into this, because it's a very different story if you're doing something for five minutes versus one to two hours. Right, it's a whole different ballgame and it's part of the conversation and also part of what you can help your patients get back to. All right, I hope that was helpful.

Rachele Burriesci: 22:01

This was a short one today. I hope you get some use out of this compendium. I'm dropping it in the show notes. Take a peek at that. If you have any questions, please reach out to me. If you are looking for mentorship one-on-one I have a link for that as well, and I hope you all have a wonderful day and whatever you have to do, get after it.