For Healthcare Professionals
This page has information for healthcare and exercise professionals. It includes the components of a transplant exercise program and outcome measures used for the evaluation of adult and pediatric transplant candidates and recipients participating in an exercise program.
Components of a Transplant Exercise Program
Exercise training can play an integral role in pre- and post-transplant rehabilitation. Clinical practice guidelines for transplant rehabilitation are not yet available, as further evidence needs to be developed. The information in this section represents the consensus opinion of the CAN-RESTORE steering committee and is based on the findings of two publications:
- Trojetto T, Elliott RJ, Rashid S, Wong S, Dlugosk K, Helm D, Wickerson L, Brooks D. Availability, characteristics, and barriers of rehabilitation programs in organ transplant populations across Canada. Clin Transplant. 2011;25:571-8.
- Didsbury M, McGee R, Tong A, Craig J, Chapman J, Chadban S, and Wong G. Exercise training in solid organ transplant recipients: A systematic review and meta-analysis. Transplantation. 2013;95:679-687.
The transplant rehabilitation program will be supported by a multidisciplinary team consisting of a medical doctor (specialist in transplantation), a registered nurse, a physical therapist, a dietician, a social worker, a psychologist, and a transplant coordinator. Respiratory therapists, occupational therapists, exercise physiologists, and kinesiologists can also be involved.
Exercise programs can be delivered in an outpatient setting, an inpatient setting, or as a home-based program. Programs should be available both pre- and post-transplantation.
Transplant rehabilitation programs should include education and exercise training. The education component includes the benefits of exercise, reasons for exercise limitation, how to progress exercise, principles of energy conservation, and strategies for lifestyle modification. The exercise training consists of aerobic and resistance training, as well as stretching/flexibility exercises. You can find examples of warm-up and stretching exercises here.
The length of a pre-transplant rehabilitation program can range from weeks to months, depending on the duration of time that a person waits for their transplant. The length of the post-transplant rehab program can range from six to twelve weeks.
Frequency, Duration and Intensity
Exercise training can be prescribed 2-5 days a week. The bouts of exercise could be as short as 15 minutes and the total session can last for up to 2 hours. Exercise intensity is usually determined using a combination of heart rate, blood pressure, respiratory rate, oximetry, and rating of perceived exertion.
A rehab program follow-up can include reassessment of a patient’s functional status and ongoing education and counseling on maintaining a physically active lifestyle.
Evaluation Tools Used in Transplant Rehabilitation
- 6-Minute Walk Test (6MWT)
- VO2 Maximum Cardiopulmonary Test
- Gait Speed
- 30-Second Sit to Stand Test (30-sec STS)
- Short Physical Performance Battery (SPPB)
- Timed Up and Go (TUG) Test
- Hand Held Dynamometry
- One-Repetition Maximum (1-RM) Testing
- Physical Activity Questionnaires (PAQ)
- Physical Activity Scale for the Elderly (PASE)
- International Physical Activity Questionnaire (IPAQ)
- Pedometers and Accelerometers
- Activities of Daily Living (ADL) Scales
- Quality of Life (QOL) Questionnaires
- Pedatric-Specific Outcome Measures
- Motor Assessments (Alberta Infant Motor Scale, Peabody Developmental Motor Scales, Bruininks-Oseretsky Test of Motor Proficiency)
- Quality of Life Tools (Pediatric Quality of Life Inventory, Health Utilities Index, Child Health Questionnaire)
6-Minute Walk Test (6MWT)
Developers: Butland RLA, Pang J, Gross ER, Woodcock AA, Geddes DM. Two-, six, and twelve-minute walking tests in respiratory disease. BMJ. 1982;284:1607-8.
Purpose of Test: The 6MWT was originally developed to assess exercise tolerance among individuals with respiratory disease. It is performed in adult and pediatric populations.
Description: This test measures the distance that an individual can walk on a flat, hard surface during a 6-minute period. A greater distance indicates a better performance.
Application/Administration: It is a practical and simple test that requires a 30-meter hallway but no exercise equipment or advanced training to conduct. The 6MWT should be performed indoors, along a long, flat, straight, enclosed corridor with a hard surface that is seldom travelled. Individuals are permitted to use a gait aid if they have one and they may rest if they become too short of breath or too tired to continue. Distance walked (6MWD) and number and duration of rests within the 6 minutes are measured. The following equation was found to account for 49% of the variance in 6MWD: 6MWD = 970.7 + (-5.5 x age) + (56.3 x gender), where females = 0, males = 1 (Hill, 2011).
Exercise Prescription: The results of an individual’s 6MWT can be used to prescribe exercise intensity. For example, physiotherapists can prescribe an individual to walk at 80% of their average 6MWT speed for a certain amount of time.
- Original Publication: Butland RLA, Pang J, Gross ER, Woodcock AA, Geddes DM. Two-, six, and twelve-minute walking tests in respiratory disease. BMJ. 1982;284:1607-8.
- Normative Values: Enright PL, Sherrill DL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med. 1998;158:1384-7.
- Normative Values (Canadian): Hill K, Wickerson LM, Woon LJ, Abady AH, Overend TJ, Goldstein RS, Brooks D. The 6-min walk test: responses in healthy Canadians aged 45-85 years. Appl Physiol Nutr Metab. 2011;36(5):643-9.
- Technical Standard: Holland AE, Spruit MA, Troosters T, Puhan MA, Pepin V, Saey D, McCormack MC, Carlin BW, Sciurba FC, Pitta F, Wanger J, MacIntyre N, Kaminsky DA, Culver BH, Revill SM, Hernandes NA, Andrianopoulos C, Camillo CA, Mitchell KE, Lee AL, Hill CJ, Singh SJ. An official European Respiratory Society/ American Thoracic Society Technical Standard: field walking tests in chronic respiratory disease. Eur Respir J. 2014;44:1428-46.
- A video link on how to conduct the testing: http://www.artp.org.uk/en/patient/exercise/6MWT.cfm
- Used in a Transplant Population: Carey EJ, Steidley DE, Aqel BA, Byrne TJ, Mekeel KL, Rakela J, Vargas HE, Douglas DD. Six-minute walk distance predicts mortality in liver transplant candidates. Liver Transpl. 2010;16(12):1373-8.
- Yimlamai D, Freiberger DA, Gould A, Zhou J, Boyer D. Pretransplant six-minute walk test predicts peri- and post-operative outcomes after pediatric lung transplantation. Pediatr Transplant. 2013;17(1):34-40.
VO2 Maximum Cardiopulmonary Test
Purpose of Test: VO2 max is a measure of the maximal rate of oxygen consumption.
Description: Maximal oxygen consumption reflects the aerobic capacity of the individual.
Application/Administration: Measuring VO2 max involves a physical effort sufficient in duration and intensity to fully tax the aerobic energy system. This is usually achieved through a graded exercise test where exercise intensity is progressively increased while measuring ventilation and gas exchange. VO2 max can be expressed as an absolute rate in litres of oxygen per minute or as a relative rate in millilitres of oxygen per body mass per minute. There are several protocols available to measure VO2 max. The most common protocols are the Bruce and the Modified Bruce treadmill protocols, used most often in cardiac stress testing. Leg cycle ergometry is also a common testing mode.
Exercise Prescription: A physiotherapist can use VO2 max results to prescribe a program that is based on some percentage of one’s maximal oxygen consumption for each individual exercise.
- ACSM’s Guidelines for Exercise Testing and Prescription. 9th Edition, 2014. Pescatello LS, Arena R, Riebe D, Thompson PD. Lippincott Williams & Wilkins, Philadelphia, PA. Chapters 4 & 5.
- Used in a Transplant Population: Haykowsky M, Taylor D, Kim D, Tymchak W. Exercise training improves aerobic capacity and skeletal muscle function in heart transplant recipients. American Journal of Transplantation. 2009;9:724-9.
- Banks L, Dipchand A, Manlhiot C, Millar K, McCrindle BW. Factors associated with low physical activity levels following pediatric cardiac transplantation. Pediatr Transplant. 2012;16(7):716-21.
Purpose of Test: Gait seed is a simple measure of physical function that measures walking speed over a short distance.
Description: Gait speed is based on the performance of individuals on a timed walk test. It is computed by dividing the distance an individual walks by the time it takes them to cover that distance.
Application/Administration: In the clinical setting, testing usually takes less than 1 minute and is conducted in a quiet location. There are many variations of this test in the literature although the 4-meter walk test is now the most favoured. The middle 4 meters of a longer walkway are used in the velocity calculation to eliminate periods of acceleration and deceleration. Gait speed has been divided into two different gait speed measures (comfortable/preferred and fast/maximum) and is often calculated using the average of three trials.
- Normative Values: Bohannon RW. Comfortable and maximum walking speed of adults aged 20-79 years: reference values and determinants. Age Ageing. 1997;26(1):15-9.
- The Rehabilitation Measures Database (http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=901) provides additional information on this test
- Used in a Transplant Population: Bohannon RW. Prediction of walking performance six months after kidney transplantation. J Phys Ther Sci. 1998;10:57-59.
30-Second Sit to Stand Test (30-sec STS)
Developers: Jones CJ, Rekli RE, Beam W. A 30-s chair-stand test as a measure of lower body strength in community-residing older adults. Research Quarterly for Exercise and Sport. 1999;70(2):113-9.
Purpose of Test: The 30-second sit to stand test is performed to measure lower limb strength.
Description: The 30-second sit to stand test involves recording the number of stands a person can complete in 30 seconds.
Application/Administration: It is a simple test that requires a straight back or folding chair without arm rests. The chair is placed against the wall and the subject sits in the middle of the seat, with their feet shoulder width apart and their arms held close to their chest. From the sitting position, the subject stands completely up, then completely back down, and this is repeated for 30 seconds.
- Original Publication: Jones CJ, Rekli RE, Beam W. A 30-s chair-stand test as a measure of lower body strength in community-residing older adults. Research Quarterly for Exercise and Sport. 1999;70(2):113-9.
- The Seniors Fitness Test Protocol and the Rehabilitation Measures Database (http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=1122) provide guidelines and additional information on the sit to stand test
- Used in a Transplant Population: Bohannon RW, Smith J, Hull D, Palmeri D, Barnhard R. Deficits in lower extremity muscle and gait performance among renal transplant candidates. Arch Phys Med Rehabil. 1995;76(6):547-51.
Short Physical Performance Battery (SPPB)
Developers: Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, Scherr PA, Wallace RB. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49:M85-M94
Purpose of Test: The SPPB is an objective assessment tool for evaluating lower extremity function.
Description: The test has been used as a predictive tool for possible disability and can aid in the monitoring of function in elderly or impaired individuals.
Application/Administration: It combines the results of gait speed, chair stand, and balance tests.
- Original Publication: Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, Scherr PA, Wallace RB. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49:M85-M94
- The developer website (http://www.grc.nia.nih.gov/branches/leps/sppb/) provides comprehensive instructions and background information on the SPPB
- Used in a Transplant Population: Mendes P, Wickerson L, Helm D, Janaudis-Ferreira T, Brooks D, Singer LG, Mathur S. Skeletal muscle atrophy in advanced interstitial lung disease. Respirology. 2015;20(6):953-9.
Timed Up and Go (TUG) Test
Developers: Podsiadlo D, Richardson S. The Timed ‘Up & Go’: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142-8.
Purpose of Test: The TUG test is used to assess mobility, balance, and locomotor performance in elderly people with balance disturbances.
Description: This performance measure was designed to easily evaluate the risk of falls using balance and basic functional mobility. The score is the actual time required to accomplish the task.
Application/Administration: The test is easily administered and requires an armchair. It involves timing the following sequence of events: the subject standing (from sitting position), walking a distance of 3 meters, turning around, walking back to the chair, and sitting down. The timing begins on the command ‘go’ and stops when the patient is seated.
- Podsiadlo D, Richardson S. The Timed ‘Up & Go’: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142-8.
- The Rehabilitation Measures Database (http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=903) provides additional information on the TUG test
- Used in a Transplant Population: Kasbia GS, Farragher J, Kim SJ, Famure O, Jassal SV. A cross-sectional study examining the functional independence of elderly individuals with a functioning kidney transplant. Transplantation. 2014;98(8):864-70.
Hand Held Dynamometry
Purpose of Test: A hand held dynamometer can be used to assess upper extremity (eg. biceps) and lower extremity (e.g. quadriceps) muscle strength in both adult and pediatric populations. This test can also be used as a measure of malnutrition (Norman, 2011).
Description: Muscle strength is scored using force production and can be compared to age-matched norms.
Application/Administration: The dynamometer is held perpendicular to the muscle being tested at a set distance from the joint.
- The Rehabilitation Measures Database (http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=1052) provides additional information on hand held dynamometry muscle strength testing
- Normative Values: Bohannon RW. Reference values for extremity muscle strength obtained by hand-help dynamometry from adults aged 20 to 79 years. Arch Phys Med Rehabil. 1997;78(1):26-32.
- Nutritional Indicator: Norman K, Stobaus N, Gonzalez MC, Schulzke JD, Pirlick M. Hand grip strength: outcome predictor and marker of nutritional status. Clin Nutr. 2011;30(2):135-42.
- Used in a Transplant Population: Van Der Woude BT, Kropmans TJ, Douma KW, Van Der Bij W, Ouwens JP, Koeter GH, Van Der Schans CP. Peripheral muscle force and exercise capacity in lung transplant candidates. Int J Rehabil Res. 2002;25:351-5.
- Patel JN, Kavey RE, Pophal SG, Trapp EE, Jellen G, Pahl E. Improved exercise performance in pediatric heart transplant recipients after home exercise training. Pediatr Transplantation. 2008;12:336-40.
One-Repetition Maximum (1-RM) Testing
Purpose of Test: 1-RM testing is used to evaluate maximal dynamic strength of muscle groups.
Description: A 1-RM is the weight that can be lifted no more than one time with acceptable form. Proper form is achieved when the exercise is performed primarily by the specified muscle groups and without the use of momentum or changes in body position (other than those directly resulting from the movement of the weight).
Application/Administration: Once the subject is familiarized with the movement (to be done before the testing), they lift a weight that they can lift 2-5 times (based on their estimated/perceived maximum). After a 2-3 minute rest, the subject attempts a 1-RM with a weight that is 5-15% heavier. If the lift is successful, they rest again for 2-3 minutes and repeat the process of increasing the weight until a failed attempt occurs. The 1-RM value is reported as the weight of the last successfully completed lift, with proper technique.
Exercise Prescription: The 1-RM is particularly useful when prescribing exercise: a physiotherapist can use 1-RM results to prescribe a program that is based on some percentage of the ‘maximum’ that the person can lift for each individual exercise (American College of Sports Medicine).
- Kraemer WJ, Fry AC (1995). Strength testing: development and evaluation of methodology. In P Maud & C Nieman, DC (1995). Fitness and sports medicine: A health-related approach (3rd ed.). Palo Alto, CA: Bull Publishing.
- American College of Sports Medicine. American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc. 2009;41(3):687-708.
- Used in a Transplant Population: Mosconi G, Cuna V, Tonioli M, Totti V, Roi GS, Sarto P, Stefoni S, Trerotola M, Costa AN. Physical activity in solid organ transplant recipients: preliminary results of the Italian project. Kidney Blood Press Res. 2014;29:220-7.
Physical Activity Questionnaires (PAQ)
There are many different physical activity scales available to assess physical activity levels. The Physical Activity Scale for the Elderly (PASE), the International Physical Activity Questionnaire (IPAQ), and the Short Questionnaire to Assess Health-Enhancing Physical Activity (SQUASH) have all been used in transplant populations. PASE is suitable for elderly populations, while IPAQ can be used in young adults. The following sections will focus on PASE and IPAQ – the PASE needs to be purchased for use while the IPAQ is free to download and administer (see links below).
Physical Activity Scale for the Elderly (PASE)
Developers: Washburn RA, Smith KW, Jette AM, Janney CA. The physical activity scale for the elderly (PASE): development and evaluation. J Clin Epidemiol. 1993;46(2):153-62.
Purpose of Test: PASE is an instrument that measures the level of physical activity in individuals aged 65 and older.
Description: PASE is comprised of questions regarding occupational, household and leisure items over a one-week period. It can be used to measure physical activity and to assess the effectiveness of interventions in older individuals.
Application/Administration: The PASE consists of 12 questions regarding the frequency and duration of different activities. It is self-reported and can be administered by telephone, mail, or in-person.
- Original Publication: Washburn RA, Smith KW, Jette AM, Janney CA. The physical activity scale for the elderly (PASE): development and evaluation. J Clin Epidemiol. 1993;46(2):153-62.
- The Rehabilitation Measures Database (http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=1103) provides additional information on this measure
- PASE Purchasing Information: http://www.neriscience.com/Products/ProductDetail/tabid/212/ArticleId/45/Physical-Activity-Scale-for-the-Elderly-PASE.aspx
- Used in a Transplant Population: Rosas SE, Reese PP, Huan Y, Doria C, Cochetti PT, Doyle A. Pretransplant physical activity predicts all-cause mortality in kidney transplant recipients. Am J Nephrol. 2012;35(1):17-23.
International Physical Activity Questionnaire (IPAQ)
Developers: Craig CL, Marshall AL, Sjostrom M, Bauman AE, Booth ML, Ainsworth BE, Pratt M, Ekelund U, Yngve A, Sallis JF, Oja P. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003;35(8):1381-95.
Purpose of Test: The IPAQ is a self-report measure of physical activity in adolescents and adults.
Description: This instrument assesses the frequency and duration of sitting, walking, moderate-intensity, and vigorous-intensity physical activity across the domains of leisure-time, domestic activities, work-related activities, and transportation. Estimates of domain-specific physical activity in metabolic equivalent of a task (MET) minutes per week, total physical activity in MET-min/week, and time spent sitting can be measured using this questionnaire.
Application/Administration: The short and long-form of the IPAQ are 7 and 27 questions, respectively, and involve a 7-day recall of time spent sitting and participating in different intensities of physical activity within different domains of life. All versions of the questionnaire can be administered by telephone interview or by self-administration.
- Original Publication: Craig CL, Marshall AL, Sjostrom M, Bauman AE, Booth ML, Ainsworth BE, Pratt M, Ekelund U, Yngve A, Sallis JF, Oja P. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003;35(8):1381-95.
- IPAQ Download Site: https://sites.google.com/site/theipaq/questionnaire_links
- Used in a Transplant Population: Masala D, Mannocci A, Unib B, Del Cimmuto A, Turchetta F, Gatto G, Santoro R, Ettorre GM, Boccia A, La Torre G. Quality of life and physical activity in liver transplant patients: results of a case-control study in Italy. Transplant Proc. 2012;44(5):1346-50.
Here is a list of other PAQs that may be suitable for the transplant population: http://appliedresearch.cancer.gov/paq/validation.html
Pedometers and Accelerometers
Purpose of Test: Pedometers and accelerometers are movement monitors that are used to evaluate daily physical activity levels.
Description: Pedometers and accelerometers come in various designs but are often worn on the waistband and are kept on all day. The pedometer is designed to measure the number of steps that a person takes during ambulatory activity. The accelerometer has an advantage over the pedometer by its ability to distinguish between different movements like walking and running.
Application/Administration: The pedometer records how many steps the wearer walks, and can convert that into a distance in order to assess physical activity levels. The accelerometer operates by measuring acceleration along 1 to 3 orthogonal planes in order to determine intensity, frequency, pattern, and duration of physical activity.
Exercise Prescription: Pedometer-based advice has been proven to be more effective than standard exercise advice in increasing physical activity levels (Kolt, 2012). Prescribing exercise using a pedometer allows for a quantifiable way to track and set goals related to physical activity.
- Berlin JE, Storti KL, Brach JS. Using activity monitors to measure physical activity in free-living conditions. Phys Ther. 2006;86(8):1137-1145.
- Kolt GS, Schofield GM, Kerse N, Garrett N, Ashton T, Patel A. Healthy steps trial: pedometer-based advice and physical activity for low-active older adults. Ann Fam Med. 2012;10(3):206-212.
- Used in a Transplant Population: Wickerson L, Mathur S, Singer LG, Brooks D. Physical activity levels early after lung transplantation. Phys Ther. 2015;95(4):517-25.
Activities of Daily Living (ADL) Scales
There are many different ADL scales available. One of these scales that has been used in the transplant population is the Nottingham Extended Activities of Daily Living (NEADL) scale.
Developers: Nouri FM, Lincoln NB. An extended ADL scale for use with stroke patients. Clin Rehabil. 1987;1:301-5.
Purpose of Test: The NEADL is used to assess patients’ independence in activities of daily living.
Description: The scale has 21 items organized into four sections, which can serve as subscales. The sections include mobility, kitchen tasks, domestic tasks, and leisure activities.
Application/Administration: The scale can be self-administered and takes between 5 and 10 minutes to complete.
- Original Publication: Nouri FM, Lincoln NB. An extended ADL scale for use with stroke patients. Clin Rehabil. 1987;1:301-5.
- Used in a Transplant Population: Alavi NM, Aliakbarsadeh Z, Sharifi K. Depression, anxiety, activity of daily living, and quality of life scores in patients undergoing renal replacement therapies. Transplant Proc. 2009;41(9):3693-6.
Quality of Life (QOL) Questionnaires
There are many QOL tools available. The Short Form 36 (SF-36) is a generic survey that is widely used in various patient populations. There are also disease-specific questionnaires that may be useful pre-transplant. The SF-36 is available for purchase at http://www.sf-36.org.
Developers: Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: manual and interpretation guide. Boston (MA): The Health Institute, New England Medical Centre; 1993.
Purpose of Test: This scale was designed as an indicator of perceived health status for use in general and specific populations.
Description: The SF-36 is a 36-item survey that includes eight multi-item scales measuring physical functioning, role limitations owing to physical health problems, bodily pain, general health perceptions, vitality, social functioning, role limitations owing to emotional problems, and mental health. The scores on all sub-scales range from 0-100 with higher scores indicating better health states.
Application/Administration: The SF-36 can be self-administered by individuals aged 14 years or older or administered by trained interviewers either in person or by telephone. It takes 5 to 10 minutes to complete.
- Original Publication: Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: manual and interpretation guide. Boston (MA): The Health Institute, New England Medical Centre; 1993.
- Used in a Transplant Population: Cicognani E, Mazzoni D, Totti V, Roi GS, Mosconi G, Nanni Costa A. Health-relation quality of life after solid organ transplantation: the role of sport activity. Psychol Health Med. 2015;20(8):997-1004.
Pediatric-Specific Outcome Measures
Pediatric transplant patients can use many of the outcome tools listed above. However, there are a few tools that are tailored specifically to children and youth. Some of these tools measure motor ability and quality of life.
Gross and fine motor ability can be assessed in children and youth using different scales, depending on the age of the participants. The Alberta Infant Motor Scale (AIMS), the Peabody Developmental Motor Scales (PDMS), and the Bruininks-Oseretsky Test of Motor Proficiency (BOT-2) have all been used in pediatric transplant patients to assess motor skill development.
Alberta Infant Motor Scale (AIMS)
Developers: Piper MC, Darrah J. Motor assessment of the developing infant. Philadelphia (PA): WB Saunders; 1994.
Purpose of Test: AIMS is an assessment that evaluates the gross motor abilities of infants at risk of motor delay from 0 to 18 months of age (or age of independent walking).
Description: The observational test evaluates weight bearing, posture, and antigravity movements of the infant. Based on the results, the infant is categorized as typically developing, delayed with typical patterns of movement, or delayed with atypical patterns of movement. The results of the assessment can be used to evaluate changes over time. AIMS consists of 58 items including 21 prone, 9 supine, 12 seated, and 16 standing. Each item is scored as either being observed, or not being observed. If an item is not observed within half an hour, the evaluator concludes that it is not in the repertoire of the infant.
Application/ Administration: The complete assessment takes 20-30 minutes to complete and should be performed on an examining table for younger infants (0-4 months) or on a mat/ carpeted area for older infants. It is usually performed by a physician, an occupational therapist, a physiotherapist, or a nurse.
Key References/ Resources:
-Original Publication: Piper MC, Darrah J. Motor assessment of the developing infant. Philadelphia (PA): WB Saunders; 1994.
-Used in a Pediatric Transplant Population: Rolim D, Gomes E, Queiroga A, Roche J, Borghi-Silva A, Sampaio L. Analysis of autonomic, respiratory and motor function of infants in pre- and post-liver transplantation. International Journal of Clinical Medicine. 2014;5:1384-91.
Peabody Developmental Motor Scales (PDMS-2)
Developers: Folio MK, Fewell R. Peabody Developmental Motor Scales and Activity Cards. Chicago, III: Riverside Publishing Co; 1983.
Purpose of Test: The PDMS-2 is an early childhood motor development program that evaluates gross and fine motor skills in children from birth to 5 years of age.
Description: The 3 composite scores of fine motor skill, gross motor skill, and overall motor skill are calculated using 6 in-depth subtests including: reflexes (8-item), stationary (30-item), locomotion (89-item), object manipulation (24-item), grasping (26-item), and visual-motor integration (72-item). The program also provides training or remediation of gross and fine motor skills.
Application/ Administration: The assessment can be performed by a healthcare professional and take approximately 45-60 minutes for the child to complete.
Key References/ Resources:
-Original Publication: Folio MK, Fewell R. Peabody Developmental Motor Scales and Activity Cards. Chicago, III. Riverside Publishing Co; 1983.
-PDMS-2 Purchasing Information: http://www.proedinc.com/customer/productView.aspx?ID=1783
-Used in a Pediatric Transplant Population: Deliva RD, Sollazzo S, Graham A, Harkness M, Manlhiot C, Dipchand AI. Neurodevelopment outcomes following heart transplant. J Heart Lung Transplant. 2013;32(4S):S124.
Bruininks-Oseretsky Test of Motor Proficiency (BOT-2)
Developers: Bruininks, RH. The Bruininks-Oseretsky Test of Motor Proficiency. Circle Pines (MN): American Guidance Service; 1978.
Purpose of Test: The BOT-2 is assessment that measures gross and motor skill in children and youth aged 4-21.
Description: There are 6 composite scores that include: fine manual control, manual coordination, body coordination, strength and agility, total motor composite, gross motor composite, and fine motor composite. They are made up of 8 subset scores that are composed of 53 items ranging a broad spectrum of fine and gross motor tasks. The scoring can only be performed by the developers and can be purchased per report or through an unlimited use prescription.
Application/ Administration: The complete assessment takes 45-60 minutes to complete, and can be performed by a healthcare professional. There is also a short form version that takes 15-20 minutes to complete.
Key References/ Resources:
-Original Publication: Bruininks, RH. The Bruininks-Oseretsky Test of Motor Proficiency. Circle Pines (MN): American Guidance Service; 1978.
-Used in a Pediatric Transplant Population: Eijsermans RM, Creemers DG, Helders PJ, Schroder CH. Motor performance, exercise tolerance, and health-related quality of life in children on dialysis. Pediatr Nephrol. 2004;19(11):1262-6.
Quality of Life Tools
With excellent rates of long-term survival in pediatric transplant patients, it becomes important to assess the quality of life years restored. There are a variety of different tools used to assess quality of life in pediatric transplant patients. The Pediatric Quality of Life Inventory (PedsQL), the Health Utilities Index (HUI), and the Child Health Questionnaire (CHQ) are described below.
Pediatric Quality of Life Inventory (PedsQL)
Developers: Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 Generic Core Scales in healthy and patient populations. Med Care 2001;39:800-12.
Purpose of Test: The PedsQL is used to assess health-related quality of life in children and adolescents (aged 2-18) and those with acute and chronic health conditions.
Description: The assessment is made up of 23 items and is scored into 4 domains: physical (8-item), emotional (5-item), social (5-item), and school functioning (5-item). These are summed into the physical health summary score, the psychosocial health summary score, and the total scale score. There is also a separate 18-item PedsQL Multidimensional Fatigue Scale that is designed to measure fatigue in pediatric patients. This Scale comprises the general fatigue scale (6-item), the sleep/ rest fatigue scale (6-item), and the cognitive fatigue scale (6-item).
Application/ Administration: The PedsQL can be performed as a self-report (only for individuals above age 5) or as a parent proxy-report. There are different versions with slight modifications in wording depending on the age of the child or adolescent. The questionnaire is brief and takes approximately 5 minutes to complete.
Key References/ Resources:
-Original Publication: Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 Generic Core Scales in healthy and patient populations. Med Care 2001;39:800-12.
-PedsQL Purchasing Information: http://www.pedsql.org/conditions.html
-Used in a Pediatric Transplant Population: Konidis SV, Hrycko A, Nightingale S, Renner E, Lilly L, Therapondos G, Fu A, Avitzur Y, Ng VL. Health-related quality of life in long-term survivors of paediatric liver transplantation. Paediatrics and Child Health. 2015.20;4:189-94.
Health Utilities Index (HUI2)
Developers: Feeny D, Furlong WJ, Boyle M, Torrance GW. Multi-attribute health status classification systems: Health Utilities Index. Pharmacoecon. 1995;7:490-502.
Purpose of Test: The HUI is used to assess health status in children and youth aged 5-18.
Description: The tool is made up of 30 items and is scored into 7 domains: cognition, emotion, fertility, mobility, pain, self-care, and sensation. Scoring algorithms are used to convert responses into health attribute levels and health utility scores.
Application/ Administration: The assessment can be in the self-report format (for children >8 years of age) or the parent-proxy format (for children aged 5-18 years). These take approximately 8 minutes to complete. The HUI can also be administered in an interview, which takes approximately 3 minutes to perform.
Key References/ Resources:
-Original Publication: Feeny D, Furlong WJ, Boyle M, Torrance GW. Multi-attribute health status classification systems: Health Utilities Index. Pharmacoecon. 1995;7:490-502.
-HUI2 Purchasing Information: http://www.healthutilities.com
-Used in a Pediatric Transplant Population: Midgley DE, Bradlee TA, Donohoe C, Kent KP, Alonso EM. Health-related quality of life in long-term survivors of pediatric liver transplantation. Liver Transpl. 2000;6(3):333-9.
Child Health Questionnaire (CHQ)
Developers: Landgraf JM, Maunsell E, Speechley KN, Bullinger M, Campbell S, Abetz L, Ware JE. Canadian-French, German and UK versions of the Child Health Questionnaire: methodology and preliminary item scaling results. Qual Life Res. 1998;7(5):433-45.
Purpose of Test: The CHQ is used to evaluate health and functional status in children and youth aged 5-18 years of age.
Description: The assessment examines different areas of health status including: physical functioning, change in health, limitations in school work or activities with friends, mental health, behavior, self-esteem, family cohesion, and limitation on family activities. The CHQ scale scores can be combined to derive overall physical and psychosocial functioning and well being scores. The scoring manual is provided with licensure.
Application/ Administration: This questionnaire can be administered as a self-report (for youth aged 10-18) or as a parent proxy-report (for children and youth aged 5-18). The child self-report version is made up of 87 items and takes between 15-25 minutes to complete. The parent proxy-report is available in 2 lengths: 28 (5-10 minutes) or 50 items (10-15 minutes).
Key References/ Resources:
-Original Publication: Landgraf JM, Maunsell E, Speechley KN, Bullinger M, Campbell S, Abetz L, Ware JE. Canadian-French, German and UK versions of the Child Health Questionnaire: methodology and preliminary item scaling results. Qual Life Res. 1998;7(5):433-45.
-CHQ Purchasing Information: https://www.healthactchq.com/registration.php
-Used in a Pediatric Transplant Population: Hirshfield AB, Kahle AL, Clarke BJ, Bridges ND. Parent-reported health status after pediatric thoracic organ transplant. J Heart Lung Transplant. 2004;23(9):1111-8.
TOOLS USED FOR EVALUATION AND/OR EXERCISE PRESCRIPTION
The table below presents the tools that can be used for evaluation and/or exercise prescription.
* – The information in this column was based on the literature. However, these tests/instruments may be suitable for adult candidates and recipients across all transplant types.
# – Pedometers and accelerometers can be used to prescribe walking programs.
Additional Resources for Pre-Transplant Rehabilitation
General guidelines for rehabilitation in individuals with chronic heart, kidney and lung diseases have been created based on research over the past few years. Below are some useful resources that may be used for rehabilitation in transplant candidates:
- The Australian Heart Foundation Health Education Assessment Rehabilitation Toolkit: www.heartonline.org.au
- The Australian Kidney Foundation Renal Resource Centre: http://www.renalresource.com/brochures/exercise.php
- The American Thoracic Society/ European Respiratory Society Statement on Pulmonary Rehabilitation: http://www.atsjournals.org/doi/pdf/10.1164/rccm.200508-1211ST
- The Australian Lung Foundation Pulmonary Toolkit: www.pulmonaryrehab.com.au
- Exercise video for Pulmonary Fibrosis: http://cpff.ca/living-with-pf/rehab-and-exercises/one-breath-at-a-time-exercise-video/
- Anthony SJ, Selkirk E, Sung L, Klaassen R, Dix D, Scheinemann K, Klassen AF. Considering quality of life for children with cancer: A systematic review of patient-reported outcome measures and the development of a conceptual model. Qual Life Res. 2014;23(3):771-89
- Cortazzo M, Helkowski W, Pippin B, Boninger M, Zafonte R. Acute inpatient rehabilitation of 55 patients after liver transplantation. Am J Phys Med Rehabil. 2005;84(11):880-4.
- Deliva R, Hassall A, Manlhiot C, Solomon M, McCrindle B, Dipchand A. Effects of an acute, outpatient physiotherapy exercise program following pediatric heart or lung transplantation. Pediatr Transplant. 2012;16(8):879-86
- Didsbury M, McGee R, Tong A, Craig J, Chapman J, Chadban S, Wong G. Exercise training in solid organ transplant recipients: A systematic review and meta-analysis. Transplantation. 2013;95:679-87.
- Gloeckl R, Halle M, Kenn K. Interval versus continuous training in lung transplant candidates: A randomized trial. J Heart Lung Transplant. 2012;31:934-41.
- Haykowsky M, Taylor D, Kim D, Tymchak W. Exercise training improves aerobic capacity and skeletal muscle function in heart transplant recipients.American Journal of Transplantation.2009;9(4):734-9.
- Ihle F, Neurohr C, Huppmann P, Simmermann G, Leuchte H, Baumgartner R, Kenn K, Sczepanski C, Hatz R, Czerner S, Frey L, Ueberfuhr P, Bittmann I, Behr J. Effect of inpatient rehabilitation on quality of life and exercise capacity in long-term lung transplant survivors: A prospective, randomized study. J Heart Lung Transplant. 2011;30:912-9.
- Langer D, Burtin C, Schepers L, Ivanova A, Verleden G, Decramer M, Troosters T, Gosselink R.Exercise training after lung transplantation improves participation in daily activity: A randomized controlled trial.American Journal of Transplantation.2012;12(6):1584-92.
- Manzetti J, Hoffman L, Sereika S, Sciurba F, Griffith B. Exercise, education, and quality of life in lung transplant candidates. J Heart Lung Transplant. 1994;13(2):297-305.
- Painter PL, Hector L, Ray K, Lynes L, Dibble S, Paul SM, Tomlanovich SL, Ascher NL. A randomized trial of exercise training after renal transplantation. Transplantation. 2002;74(1):42-8.
- Patterson C, So S, Schneiderman JE, Stephens D, Stephens S. Physical activity and its correlates in children and adolescents post-liver transplant. Pediatr Transplant. 2016;20:227-34.
- Williams T, McKenna M. Exercise limitation following transplantation. Compr Physiol. 2012;2(3):1937-79.
- Wickerson L, Mathur S, Brooks D. Exercise training after lung transplantation: A systematic review. J Heart Lung Transplant. 2010;29(5):497-503.
Special thanks given to the physiotherapists Nancy Howes (London Health Sciences Centre), Lisa Wickerson (Toronto General Hospital), Robin Deliva (Hospital for Sick Children; HSC), Catherine Patterson (HSC), Degen Southmayd (HSC), Stephanie So (HSC), and Samantha Anthony (HSC) for contributing to the creation of this page.