Appraising Psychiatric Care From a Different Angle: Occupational Therapy Activities and Cardiorespiratory Fitness for Inpatients With Chronic Mental Illness

Abstract

Importance: People with chronic mental illness (CMI) are at high risk of poor cardiorespiratory fitness as a result of sedentary behavior and physical inactivity. Occupational therapy practitioners play a key role as advocates for positive lifestyle change for people with CMI.

Objective: To determine the relationships between occupational therapy activities and cardiorespiratory fitness among inpatients with CMI.

Design: This retrospective research included three phases: descriptive cohort, case–control, and cross-sectional studies.

Setting: Psychiatric inpatient facility.

Participants: Inpatients with CMI, ages 18 to 65 yr (N = 325).

Outcomes and Measures: Data were collected over a 12-mo period. Each daily occupational therapy activity performed by participants was converted to energy expenditure (in kcal). Cardiorespiratory fitness was measured by means of the 3-Minute Step Test.

Results: After daily occupational therapy activities, significantly more participants increased cardiorespiratory fitness than declined (McNemar χ² [1] = 29.18, p < .05). Prevocational activities and moderate- to high-intensity exercises met the optimal energy expenditure level (>352 kcal) necessary to achieve an increase in cardiorespiratory fitness.

Conclusions and Relevance: Occupational therapists in psychiatric inpatient settings should prescribe individualized occupation-based or physical activities that meet the optimal daily energy expenditure for each client to improve their cardiorespiratory function.

What This Article Adds: This study is one of the first attempts to explore cardiorespiratory fitness outcomes after daily occupational therapy activities for people with CMI. Physical benefits unfolded throughout psychiatric care, echoing the profession’s stance on holistic practice.

This study affirms the need for occupational therapists in psychiatric inpatient settings to prescribe individualized occupation-based or physical activities for people with chronic mental illness to improve their cardiorespiratory function.

People with a chronic mental illness (CMI) such as schizophrenia have a remarkably reduced life expectancy compared with people in the general population (John et al., 2018). The prevalence of cardiovascular disease (CVD), including coronary heart disease, atherosclerosis, hypertension, and stroke, is 3.6 times greater among those with CMI, making the disease one of the leading causes of premature mortality in this vulnerable population (Ilyas et al., 2017). Research has demonstrated that poor cardiorespiratory fitness (deficient capacity of circulatory and respiratory systems for delivering oxygen to working muscles) serves as a significant and independent predictor of CVD and all-cause mortality for all people (Ross et al., 2016). Cardiorespiratory fitness should be considered an important health outcome in service delivery for people with CMI.

After age 25 yr, maximal oxygen consumption, an indicator of cardiorespiratory fitness, declines at the rate of 5% to 15% per decade (Hawkins & Wiswell, 2003). Sedentary behavior and physical inactivity can serve as a catalyst that further escalates the decline in cardiorespiratory function. Abundant research has indicated that people with CMI are highly sedentary (John et al., 2018; Lavie et al., 2019; Vancampfort et al., 2017) and often experience barriers to physical activity such as psychological symptoms, low motivation, side effects of medications, fatigue, and pain (Firth et al., 2016; Stubbs et al., 2016). However, promising evidence has suggested that sedentary behavior and physical inactivity are distinctly modifiable risk factors for CVD and all-cause mortality. For people who are inactive, even small increases in physical activity can lead to improved levels of cardiorespiratory fitness and reduction in the risk of CVD (Lavie et al., 2019; Sattelmair et al., 2011). A meta-analysis revealed that people with schizophrenia significantly improved their cardiorespiratory fitness after exercise interventions (medium effect size, Hedges’ g = .43, p = .02), despite the absence of a reduction in body mass index (BMI; Vancampfort et al., 2015).

Occupational therapy practitioners working in mental health use interventions that enhance occupational functioning and participation and thus contribute to clients’ overall health (Swarbrick & Noyes, 2018). In a chronic psychiatric inpatient setting, therapists have the opportunity to establish a holistic program that incorporates a wide range of occupations (e.g., activities of daily living [ADLs], leisure, vocational training) and activities (e.g., exercise) into clients’ daily routines. Several meta-analyses and systematic review studies have provided the accumulated evidence to support the efficacy of occupational therapy in improving occupation-based or psychosocial outcomes (e.g., employment, social participation, ADLs, quality of life, depression, satisfaction) for people with various mental illnesses (D’Amico et al., 2018; Ikiugu et al., 2017; Noyes et al., 2018). However, a paucity of empirical research has shed light on physical outcomes, such as cardiorespiratory fitness after occupational therapy, for people with CMI. In the era of health promotion for all people, addressing the physical benefits of occupational therapy for this vulnerable population is equally imperative.

Study Purpose and Questions

In this study, we aimed to determine the relationship between daily occupational therapy activities (including occupation-based activities and routine exercises) and cardiorespiratory fitness among inpatients with CMI. Three research questions were proposed:

What percentage of inpatients with CMI demonstrate an increase, a decline, or no change in cardiorespiratory fitness after daily occupational therapy activities?

To what degree does an inpatient with CMI have to participate in occupational therapy activities to increase their cardiorespiratory fitness?

What specific types of occupation-based activity and routine exercise are associated with a favorable cardiorespiratory outcome?

Method

Participants

We used data collected between July 2017 and July 2018 from inpatients in the chronic care ward of a 1,200-bed psychiatric center in central Taiwan. To be included, participants had to be between ages 18 and 65 yr, have been hospitalized throughout the 12-month study term, have regularly participated in occupational therapy activities, and have completed two annual tests (2017 and 2018) of cardiorespiratory fitness. The Tsaotun Psychiatric Center’s Research Ethics Committee approved the study.

Design

This was a retrospective study that consisted of three phases carried out in sequence:

Phase 1 (n = 325): a descriptive cohort study that traced participants’ daily occupational therapy activities (including occupation-based activities and routine exercises) during the 12-mo study term and determined the outcome of cardiorespiratory fitness (increase, decline, or no change).

Phase 2 (n = 289): a case–control study that explored the relationship between the dose (specified amount) of occupational therapy activities (as measured by energy expenditure in kilocalories) and the cardiorespiratory fitness outcome: increase (case) versus no change (control).

Phase 3 (n ₁ = 2,940 person-time entries; n ₂ = 484 person-time entries): a cross-sectional study that further determined the specific types of occupation-based activity and routine exercise that met the optimal dose (in kilocalories) that is beneficial for cardiorespiratory fitness.

Activity Variables and Outcome Measure

Occupational Therapy Activities

Occupation-based activities.

The Occupational Therapy Department of the psychiatric center established a five-stage occupational rehabilitation model for inpatient clients with CMI: Stage 1, time use and orientation; Stage 2, living skills; Stage 3, work behaviors and prevocational exploration; Stage 4, vocational training; and Stage 5, community reintegration (Lin & Lee, 2020). Each client participates in activities suitable for their current functional stage. For this study, the occupation-based activities embedded in the model were categorized into (1) leisure activities, mostly for Stage 1 (e.g., karaoke singing, watching movies, card games, picnicking); (2) independent or daily living skills training, mostly for Stage 2 (e.g., social skills group, ADL and instrumental ADL [IADL] training; art, music, or drama therapy; stress management); and (3) prevocational activities for Stages 3 and 4 (e.g., vocational group activities, work behavior shaping, job-specific skill training). Activities for Stage 5 were excluded from this study because they are community- and employment-based activities for people transitioning from the inpatient setting to the center’s affiliated community programs.

Routine exercises.

Occupational therapists prescribe routine exercise programs tailored to the needs of inpatient clients in each ward unit. The exercises have three intensity levels: (1) low intensity, with 1.5 to 3.0 metabolic equivalents (METs; e.g., marching or walking, light calisthenics); (2) moderate intensity, with 3.0 to 5.0 METs (e.g., low-impact aerobics, moderate strengthening); and (3) moderate to high intensity, with 5.0 to 7.0 METs (e.g., step aerobics, moderate sports). Each client engages in the prescribed exercises with a documented goal for achieving the desired frequency, duration, and variety. The exercise routine is aimed at helping clients cultivate autonomy and independence in practicing healthy lifestyle behaviors. In this facility, most exercises take place in the lobby or the yard of each ward unit and in small groups without the therapists’ direct involvement. Some high-functioning fellow inpatients are trained by the therapists to help record daily exercise time and items completed by each person on a printed spreadsheet. The therapists lead or supervise a few moderate- to high-intensity exercises when some clients’ cardiorespiratory capacity requires monitoring. Each ward unit has incentive programs (e.g., monthly full-attendance awards, tokens, pennants) in place to endorse goal achievement.

Conversion of occupational therapy activities to energy expenditure.

As part of routine practice, occupational therapists document each inpatient’s daily intervention, including activity participation. Each of the nearly 100 different occupation-based activities and routine exercises is coded with a numeric identifier. The Excel program set up by the facility allows therapists to keep track of all daily activity and exercise entries (codes + time parameters) completed by each client. For our study participants, we further calculated energy expenditure for each activity and exercise entry using the activity–calorie conversion directory published by the Ministry of Health and Welfare of Taiwan (2018). For example, if a participant who weighs 60 kg performed karaoke singing (0.8 kcal/kg/hr) for 30 min during occupational therapy, we recorded 24 kcal (0.8 × 60 × .05 = 24) for this activity entry.

Cardiorespiratory Fitness (Outcome)

Cardiorespiratory fitness was measured by means of the 3-Minute Step Test, standardized by the Sports Administration, Ministry of Education of Taiwan (2006). This test was part of the annual functional evaluation for all inpatients at the facility. To begin the test, the person stands facing a 35-cm step box and steps up on and down from the box (up, up, down, down) to the beat of a metronome for 3 min (or less if unable to finish). At the end of 3 min, the person stops and remains seated while their pulse is taken at 1 to 1.5 min, 2 to 2.5 min, and 3 to 3.5 min posttest (yielding three readings of 30-s pulse). The cardiorespiratory fitness index (CFI) is calculated with the following formula: $CFI = \frac{Test time completed (≤ 180 s) \times 100}{Total of three 30 ‐ s pulse readings) \times 2}$

The computed CFI is then turned to the gender- and age-specific norms to determine a cardiorespiratory fitness level (CFL): 1 (poor), 2 (fair), 3 (average), 4 (good), or 5 (excellent). The CFL was adopted for the subsequent data analyses in this study.

Statistics

We analyzed the data using IBM SPSS Statistics (Version 27). McNemar’s test was used to determine the significance of the repeatedly observed dichotomous outcome (increase vs. decline in cardiorespiratory fitness). Multiple logistic regression analysis was conducted to measure the predictability of the energy expenditure of occupational therapy activities on the cardiorespiratory fitness outcome (increase or no change) with the confounding variables (e.g., gender, age, diagnosis) taken into consideration. A χ² test was performed to examine the level of energy expenditure and the types of occupational therapy activity (occupation-based activities and routine exercises) associated with an increased cardiorespiratory fitness outcome. The two-tailed significance level was set to .05.

Results

A total of 325 participants (212 [65.2%] men, 113 [34.8%] women) met the criteria for inclusion. The participants’ mean age was 49.7 yr (SD = 8.6, range = 21–65), their mean age at disease onset was 23.6 yr (SD = 7.6, range = 7–56), and the mean disease duration was 26.1 yr (SD = 9.0, range = 1–48). The majority of participants had a diagnosis of schizophrenia (90.5%; other diagnoses, 9.2%).

Descriptive Cohort Study Phase

The pretest–posttest comparison of the 3-Minute Step Test results (i.e., CFL; 1 = poor to 5 = excellent) indicated that, through the 12-mo study term, 100 (30.8%) of the 325 participants increased their level of cardiorespiratory fitness (CFL), 36 (11.1%) had a decline, and 189 (58.2%) maintained the same level. McNemar’s test confirmed that significantly more participants had an increase rather than a decline in cardiorespiratory fitness level over time (McNemar χ² [1] = 29.18, p < .05). The incidence rate of a decline in cardiorespiratory fitness for the study participants over the 12-mo period was about 11% (a one-in-nine chance). The majority of participants (n = 289; 89%) either maintained or improved their cardiorespiratory fitness over the study course.

Case–Control Study Phase

We drew on the results from the descriptive cohort phase to further explore the association between occupational therapy activity participation and the outcome of cardiorespiratory fitness: increase (case; n = 100) or no change (control; n = 189). The results of the multiple logistic regression (Table 1) indicated that, with all potential confounding variables (age, gender, age at disease onset, disease duration, diagnosis, BMI) offset, participants’ daily energy expenditure (in kilocalories) during occupational therapy activities was a significant predictor (p = .001) of the dichotomous outcome of cardiorespiratory fitness (increase or no change). The odds ratio of 1.001 suggests that, for every additional 1 kcal spent on daily occupational therapy activities, participants may have an increased 0.1% (1/1,000) chance of attaining an improved cardiorespiratory outcome.

Table 1.

Relationship Between the Daily Energy Expenditure of Occupational Therapy Activities and the Outcome of Cardiopulmonary Fitness

Variable	Regression Coefficient	Odds Ratio	p
Cardiorespiratory fitness outcome: Daily energy expenditure of occupational therapy activities, kcal (ref. = no change)	0.001	1.001	.001
Confounding factors
Age	−0.519	0.595	.257
Age at disease onset	0.520	1.683	.256
Disease duration	0.486	1.626	.287
Gender (ref. = female)	0.803	2.232	.008
Schizophrenia (ref. = no)	−0.099	0.906	.832
BMI (ref. = obese)
Skinny	0.433	1.541	.270
Underweight	0.081	1.085	.857
Normal	0.098	1.103	.851
Overweight	0.220	1.246	.620

Note. N = 289. ref. = reference.

The daily energy expenditure in occupational therapy activities for both the increase (case) and no-change (control) groups ranged from 8.5 to 1,927.2 kcal (M = 318.5, SD = 31.5, Mdn = 197.8). This range of energy expenditure was divided into four levels by quartiles: Level 1, <128 kcal; Level 2, 128 to 197 kcal; Level 3, 198 to 352 kcal; and Level 4, >352 kcal. These four levels had an approximately equal number of participants (≈70) and allowed for an examination of the dose–response relationship. As seen in Table 2, the progression of energy expenditure from Level 1 to Level 2 resulted in an unnoticeable improvement in the chance of an increase (24.6% to 25.3%), and the next progression of energy expenditure from Level 2 to Level 3 showed a modest improvement in the chance of increase (25.3% to 32.9%). By contrast, a surge in the chance of increase was observed from Level 3 to Level 4 (32.9% to 55.6%). In addition, compared with Level 1 and Level 2, respectively, Level 4 had twice the chance of increase. The Level 4 daily energy expenditure of occupational therapy activities (>352 kcal) carried out by the participants was associated with the favorable outcome of cardiorespiratory fitness (increase).

Table 2.

Relationships Between the Level of Daily Energy Expenditure of Occupational Therapy Activities and the Outcome of Cardiopulmonary Fitness

Daily Energy Expenditure Level	Cardiopulmonary Fitness Outcome, n (%)
Daily Energy Expenditure Level	No Change	Increase
Level 1 (<128 kcal)	52 (75.4)	17 (24.6)
Level 2 (128–197 kcal)	56 (74.7)	19 (25.3)
Level 3 (198–352 kcal)	49 (67.1)	24 (32.9)
Level 4 (>352 kcal)	32 (44.4)	40 (55.6)

Note. N = 289. For daily energy expenditure level, χ² (3) = 19.9, p < .0001.

Cross-Sectional Study Phase

With the Level 4 daily energy expenditure proven to be beneficial, we further explored the types of occupation-based activity and routine exercise that were associated most with this energy level. We converted our 12-mo longitudinal data to aggregated person-time entries by participants’ four energy expenditure levels (Levels 1, 2, 3, and 4) and by the three categories of occupation-based activities (i.e., leisure activities, ADL and IADL skills training, and prevocational activities). A total of 2,940 person-time entries for occupation-based activities were generated. Likewise, we calculated the aggregated person-time entries by the four energy expenditure levels and by the three routine exercises (i.e., low intensity, moderate intensity, and moderate to high intensity), which yielded a total of 484 person-time entries for routine exercises. Table 3 shows that the types of occupation-based activity and routine exercise associated most with Level 4 energy expenditure were prevocational activities and moderate- to high-intensity exercises, respectively. These two types of activity and exercise met the optimal energy expenditure level necessary for achieving the favorable cardiorespiratory fitness outcome (increase).

Table 3.

Relationships Between the Level of Daily Energy Expenditure of Occupational Therapy Activities and Types of Occupation-Based Activity and Types of Routine Exercise

Occupational Therapy Activities	Level, n (%)				χ²(6)	p
Occupational Therapy Activities	1	2	3	4	χ²(6)	p
Occupation-based activities (n = 2,940 person-time entries)					64.8	.0001
Leisure	237 (20.8)	383 (33.6)	306 (26.9)	213 (18.7)
ADL and IADL training	278 (20.4)	453 (33.3)	374 (27.5)	255 (18.8)
Prevocational	69 (15.6)	106 (24.0)	110 (24.5)	156 (35.4)
Routine exercises (n = 484 person-time entries)					13.5	.036
Low intensity	48 (24.5)	50 (25.5)	52 (26.5)	46 (23.5)
Moderate intensity	61 (25.5)	65 (27.2)	59 (24.7)	54 (22.6)
Moderate to high intensity	4 (8.2)	10 (20.4)	14 (28.6)	21 (42.9)

Note. ADL = activities of daily living; IADL = instrumental activities of daily living.

Discussion

“Achieving health, well-being, and participation in life through engagement in occupation” (American Occupational Therapy Association, 2020, p. 5) elucidates the ultimate goal of occupational therapy. Occupational therapists serving in chronic psychiatric inpatient settings have an extensive opportunity to work in close partnership with the clients to establish health-promoting habits and routines. With the high prevalence of CVD ascribed to poor cardiorespiratory fitness, daily occupational therapy activities intended for inpatient clients with CMI should take measures to reduce this modifiable risk factor. We undertook this study on the premise that occupational therapy, including occupation-based activities and routine exercises, has a positive impact on clients’ cardiorespiratory fitness.

After the 12-mo study period, 100 (30.8%) participants had an increase in cardiorespiratory fitness; in contrast, 36 (11.1%) had a decline. The difference reached statistical significance (McNemar χ² = 29.18, p < .05). Despite the unique participant demographics (e.g., M age = 49.7 yr, M disease duration = 26.1 yr) and the fact that cardiorespiratory capacity declines with age (Hawkins & Wiswell, 2003), the majority of our participants (89%) were able to maintain or improve their level of cardiorespiratory fitness. This encouraging finding echoes a conclusion from a systematic review that inpatient setting was one significant independent predictor of higher cardiorespiratory levels among people with severe mental illness (Vancampfort et al., 2017). Clients in an inpatient setting have an opportunity to carry out a high degree of physical activity through routine interventions such as occupational therapy. It was also suggested that peers’ social support can enhance inpatient clients’ adherence to therapeutic activities and exercises (Gross et al., 2016).

With all confounding factors taken into consideration, participants’ level of participation in daily occupational therapy served as a significant predictor for the cardiorespiratory fitness outcome (p = .001). Every additional 1 kcal exerted through an occupation-based activity or a routine exercise can result in an increase of 0.1% (1/1,000) chance of achieving an improved outcome. For example, if a person who weighs 60 kg adds 30 min of slow walking (3.5 kcal/kg/hr) to their activity routine, this newly occurring energy expenditure entry (3.5 × 60 × 0.5 = 105 kcal) would provide a 10.5% chance of achieving better cardiorespiratory function in the fullness of time. Even modest, achievable levels of physical activity can lead to favorable health outcomes (Sattelmair et al., 2011).

The dose–response relationship indicated that the optimal daily energy expenditure (>352 kcal) carried out through occupational therapy (occupation-based activities + routine exercises) was associated with increased cardiorespiratory fitness in inpatients with CMI. Occupational therapists practicing in chronic psychiatric inpatient settings should adopt this optimal energy expenditure level to prescribe daily occupation-based intervention activities (e.g., leisure groups, ADL and IADL training, prevocational activities), routine exercises, or both, for each client.

Among the various types of occupation-based activity, prevocational activities were most associated with the optimal energy expenditure level (>352 kcal) that could result in a favorable cardiorespiratory outcome. This finding ties in with the fact that most prevocational activities, such as job-specific training, are performed by high-functioning inpatients and are carried out at a higher dose (e.g., 3–5 hr/day; Lin & Lee, 2020). The extensive benefits of prevocational activities for people with CMI can rise to all functional aspects: psychological, social, economic, and physical (Lee et al., 2018). Among the three routine exercise levels, moderate- to high-intensity exercises (e.g., step aerobics, moderate sports) best corresponded with participants’ optimal energy expenditure level. The literature regarding exercise recommendations for people with CMI has inconsistent results. Some collective evidence has supported high-intensity interval training (e.g., Martland et al., 2020), whereas other evidence has supported moderate to vigorous physical activity (e.g., Stubbs et al., 2016) akin to the moderate- to high-intensity exercises (5.0–7.0 METs) in our study. Nonetheless, as a result of unique client demographics (e.g., older age, long disease duration), the occupational therapists in this chronic inpatient setting did not adopt high-intensity exercises for the participants. In the Appendix, we provide some actual samples of daily activity combinations (prevocational activities + routine exercises) that meet the optimal energy expenditure level of occupational therapy.

Study Limitations and Future Research

Retrospective research has inherent limitations. The lack of control and randomization in our study limits conclusions regarding cause-and-effect relationships for our variables. Our inclusion criteria ruled out a sizable number of the facility’s inpatients. The patients included were those who possibly had a better potential to benefit from occupational therapy. Caution is warranted in interpreting the reported rates or percentages drawn from our participants. Our outcomes did not include other physical functions, such as musculoskeletal flexibility and muscle strength and endurance, which are also considered important for people with CMI (Gretchen-Doorly et al., 2012). Data on each participant’s total daily energy expenditure (basal metabolic rate + energy expenditure of all daily activities) were not available and were deemed unnecessary given our study’s purpose. We assumed that occupational therapy activities made up a predominant portion of the participants’ daily physical activity and that inpatients in this facility shared similarities in their supervised daily routines. Last, this study was conducted in Taiwan. Interpretation of our findings should take into consideration the potential differences in service delivery, cultural practice, and anthropometric measurements.

Future studies should adopt a prospective longitudinal design that applies systematic and timely measures for monitoring a broad range of psychosocial and physical outcomes after routine occupational therapy services for people with CMI. Likewise, randomized controlled trials should be prioritized to consolidate the physical benefits of occupation-based activities and routine exercises for the client population. In this respect, all future research can expand participant recruitment from hospital to community settings to compare nuances in findings.

Implications for Occupational Therapy Practice

The results of this study have the following implications for occupational therapy practice:

People with CMI are at high risk for poor cardiorespiratory fitness as a result of sedentary behavior and physical inactivity. Occupational therapists should play a key role as advocates for positive lifestyle change with enhanced activity engagement among these people.

Occupational therapy activities carried out by inpatients with CMI exhibit a dose–response relationship; the higher the amount of activity, the greater the health benefits. However, clients have a chance to achieve an improved cardiorespiratory outcome even with small increases in activity participation over time.

Keeping to the optimal energy expenditure of occupational therapy activities (>352 kcal), therapists can prescribe a daily activity menu for each client to meet their individualized needs, enhance occupational performance, and carry out the anticipated degree of physical activity.

Occupational therapy practitioners working with high-functioning clients can use prevocational activities to help clients meet the optimal energy expenditure level and gain an opportunity for community reintegration and independence.

Helping clients with CMI establish a self-administered exercise routine is challenging. Although moderate- to high-intensity exercises provide a chance for a better cardiorespiratory outcome, low- or moderate-intensity exercises are easier for clients to follow through on with autonomy and independence.

Conclusion

This study is one of the first attempts to explore the outcome of cardiorespiratory fitness after daily occupational therapy activities for people with CMI. Our research method was also unique in that we adopted three sequential epidemiological designs to undertake our inquiries. Our intervention variables consisted of routine occupational therapy activities that are commonly implemented in hospital and community settings for people with CMI. Translating our research findings to real-world practice is viable. Occupational therapy activities, including occupation-based activities and routine exercises, can contribute to improved levels of cardiorespiratory fitness for people with CMI and, we expect, can reduce the risk of CVD, one of the leading causes of premature mortality in this vulnerable population. Future research is needed to consolidate the causal relationship.

Footnotes

Acknowledgments

We thank the occupational therapists at Tsaotun Psychiatric Center, Nantou County, Taiwan, for assisting in data collection. This project was sponsored by Tsaotun Psychiatric Center (Project ID 108017).

Appendix. Actual Samples of Daily Activity Combinations (Prevocational Activities + Routine Exercises) That Meet the Optimal Occupational Therapy Expenditure Level (>352 kcal)

Occupational Therapy Activities and Exercises	Kcal/kg/hr	Frequency, days/wk	Duration, hr/day
Sample 1
Prevocational activities
Hospital-wide landscaping and gardening	4.2	3	3
Landscaping and yard maintenance within a ward unit	4.0	2	1
Routine exercises (MHIE)
Mon: Step aerobics	6.8	1	0.5
Tue: Strengthening	7.0	1	0.5
Wed: Moderate sports	6.6	1	0.5
Thu: Cardiorespiratory endurance training	5.5	1	0.5
Sample 2
Prevocational activities
Working in the hospital’s laundry facility: clothes and linen cleaning, ironing and folding (delivery included)	4.0	3	5
Janitorial service: sweeping, mopping, etc., for conference rooms	3.7	2	1
Routine exercises (MHIE)
Mon: Step aerobics	6.8	1	0.5
Tue: Strengthening	7.0	1	0.5
Wed: Moderate sports	6.6	1	0.5
Thu: Cardiorespiratory endurance training	5.5	1	0.5
Sample 3
Prevocational activities
Working at the hospital’s soy milk stand: making, packing, selling, and delivery	3.5	5	2
Janitorial service: sweeping, mopping, etc., of conference rooms	3.7	2	1
Routine exercises (MHIE)
Mon: Step aerobics	6.8	1	0.5
Tue: Strengthening	7.0	1	0.5
Wed: Moderate sports	6.6	1	0.5
Thu: Cardiorespiratory endurance training	5.5	1	0.5
Sample 4
Prevocational activities
Working in the hospital’s sorting and recycling facility (nonhazardous waste)	4.0	5	3
Landscaping and yard maintenance within a ward unit	4.0	2	1
Routine exercises (MIE)
Mon: Marching workout	3.5	1	0.5
Tue: Moderate aerobic boxing	5.0	1	0.5
Wed: Moderate strengthening	5.0	1	0.5
Thu: Towel workout	4.2	1	0.5
Sample 5
Prevocational activities
Working in the hospital’s thrift store: stacking, selling, packing, and bookkeeping	3.2	5	3
Landscaping and yard maintenance within a ward unit	4.0	2	1
Routine exercises (MIE)
Mon: Marching workout	3.5		0.5
Tue: Moderate aerobic boxing	5.0		0.5
Wed: Moderate strengthening	5.0		0.5
Thu: Towel workout	4.2		0.5

Note. MHIE = moderate- to high-intensity exercise; MIE = moderate-intensity exercise.

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