388

ORIGINAL
Assessment of dyspnea, ADL, and QOL in the perioperative
period in lung cancer patients treated with minimallyinvasive surgery
Zhang Linwan1, Kazuya Kondo1, Takae Bando2, Naoya Kawakita3, Hiroaki Toba3, Yoshie Imai4,and Hiromitsu Takizawa3
Department of Oncological Medical Services, 2Department of Medical Treatment Recovery Nursing, 3Department of Thoracic, Endocrine
Surgery and Oncology, 4Department of Oncology Nursing, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan

1

Abstract : Objective : Patients with lung cancer generally undergo minimally invasive surgery, such as video-assisted thoracoscopic surgery (VATS). This study examined the changes in health conditions and symptoms of patients with lung cancer using the European Organization for Research and Treatment of Cancer-Quality of Life
Questionnaire (EORTC QLQ) C-30 questionnaires after surgery. Methods : This was a longitudinal descriptive
study. One hundred and three patients with lung cancer who underwent lung resection at Tokushima University
Hospital between 2012 and 2021 were eligible. They completed EORTC QLQ-C30, QLQ-LC13, the Cancer Dyspnea
scale (CDS), and pulmonary-ADL (P-ADL) before and 1, 3, and 6 months after surgery. Results : Regarding functional scale scores, impairments in physical and role functions persisted for 6 months after surgery. In symptom
scale scores, fatigue, pain, dyspnea, and appetite loss continued for 6 months after surgery. In CDS, sense ofeffort, discomfort, and total dyspnea scale scores were elevated for 6 months after surgery. In P-ADL, most ADL
were impaired 1 month after surgery, but recovered by 3 months. The dyspnea index of ADL was lower for 6
months after surgery. Conclusions : Impairments in health conditions and symptoms persisted for 6 months after
surgery despite its minimally invasive nature. J. Med. Invest. 70 : 388-402, August, 2023
Keywords : ADL dyspnea, lung cancer, minimally invasive surgery, patient-reported outcome, QOL

INTRODUCTION
Lung cancer is the most common cancer and the leading causeof death in Japan and worldwide (1, 2). Available treatments
include surgery, radiotherapy, chemotherapy, targeted therapy,
and immunotherapy, and patients with early-stage (stages I
and II) lung cancer generally undergo surgery, while those withadvanced or metastatic disease receive chemotherapy (3). The
5-year survival rate of early-stage lung cancer was previously
reported to be 92% in patients with resected stage IA1 disease
and 53% in those with stage IIB disease (4). However, despite
improvements in treatment, patients with advanced lung cancer
still have a poor prognosis (3). Lung resection is the mainstayof therapy for early-stage lung cancer. Treatment methods haveshifted over the last few decades. Although resection is traditionally performed using thoracotomy, in the past two decades,
video-assisted thoracoscopic surgery (VATS) and, more recently,
robot-assisted thoracoscopic surgery (RATS) have emerged as aminimally invasive alternative method (5-7). Previous studies
demonstrated that VATS was less invasive than thoracotomy,
resulting in less postoperative pain, less perioperative bleeding,and shorter hospital stays (8, 9).
In patient-reported outcomes (PROs), patients directly report the status of their health condition and symptoms without
Abbreviations : video-assisted thoracoscopic surgery (VATS), robot-assisted thoracoscopic surgery (RATS), Patient-reported outcomes(PROs), European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire (EORTC QLQ), QLQ-Lung Cancer-13 (QLQ-LC13), Quality of life (QOL), global health status (GHS),
Hospital Anxiety and Depression Scale (HADS), Mental adjustment
to cancer (MAC), Activities of Daily Living (ADL), Cancer Dyspnea
scale (CDS), index pulmonary-ADL (P-ADL), standard deviation (SD),randomized controlled trials (RCT), chronic obstructive pulmonary
disease (COPD).

interpretation by medical staff (10). The PRO questionnaire isan effective and accurate assessment of symptoms in patientstreated with surgery, radiotherapy, and chemotherapy (11).
Frequently used QOL questionnaires for cancer patients are theEuropean Organization for Research and Treatment of Cancer-Quality of Life Questionnaire (EORTC QLQ), QLQ-Lung
Cancer-13 (QLQ-LC13), Functional Assessment of Cancer Therapy, and Medical Outcome Study Short Form-36 (12-14). EORTCQLQ-C30 and QLQ-LC13 are mostly used for patients withlung cancer. QLQ-LC13 consists of 13 items that assess specificsymptoms of lung cancer and, based on the use of QLQ-C30, thefindings of an extensive field study confirmed the reliability of
LC13 to assess respiratory function (14).
Quality of life (QOL) after lung cancer surgery is currently attracting increasing attention. In the Akezaki study, QOL, pain,
and fatigue did not sufficiently improve within the first week
after minimally invasive surgery from those before surgery (15).
However, the findings of a randomized study on VATS and open
thoracotomy showed a better QOL in the VATS group one monthafter surgery (16).
We herein used EORTC QLQ-C30, QLQ-LC13, the Hospital
Anxiety and Depression Scale (HADS), and Mental Adjustment
to Cancer (MAC scale) to examine perioperative QOL, anxiety,depression, and mental adjustments in patients with lung cancer
Received for publication May 8, 2023 ; accepted May 31, 2023.
Address correspondence and reprint requests to Kazuya Kondo,
Department of Oncological Medical Services, Graduate Schoolof Biomedical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima 770-8509, Japan and Fax : +81-88-633-9031.
E-mail : kzykondo@tokushima-u.ac.jp

The Journal of Medical Investigation Vol. 70 2023

The Journal of Medical Investigation Vol. 70 August 2023
treated with minimally invasive surgery (14, 17, 18). Our preliminary study showed impairments in physical and role functions
and several symptoms, such as coughing, dyspnea, and chest
pain, persisted for up to 6 months after surgery. Shortness ofbreath in patients limits ADL and affects health-related QOL(19). Therefore, this study confirms impairments in physical androle functions and several symptoms persisted for up to 6 months
after surgery by increasing the number of case, and clarifies
whether dyspnea impair activities of daily living (ADL) or notusing the Cancer Dyspnea Scale (CDS), a more detailed tool forassessing dyspnea, and the index pulmonary-ADL (P-ADL), an
assessment of impaired ADL specific to respiratory disease inlung cancer patients (20, 21).

METHODS
DesignA longitudinal descriptive study

Patients
A flowchart summarizing the number of patients in 2 projects is shown in Supplementary Figure 1. Forty-nine patientswith lung cancer who underwent lung resection at Tokushima
University Hospital between 2012 and 2015 were eligible for inclusion in the present study (Project A). They completed EORTCQLQ-C30, QLQ-LC13, HADS, and MAC before and 1, 3, 6
months after surgery. Fifty-four lung cancer patients who underwent lung resection at Tokushima University Hospital between
2019 and 2021 were also eligible for inclusion in the present
study (Project B). They completed EORTC QLQ-C30, QLQLC13, CDS, and P-ADL before and 1, 3, 6 months after surgery.
The following patients were excluded from this study : patientswith mental instability before surgery, patients with an inability
to communicate or those with impaired cognitive function, andpatients with mental illness.

Ethical considerations
The present study was approved by the Clinical Research Ethical Review Board of Tokushima University Hospital (approval
no. 1460 for project A, approval no. 3543 for project B). Prior to
the initiation of the study, subjects were informed of all necessary information regarding the publication of the study data,
both verbally and in writing. They were also provided with thefollowing details : the privacy of study subjects will be protected,
there will be no treatment-related disadvantages regardless ofwhether they participate in the study, they will not be identifiable from the study data, and they may discontinue at any time.
Patients who consented to these conditions were included in thepresent study. This study was conducted on patients who wererecovering from invasive treatment associated with significant
mental and physical burdens. Therefore, investigators conductedeach interview after discussing the physical and mental conditions of the patient with the attending nurses, while carefully
considering the mental and physical stress of the interview on
the patient and the patient’s physical condition.

Research tools
1. EORTC QLQ-C30 (version 3.0) and LC-13
EORTC QLQ-C30 (version 3.0) and LC-13 were used (14, 22).
Version 3.0 is currently the standard version of QLQ-C30. It isa core cancer-specific questionnaire containing 30 items on patients’ functioning, global QOL, and disease- and treatment-related symptoms. It includes five functional scales (physical, role,emotional, social, and cognitive functioning), three symptom
scales (fatigue, pain, and nausea/vomiting), a Global Health389

Status / QoL scale, a number of single items assessing additionalcommon symptoms of cancer (dyspnea, loss of appetite, insomnia, constipation, and diarrhea), and a single item measuring
the financial impact of disease. QLQ-LC13 is a site-specificquestionnaire consisting of 13 items on lung cancer symptoms(cough, hemoptysis, dyspnea, and site-specific pain) and its
treatment-related side effects (sore mouth, dysphagia, peripheral
neuropathy, and alopecia). Scores for all of the multi-item scales
and single-item measures ranged between 0 to 100, with a highscore for a functional scale indicating a healthy level of functioning and that for a symptom scale representing worse symptoms.
EORTC QLQ-C30 has been translated into more than 110
languages and validated in different samples of cancer patientsin many countries (23, 24). The Japanese version was confirmed
to be a reliable and valid questionnaire for assessing lung cancer
patients in Japan (25). The EORTC QLQ-C30 summary score
was previously shown to be more sensitive for detecting changes
in QOL after lung cancer surgery than each QOL-C30 GHS(26-28). We also used the EORTC QLQ-C30 summary score in
the present study. QLQ-C30 Summary Score = { Physical Functioning + Role Functioning + Social Functioning + Emotional
Functioning + Cognitive Functioning + (100-Fatigue) + (100Pain) + (100-Nausea/Vomiting) + (100-Dyspnea) + (100-Sleeping
Disturbances) + (100-Appetite Loss) + (100-Constipation) +(100-Diarrhea) }/13.

2. HADS (17)The purpose of HADS was to screen for clinically significant
anxiety and depressive symptoms in medically ill patients.
This is an individually administered questionnaire and may be
given via a self-report or by an interviewer. There are 7 items
for anxiety and 7 items for depression. Responses are rated on
a 4-point Likert scale and range between 0 and 3. The total
score for HADS ranges between 0 and 21 : 0–7 for normal orno anxiety or depression, 8–10 for mild anxiety or depression,
11–14 for moderate anxiety or depression, and 12–21 for severe
anxiety or depression. In adults, this measure typically requires<5 minutes to complete.

3. MACThe MAC scale was developed in England by Watson et al.
(18). This is a unique scale that was developed in an attempt
to measure the specific mental adjustments of cancer patients.
The MAC scale is a 40-item self-rating scale. It consists of fivesubscales : fighting spirit (16 items), anxious preoccupation(nine items), fatalism (eight items), helplessness : hopelessness(six items), and avoidance (one item). Possible responses to eachstatement are : (1) ‘definitely does not apply to me’, (2) ‘does not
apply to me’, (3) ‘applies to me’, and (4) ‘definitely applies to me’.
The MAC scale has adequate validity and reliability (18, 29, 30).
The Japanese version, similar to the original MAC scale, is areliable and valid clinical research tool in Japan (31).

4. CDS (20)
CDS is the first scale that evaluates the multidimensional nature of dyspnea. It is a brief self-rating questionnaire composedof 3 factors and 12 items (‘sense of effort’ for 5 items, ‘sense ofanxiety’ for 3 items, and ‘sense of discomfort’ for 4 items). Its feasibility, reliability, and validity are satisfactory for clinical use.
The average time required to complete CDS is 140 seconds. The
English version of CDS is currently used worldwide.

5. P-ADL
Some of the ADL measurements introduced for patients withrespiratory disorder are not the golden standard (32, 33). Goto et
al. reported a new ADL measurement, Pulmonary emphysema

Z. Linwan, et al. Perioperative QOL in lung cancer patients390

ADL (P-ADL, version 1.0), and revised it to P-ADL, version 2.0(19, 21). P-ADL calculates scores by categories (Meals, Toileting, Bathing, Washing one’s hair, Cosmetic, Gowning, Walking
around indoors, Staircase, and Walking outdoors) or by an index(Distance, Accomplishment, Frequency, Velocity, Dyspnea andOxygen content). It is possible to identify actions in ADL thatare affected by respiratory disturbance. P-ADL is associatedwith respiratory function (such as vital capacity and forced vital
capacity), the 6-minute walking distance test, and the functional
independent measure, which measures ADL scores (19, 34).
P-ADL is a reliable and valid clinical research tool for ADL byrespiratory disturbance in Japan.

6. Statistical analysis
Data from EORTC QLQ-C30 and QLQ-LC13 were combinedfrom project A (n = 49) and project B (n = 54) and analyzed.
Data on HADS (n = 49), MAC (n = 49), CDS (n = 54), and P-ADL(n = 54) were analyzed separately. The Shapiro-Wilk test wasused to examine whether numerical datasets were normally
distributed. Statistical analyses were performed using theFriedman test and Scheffé’s test (post-hoc), which calculated

the p-value in multiple comparisons with a significance level ofp < 0.05. The Friedman test is a non-parametric statistical test
that was developed by Milton Friedman (35). It is used for a oneway repeated measure analysis of variance by ranks. Scheffé’stest is a type of post-hoc statistical analysis that is used for unplanned comparisons. Statistical analyses were performed using
Excel statistics version 3.21 (BellCurve, Inc.).

RESULTS
Participants

The clinicopathological characteristics of 103 patients are
summarized in Table 1. There were 61 men (59%) with a mean
age of 69 (46–88) years. There were 57 smokers with a mean
Brinkman index of 900. Tumors were classified according to
the predominant histological subtype, as proposed by the 2015
WHO classification (36). There were 83 cases (81%) of adenocarcinoma and 15 (15%) of squamous cell carcinoma. Tumor staging
was selected based on the seventh edition of the tumor nodemetastasis classification for lung cancer (37). The numbers ofTable 1. Patient characteristics in the present study
Age

68.6

Gender (male / female)

61/42

Smoker57
Brinkman index (mean)(46 - 88)55%

900(200 - 2250)

Pathology*
adenocarcinoma

83

81%

squamous cell carcinoma

15

15%

large-cell lung carcinoma

11%

small cell lung cancer

22%others

2

2%

IA

65

63%

IB

13

13%

IIA

8

8%

IIB

4

4%

IIIA

9

9%

IIIB

1

1%

IVA

2

2%

restrictive dysfunction (VC)

3

3%

obstructive dysfunction (FEV1.0)

31

30%

diffusion dysfunction (DLco)

19

18%

lobectomy

79

77%

segmentectomy or wedge resection

24

23%

video-assisted thoracic surgery (VATS)

91

88%

robot-assisted thoracic surgery (RATS)

9

9%

3

3%

Pathological stage*

Respiratory function

Surgery

Surgical approach

thoracotomy
Surgery time (min)248.6(89 - 521)

VC ; vital capacity, FEV1.0 ; forced expiratory volume in 1 second, DLco ; diffusing capacity of thelungs for carbon monoxide

The Journal of Medical Investigation Vol. 70 August 2023
pStage IA, IB, IIA, IIB, and IIIA cases were 65 (63%), 13 (13%),8 (8%), 4 (4%), and 9 (9%), respectively. Three cases (3%) showeda disorder in preoperative restrictive respiratory function, 31(30%) in obstructive function, and 19 (18%) in diffusion function.
Lobectomy was performed on 79 patients (77%) and segmentectomy or wedge resection on 24 (23%). Ninety-one patients (88%)
underwent surgery using the VATS method and 9 (9%) using the
RATS method. The mean operation time was 249 (89-521) min.

Perioperative changes in EORTC-QLQ-C30, QLQ-LC13, HADS,
and MAC scale scores of lung cancer patients treated with surgery
1. Functional scales in EORTC-QLQ-C30 (Figure 1, Table 2)
Perioperative changes in QOL is shown in Figure 1. The mean,
standard deviation (SD), and Scheffé’s paired comparisons foreach scale are shown in Table 2. In 5 functional (physical, role,emotional, social, and cognitive) scale scores, physical and role
function scale scores were significantly lower 1, 3, and 6 months
after surgery than before surgery (Fig. 1-b, 1-c). The emotional
functioning score was higher 3 and 6 months after surgery than
before surgery (Fig. 1-d). Although the GHS score was significantly lower 1 month after surgery than before surgery, it recovered to the pre-surgery value after 3 months (Fig. 2-a).

2. Symptom scales in EORTC-QLQ-C30 (Figure 1, Table 2)
In 9 symptom (fatigue, nausea and vomiting, pain, dyspnea,
insomnia, anorexia, constipation, diarrhea, and financial difficulties) scale scores, fatigue, pain, dyspnea, and appetite loss
scores were significantly higher 1, 3, and 6 months after surgery
than before surgery (Fig. 1-e, f, g, and h).

3. EORTC QLQ-C30 summary score
EORTC QLQ-C30 summary scores were significantly lower 1
and 3 months after surgery than before surgery (Fig. 1-i).

4. Symptom scales in EORTC-LC-13 (Figure 1, Table 2)
Among 13 lung cancer-specific symptoms (cough, hemoptysis,
severity of shortness of breath, chest / body pain, and chemotherapy/radiotherapy side effects, such as a sore mouth, dysphagia,
peripheral neuropathy, and hair loss), dyspnea, cough, and painin the chest scores were significantly higher 1, 3, and 6 months
after surgery than before surgery (Fig. 1-j, k, l).

5. Symptom scales in HADS (Supplementary Figure 2-a and b, Table 2)
HADS is used to screen for clinically significant anxiety anddepressive symptoms in medically ill patients. The anxiety score
gradually decreased over time after surgery (Supplementary
Figure 2-a, Table 2). No significant differences were observed
perioperatively in depressive symptoms (Supplementary Figure
2-b, Table 2).

6. Symptom scales in MAC (Supplementary Figure 3-a, b, c, d, e, andg, Table 2)
The MAC scale consists of five subscales : fighting spirit, anxious preoccupation, fatalism, helplessness : hopelessness, andavoidance. No significant differences were observed in any of thesubscales perioperatively.

CDS of lung cancer patients treated with surgery perioperatively(Figure 2 and Table 2)
Perioperative changes in CDS are shown in Figure 2. The
mean, SD, and Scheffé’s paired comparisons for each scale areshown in Table 2. Sense of effort and discomfort scale scores
were significantly higher 1, 3, and 6 months after surgery than
before surgery (Fig. 2-a, 2-b). The sense of anxiety score wassignificantly higher 3 months after surgery than before surgery(Fig. 2-c). The total dyspnea score was significantly higher 1, 3,391

and 6 months after surgery than before surgery (Fig. 2-d).

P-ADL of lung cancer patients treated with surgery perioperatively(Figure 3 and Table 2)
Perioperative changes in P-ADL are shown in Figure 3. The
mean, SD, and Scheffé’s paired comparisons for each scale areshown in Table 2. Most ADL (Meals, Excretion, Bathing, Cosmetic, Gowning, Walking around indoors, and Staircase) weresignificantly more impaired 1 month after surgery than before
surgery. All ADL, except for Cosmetic, recovered 3 months after
surgery. The total ADL score was significantly lower 1 monthafter surgery than before surgery. The frequency and velocity
index of ADL were significantly lower 1 month after surgery
than before surgery. The dyspnea index of ADL was significantly
lower 1, 3, and 6 months after surgery than before surgery.

DISCUSSION
Minimally invasive surgery, such as VATS, is increasingly
used to surgically treat early-stage lung cancer (5-7). A generalassumption among surgeons is that VATS is less traumatic thanthoracotomy and is associated with less postoperative pain, lessoperative bleeding, and shorter hospital stays (8, 9). The PROquestionnaire was recently shown to be an effective and accurate
assessment of symptoms in patients treated with surgery, radiotherapy, and chemotherapy (11). However, limited information iscurrently available on the impact of minimally invasive surgery
on lung cancer using PRO. Surgery studies use PRO-QOL lessthan chemotherapy studies. Koller et al. reviewed the use of
EORTC QLQ C30 and LC13 in 109 randomized controlled trials(RCT) on lung cancer patients, and showed that chemotherapy
was the most frequently applied treatment (79%), followed byradiotherapy (16%), and targeted therapy (16%). RTC included
only 2 surgery studies (1.8%) (38).
Previous studies that measured PRO-QOL after thoracotomy
or VATS have been retrospective or cross-sectional in design andwith a small sample size (39-42). A few recent studies on PROQOL have been prospective, longitudinal descriptive-before andafter VATS 6-12 months and with a moderate sample size, which
is similar to the present study (43-45). We prospectively measured EORTC-QLQ C30 and LC-13 before and 6 months after
VATS. The surgery modality was mostly minimally invasive
surgery, namely, VATS (88%) and RATS (9%). However, impairments in physical and role functions persisted until 6 months
after surgery, as did symptoms such as fatigue, pain, dyspnea,
and cough. Bendixen et al. compared pain and QOL between
lung cancer patients treated with VATS and those treated withthoracotomy using RCT, and reported that VATS was associatedwith less postoperative pain and better QOL than thoracotomy
in the first year after surgery (43). Avery et al. examined EORTC-QLQ-C30 for lung cancer patients who underwent VATS(84%), and reported that PRO QOL had not fully recovered 12months post-surgery, with reduced physical, role, and social
functions and increased fatigue and dyspnea (44). Pompili et al.
examined PRO-QOL in lung cancer patients treated with VATS,
and reported a deterioration in role, physical, and social functions and global health, fatigue, dyspnea, pain, appetite loss, andconstipation 6 weeks after surgery. These scores improved by 12months, but did not reach preoperative values (45). Collectively,
these findings and the present results revealed impairments inphysical and role functions and the worsening of fatigue, dyspnea, and pain symptoms immediately after surgery without
full recovery after 6-12 months ; however, VATS was associatedwith less postoperative pain and better QOL than thoracotomy.
Dyspnea predominantly affects physical activities, such as

Statistical analyses were performed using the Freidman test and Scheffé’s test (post-hoc).
(a) Global health status (Freidman : P <  0.001). GHS scores were significantly lower 1 month after surgery than before surgery.
(b) Physical function (Freidman : P <  0.001). Physical function scores were significantly lower 1 (P <  0.001), 3 (P <  0.001), and 6 months (P = 0.0014) after surgery than before surgery.
(  c    ) Role function (Freidman : P <  0.001). Role function scores were significantly lower 1 (P <  0.001), 3 (P <  0.001), and 6 months (P <  0.001) after surgery than before surgery.
(d) Emotional function. (Freidman : P <  0.001). Emotional function scores were significantly lower 3 (P = 0.0034) and 6 months (P <  0.001) after surgery than before surgery.
(e  ) Fatigue (Freidman : P <  0.001). Fatigue scores were significantly higher 1 (P <  0.001), 3 (P = 0.0011), and 6 months (P = 0.0014) after surgery than before surgery.
(f  ) Pain (Freidman : P <  0.001). Pain scores were significantly higher 1 (P <  0.001), 3 (P = 0.0041), and 6 months (P = 0.0198) after surgery than before surgery.
(g) Dyspnea (Freidman : P <  0.001). Dyspnea scores were significantly higher 1 (P <  0.001), 3 (P <  0.001), and 6 months (P <  0.001) after surgery than before surgery.
(h) Appetite loss (Freidman : P <  0.001). Appetite loss scores were significantly higher 1 (P <  0.001), 3 (P <  0.001), and 6 months (P = 0.0068) after surgery than before surgery.
(i ) QLQ-C30 Summary Score = (Physical Functioning + Role Functioning + Social Functioning + Emotional Functioning + Cognitive Functioning + 100-Fatigue + 100-Pain + 100-Nausea_Vomiting +100-Dyspnea + 100-Sleeping Disturbances + 100-Appetite Loss + 100-Constipation + 100-Diarrhea)/13. (Freidman : P <  0.001). QLQ-C30 Summary Scores were significantly higher 1 (P <  0.001) and 3
months (P = 0.011) after surgery than before surgery.
( j  ) Dyspnea (Freidman : P <  0.001). Dyspnea scores were significantly higher 1 (P <  0.001), 3 (P <  0.001), and 6 months (P = 0.02) after surgery than before surgery.
(k) Cough (Freidman : P <  0.001). Cough scores were significantly higher 1 (P <  0.001), 3 (P <  0.001), and 6 months (P = 0.0361) after surgery than before surgery.
( l   ) Pain in chest (Freidman : P <  0.001). Pain in chest scores were significantly higher 1 (P <  0.001), 3 (P <  0.001), and 6 months (P <  0.001) after surgery than before surgery.

Figure 1. Perioperative time-dependent changes in EORTC-QLQ-C30 and LC-13 in lung cancer patients treated with surgery

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The Journal of Medical Investigation Vol. 70 August 2023
Table 2. Results of Scheffé’s paired comparisons for each scale
Before op

1 month after op(Mean ± SD)(Mean ± SD)

Global health status・QOL

70.4 ± 21.1

60.0 ± 21.3

< 0.00168.1 ± 21.8

Physical functioning

91.3 ± 12.2

80.1 ± 14.5

< 0.00185.2 ± 12.4

< 0.001

87.1 ± 11.1

0.001

Role functioning

94.5 ± 11.5

73.8 ± 22.8

< 0.001

81.2 ± 20.3

< 0.00185.6 ± 17.8

< 0.001

Emotional functioning

80.8 ± 18.0

82.9 ± 16.1

86.7 ± 16.1

0.003

87.9 ± 13.8

< 0.001

Cognitive functioning

85.0 ± 15.0

85.8 ± 16.6

84.6 ± 17.4

Social functioning

84.8 ± 17.6

81.4 ± 21.3

Fatigue

16.9 ± 15.5

33.1 ± 18.2

Nausea and vomiting

1.5 ± 7.8

3.0 ± 9.3

Pain

4.9 ± 10.9

30.7 ± 29.9

< 0.001

Dyspnea

10.0 ± 18.0

29.1 ± 21.2

< 0.001

Insomnia

9.7 ± 16.6

20.1 ± 26.5

0.003

10.5 ± 19.3

Appetite loss

3.9 ± 10.7

14.9 ± 21.8

< 0.00112.3 ± 18.1

Constipation

14.6 ± 19.1

16.2 ± 24.6

ScalesP

3 months after op(Mean±SD)P

6 months after op(Mean ± SD)

P

QLQ-C30
69.3 ± 20.9

84.1 ± 19.2

87.7 ± 15.6
< 0.00189.2 ± 15.8

25.7 ± 18.1

0.001

26.1 ± 18.4

3.7 ± 8.1

0.019

2.3 ± 8.1

12.8 ± 15.9

0.004

11.3 ± 15.5

0.020

23.0 ± 21.4

< 0.001

22.0 ± 22.7

< 0.001< 0.001

11.7 ± 17.9
< 0.001

15.9 ± 20.3

12.6 ± 23.4

0.007

12.3 ± 18.7

Diarrhea

5.5 ± 14.1

5.5 ± 14.1

9.1 ± 18.8

8.7 ± 17.4

Financial difficulties

16.8 ± 21.3

18.4 ± 21.8

12.9 ± 20.5

10.8 ± 19.4

C30 summary score90.0 ± 7.6

80.9 ± 12.6

< 0.00185.6 ± 10.5

0.011

86.7 ± 11.0

Dyspnea

10.4 ± 11.7

24.6 ± 15.5

< 0.001

19.7 ± 16.5

< 0.001

17.0 ± 15.5

0.020

Coughing

17.5 ± 21.8

39.2 ± 24.9

< 0.00131.1 ± 20.5

< 0.00124.6 ± 20.3

0.036

Hemoptysis

1.9 ± 9.1

0.6 ± 4.6

0.0 ± 0.0

0.3 ± 3.3

Sore mouth

6.1 ± 14.6

8.1 ± 17.1

9.4 ± 18.3

8.1 ± 15.1

Dysphagia

3.2 ± 9.9

7.8 ± 17.0

7.8 ± 17.0

9.4 ± 19.5

Peripheral neuropathy

8.7 ± 18.6

7.8 ± 16.3

8.7 ± 19.8

11.3 ± 21.7

Alopecia

2.6 ± 12.1

2.3 ± 8.4

5.9 ± 19.0

5.8 ± 18.9

Pain in the chest

5.8 ± 14.3

29.8 ± 26.0

Pain in an arm or shoulder

12.0 ± 21.8

14.6 ± 21.7

10.7 ± 19.9

11.0 ± 17.7

Pain in other parts

8.4 ± 19.1

15.9 ± 24.6

10.4 ± 19.3

13.3 ± 23.0

Fighting spirit

50.6 ± 7.2

45.6 ± 12.7

47.4 ± 8.6

44.7 ± 13.1

Helplessness

10.2 ± 3.6

9.1 ± 3.3

10.3 ± 4.0

9.2 ± 3.4

0.033

QLQ-LC13< 0.00118.1 ± 22.3

< 0.001

16.2 ± 20.8

< 0.001

MAC

Anxious preoccupation

22.5 ± 4.1

20.7 ± 5.5

22.0 ± 4.9

19.9 ± 5.9

Fatalism20.8 ± 4.9

20.4 ± 6.2

20.8 ± 5.0

19.7 ± 6.5

Avoidance

2.3 ± 1.1

1.7 ± 1.1

1.8 ± 0.9

2.0 ± 1.2

Anxiety

5.1 ± 4.0

3.6 ± 3.5

3.2 ± 4.0

3.1 ± 3.3

Depression

4.8 ± 3.8

4.9 ± 4.3

4.3 ± 4.6

4.0 ± 3.8

1.5 ± 2.6

3.5 ± 3.0

< 0.001< 0.001

HADS

CDS
sense of effort
sense of discomfort

1.2 ± 2.0

3.8 ± 2.7

sense of anxiety

0.2 ± 1.1

0.6 ± 1.6

total dyspnea

2.8 ± 4.6

7.9 ± 6.1

Meals

99.0 ± 2.7

97.2 ± 4.8

2.7 ± 2.8

0.029

2.9 ± 3.4

0.007
0.044

2.7 ± 2.6

0.013

2.4 ± 2.2

0.6 ± 1.4

0.018

0.4 ± 1.2

< 0.001

6.0 ± 5.50.004

5.6 ± 5.6

0.020

97.5 ± 5.6

PADL
99.0 ± 2.9

Excretion

100.0 ± 0.0

98.2 ± 3.9< 0.001

98.5 ± 4.3

99.3 ± 2.5

Bathing98.7 ± 3.2

95.3 ± 6.9< 0.001

97.4 ± 4.6

98.1 ± 4.6

Washing one’s hair

99.5 ± 2.6

98.7 ± 3.4

98.1 ± 4.4

0.021
0.032

Cosmetic

99.9 ± 0.6

98.4 ± 4.4

0.007

98.3 ± 5.0

Gowning

99.7 ± 1.2

98.2 ± 4.3

0.024

98.2 ± 5.1

99.0 ± 3.0
99.4 ± 2.9
99.0 ± 3.6

0.006

Z. Linwan, et al. Perioperative QOL in lung cancer patients

394

Before op

1 month after op(Mean ± SD)(Mean ± SD)

Walking around indoors

99.5 ± 2.0

97.5 ± 4.8

0.005

98.2 ± 4.3

98.7 ± 3.4

Staircases

94.8 ± 7.7

89.6 ± 11.3

< 0.001

92.1 ± 9.1

93.4 ± 7.7

Walking outdoors

96.7 ± 6.1

93.8 ± 7.7

94.5 ± 7.3

95.3 ± 6.7

Total score98.7 ± 2.0

96.3 ± 4.5

97.0 ± 4.8

97.9 ± 3.2

Distance

98.0 ± 3.6

96.8 ± 4.1

97.4 ± 3.7

98.1 ± 3.0

Accomplishment

99.8 ± 1.1

99.3 ± 2.2

99.8 ± 0.9

99.8 ± 0.8

Frequency

98.7 ± 3.0

97.2 ± 3.9

0.030

99.0 ± 2.9

99.1 ± 2.1

Velocity

97.2 ± 4.7

93.8 ± 8.2

0.005

95.6 ± 6.0

Dyspnea

98.1 ± 3.5

95.3 ± 6.6< 0.00195.9 ± 6.3

Oxygen content

100.0 ± 0.0

96.7 ± 15.2

ScalesP< 0.001

3 months after op(Mean ± SD)

94.6 ± 19.7

Figure 2. Perioperative time-dependent changes in CDS in lung cancer patients treated with surgeryP

6 months after op(Mean ± SD)

P96.3 ± 5.5
0.015

96.3 ± 5.5

0.026

98.0 ± 12.0

Statistical analyses were performed using the Freidman test and Scheffé’s test (post-hoc).
(a) Sense of effort score (Freidman : P < 0.001). Sense of effort scores were significantly higher 1 (P < 0.001), 3 (P = 0.029), and 6 months (P =0.007) after surgery than before surgery.
(b) The discomfort scale score (Freidman : P < 0.001). Discomfort scores were significantly higher 1 (P < 0.001), 3 (P = 0.013), and 6 months (P =0.044) after surgery than before surgery.
(c) Sense of anxiety score (Freidman : P < 0.001). Sense of anxiety scores were significantly higher 3 months (0.018) after surgery than before
surgery.
(d) Total dyspnea score (Freidman : P < 0.001). Total dyspnea score scores were significantly higher 1 (P < 0.001), 3 (P = 0.004), and 6 months (P= 0.006) after surgery than before surgery.

Statistical analyses were performed using the Freidman test and Scheffé’s test (post-hoc).
(a) Meals (Freidman : P = 0.006). Meals scores were significantly higher 1 month (P = 0.020) after surgery than before surgery. They recovered after 3 months.
(b) Excretion (Freidman : P < 0.001). Excretion scores were significantly higher 1 month (P < 0.001) after surgery than before surgery. They recovered after 3 months.
(c) Bathing (Freidman : P < 0.001). Bathing scores were significantly higher 1 month (P < 0.001) after surgery than before surgery. They recovered after 3 months.
(d) Washing one’s hair (Freidman : P = 0.0071). Washing one’s hair scores were significantly higher 3 months (P < 0.021) after surgery than before surgery.
(e) Cosmetic (Freidman : P < 0.001). Cosmetic scores were significantly higher 1 (P = 0.007) and 3 months (P = 0.0032) after surgery than before surgery.
(f) Gowning (Freidman : P = 0.0168). Gowning scores were significantly higher 1 month (P = 0.024) after surgery than before surgery. They recovered after 3 months.
(g) Walking around indoors (Freidman : P = 0.0052). Walking around indoors scores were significantly higher 1 month (P = 0.005) after surgery than before surgery. They recovered after 3 months.
(h) Staircase (Freidman : P < 0.001). Staircase scores were significantly higher 1 month (P < 0.001) after surgery than before surgery. They recovered after 3 months.
(i) Walking outdoors. Walking outdoors scores remained unchanged after surgery.
(j) Total score (Freidman : P < 0.001). Total scores were significantly higher 1 month (P < 0.001) after surgery than before surgery. They recovered after 3 months.
(k) Frequency (Freidman : P < 0.001). Frequency scores were significantly higher 1 month (P = 0.030) after surgery than before surgery. They recovered after 3 months.
(l) Velocity (Freidman : P = 0.0028). Velocity scores were significantly higher 1 month (P = 0.005) after surgery than before surgery. They recovered after 3 months.
(m) Dyspnea (Freidman : P < 0.001). Dyspnea scores were significantly higher 1 (P< 0.001), 3 (P< 0.001), and 6 months (P< 0.001) after surgery than before surgery.
(n) Distance. Then is no significance(o) Accomplishment

Figure 3. Perioperative time-dependent changes in P-ADL in lung cancer patients treated with surgery

The Journal of Medical Investigation Vol. 70 August 2023

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Z. Linwan, et al. Perioperative QOL in lung cancer patients

walking, taking meals, and climbing staircases, because it causes an imbalance between oxygen demand and supply. On theother hand, pain affects psychological conditions and physical activities to the same degree (46). In the present study, we focusedon the relationship between “dyspnea” and “ADL” using CDS
and P-ADL questionnaires. To the best of our knowledge, CDS
developed by Tanaka et al. (20) is the first scale to evaluate themultidimensional nature of dyspnea in cancer patients. It comprises 3 factors (sense of effort, sense of discomfort, and sense ofanxiety) and 12 items. Tanaka et al. reported that ‘sense of effort’correlated with the performance status, which represents physical status, and reflected impairments in physical activity aspects
because of dyspnea. They reported that ‘sense of discomfort’correlated with the saturation of percutaneous oxygen measured
at rest, which reflected an uncomfortable feeling at rest rather
than shortness of breath during exercise. They also demonstrated that ‘sense of anxiety’ correlated with the psychological statusmeasured by the State-Trait Anxiety Inventory questionnaire(47), which reflected the psychological nature of dyspnea amplified by anxiety rather than a patient’s physical condition (20, 48).
The present study showed that sense of effort, discomfort scale,and total dyspnea scores were significantly higher 1, 3, and 6
months after surgery than before surgery, whereas no significant differences were observed in the sense of anxiety. These results revealed that the psychological nature of dyspnea remained
stable over time after surgery, whereas dyspnea on exercise andat rest continued until 6 months after surgery.
Patients with respiratory disorders, such as chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis, have restricted ADL and impaired QOL (48). Difficulties
are associated with accurately measuring ADL in these patientsusing a standard ADL scale because of dyspnea. Goto et al. produced and developed the P-ADL questionnaire (versions 1 and 2),
which is a specific ADL scale for patients with respiratory disorders (21, 49, 50). Dyspnea is classified not only by the categoriesof the action, but also by the index of the action. P-ADL consistsof 9 categories (Meals, Excretion, Bathing, Washing one’s hair,
Cosmetic, Gowning, Walking around indoors, Walking outdoors,
and Staircase) and estimates 6 indexes (Distance, Accomplishment, Frequency, Velocity, Dyspnea, and Oxygen content). We
used P-ADL to perioperatively estimate ADL in lung cancer
patients treated with surgery ; however, it is frequently used forpatients with COPD. The present study showed that most of thecategories of ADL were impaired 1 month after surgery, but recovered by 3 months after surgery. Blackwood reported that lungcancer survivors showed the greatest impairments in five ADL
categories : transferring, bathing, dressing, toileting, and feeding (51). This is consistent with the present results. In P-ADL,
the frequency and velocity of performing ADL were reduced at 1
month, but were not observed at 3 months.
However, only dyspnea when performing ADL persisted until
6 months. Patients with lung cancer need advice regarding
QOL-dyspnea, pain and fatigue, and ADL from medical doctors
and nurses in the 3 months after surgery, particularly within 1month. They may perform most ADL without any restrictions at
3 months. However, medical staff need to consider the impact ofdyspnea 6 months after surgery despite the minimally invasivenature of surgery.
Since dyspnea is an uncontrollable symptom that occurs
at an indeterminate time, it is not possible to plan for timely
treatment (52). Comprehensive breathlessness services that
integrate self-management support are ideal for improving
breathlessness and QOL (53). Breathing exercises for pulmonary
expansion, such as pursed-lip breathing, abdominal breathing,thoracic breathing, incentive spirometry, inspiratory and muscle
training, bronchial hygiene, early mobilization, deambulation,

postural correction, and shoulder range of motion activities
during the perioperative period, improve dyspnea in lung cancer
patients (54, 55). Nursing interventions are needed for patientsto understand the multiple benefits of perioperative exercise
training for physical function, the prevention of postoperativecomplications, and reductions in hospitalization. Nurses may
assist a patient’s family to help the patient get out of bed forwalking as early as possible after surgery and provide appropriate assistance with ADL.
We used the MAC scale and HADS to examine whether surgery affected the psychological status perioperatively. The MAC
scale measures the specific mental adjustment of cancer patientsusing 5 subscales : helpless/hopeless, anxious preoccupation,fighting spirit, cognitive avoidance, and fatalism. All 5 subscales
were stable 6 months after surgery. Surgery did not affect mental adjustment. However, although it was not significant, anxiety
gradually decreased after surgery. Khullar et al. reported thatanxiety-fear and depression both significantly improved after
surgery (56). Therefore, patients may become comfortable after
successful surgery.

STUDY LIMITATIONSThere are several limitations that need to be addressed. 1)
This was a single-center study with a moderate sample size(n = 103). 2) There was an interval of 4 years between Projects
A (n = 49) and B (n = 54). We simultaneously analyzed EORTCQLQ C30 and QLQ C-13 data from the two projects. However,the patient population was almost homologous for early-stagelung cancer (pStage I or II), lobectomy, minimally invasive
surgery (VATS or RATS), and adenocarcinoma. This was a prospective longitudinal descriptive study. 3) P-ADL may be used
to clarify which actions in ADL are affected by respiratory disturbance. However, since there is currently no English version of
P-ADL, researchers outside of Japan cannot use it.

CONCLUSIONS
Impairments in physical and role functions and the symptoms
of pain and dyspnea persisted until 6 months after surgery despite the minimally invasive nature of surgery. Dyspnea after
surgery was physiological, not psychological. Impairments in
ADL were related to dyspnea. Breathing exercises are necessary
to improve dyspnea in lung cancer patients.

CREDIT AUTHORSHIP CONTRIBUTION STATEMENT
Zhang Linwan : Conceptualization, Methodology, Formal
analysis, Investigation, Data curation, Writing-original draft,
Writing-review and editing. Kazuya Kondo : Conceptualization,
Methodology, Formal analysis, Data curation, Writing-originaldraft, Writing-review and editing, Project administration. Takae
Bando : Conceptualization, Methodology, Validation, Formal
analysis, Data curation, Writing-review and editing. Yoshie
Imai : Conceptualization, Investigation, Data curation, Writing-review and editing. Naoya Kawakita : Conceptualization,
Investigation, Data curation. Hiroaki Toba : Conceptualization,
Investigation, Data curation. Hiromitsu Takizawa : Conceptualization, Methodology, Formal analysis, Supervision, Writingreview and editing.

The Journal of Medical Investigation Vol. 70 August 2023
FUNDINGNo funding was received.

AVAILABILITY OF DATA AND MATERIALSThe datasets used and / or analyzed during the present study
are available from the corresponding author upon reasonable
request.

DECLARATION OF COMPETING INTERESTS
There is no conflict of interest.

ETHICS APPROVAL AND CONSENT TO PARTICIPATEThe Ethics Committee of the University of Tokushima approved the present study (Tokushima University Hospital,
approval no. 4071), and all procedures were conducted according
to the Declaration of Helsinki. All patients provided written
informed consent.

PATIENT CONSENT FOR PUBLICATION
Not applicable.

ACKNOWLEDGMENTS
Not applicable.

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54. Kendall F, Abreu P, Pinho P, Oliveira J, Bastos P : The roleof physiotherapy in patients undergoing pulmonary surgery
for lung cancer. A literature review. Revista Portuguesa dePneumologia (English Edition) 23 : 343-351, 2017
55. Cavalheri V, Granger CL : Exercise training as part of lungcancer therapy. Respirology 25 : 80-87, 2020
56. Khullar OV, Rajaei MH, Force SD, Binongo JN, Lasanajak
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Supplementary Figure 1. Flowchart summarizing the number of patients in 2 projects.
EORTC-QLQ : European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire,
HADS : Hospital Anxiety and Depression Scale, MAC : Mental Adjustment to Cancer, CDS : Cancer Dyspnea Scale,
P-ADL : Pulmonary Activities of Daily Living, op : operation

400

Z. Linwan, et al. Perioperative QOL in lung cancer patients

Supplementary Figure 2. Perioperative time-dependent changes in HADS in lung cancer patients treated with surgery
Statistical analyses were performed using the Friedman test and Scheffé’s test (post-hoc).
(a) Anxiety. Anxiety scores gradually decreased after surgery.
(b) Depression. Depression scores remained constant perioperatively.

Supplementary Figure 3. Perioperative time-dependent changes in MAC in lung cancer patients treated with surgery
Statistical analyses were performed using the Friedman test and Scheffé’s test (post-hoc).
(a) Fighting spirit. Fighting spirit scores remained constant perioperatively.
(b) Helplessness. Helplessness scores remained constant perioperatively.
(c) Anxious preoccupation. Anxious preoccupation scores remained constant perioperatively.
(d) Fatalism. Fatalism scores remained constant perioperatively.
(e) Avoidance. Avoidance scores remained constant perioperatively.

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The Journal of Medical Investigation Vol. 70 August 2023
Supplementary Table 1
Pulmonary ADL : P-ADL evaluation table
Please describe your life at home. (If you are in hospital, please describe your situation immediately prior to admission)

Prescribed oxygen volume : 1) at rest ( ) L / min, 2) during movement ( ) L / min, 3) during sleep ( ) L / min)◇ Please indicate the activity that changes your oxygen level (Please select and circle one number (0-4) for each item.
Meals
Accomplishment

0 Need assistance ineating1

2 Eat without assistance(e.g. chopped food needs to 3
be processed)

4 Eat without assistance(normal diet)

Distance

0 My own room
(recumbent position)

1

2 My own room (on thebed)

3

4 Outside my own room
(e.g. canteen)

Frequency

0 Every time I am fed

1

2 Eat without assistance3
depending on the situation

4 Eat without assistanceevery time

Velocity

0 Cannot eat at all

1 With a lot of rest

2 Take a break on the way 3 Slowly and without rest

4 Smoothly done

Dyspnea

0 Severe

1 Marked

2 Moderate

3 Slight

4 None0 Cancel by myself

1 Make changes myself

2 Mostly adhere toprescribed doses

3 Always adhere toprescribed doses

4 Not prescribed

1 Use a urinal andportable toilet

2 Use a urinal and3 Use a toilet withportable toilet at night only assistance

4 Use a toilet without
assistance1

2 By the bed

3

4 Separate toilet

1 Defecate in the toilet

2 May go to the toileting
during the day

3 Use the toilet every time
4 Use the toilet every time
during the day only

Oxygen content
ToiletingAccomplishment 0 Use a plug-in toilet
Distance

0 In the bed

Frequency

0 Do not use the toileting
to defecate

Velocity

0 Do not use to the toilet
at all

1 With a lot of rest

2 Take a break on the way 3 Slowly and without rest

4 Smoothly done

Dyspnea

0 Severe

1 Marked

2 Moderate

3 Slight

4 None0 Cancel by myself

1 Make changes myself

2 Mostly adhere toprescribed doses

3 Always adhere toprescribed doses

4 Not prescribed

1 Bed bath by myself

2 Mostly assisted bathing

3 Occasionally assisted
bathing

4 Self bathing

0 My own room

1

2 Shower only inbathrooms

3

4 Step into the bathtub

Frequency

0 No bathing at all

1

2 Occasional bathing

3

Velocity

0 Cannot do it myself at all 1 With a lot of rest

Oxygen content
Bathing

Accomplishment 0 Assisted bed bath
Distance

Dyspnea
Oxygen content

2 Take a break on the way 3 Slowly and without rest

4 Bathe daily
4 Smoothly done

0 Severe

1 Marked

2 Moderate

3 Slight

4 None0 Cancel by myself

1 Make changes myself

2 Mostly adhere toprescribed doses

3 Always adhere toprescribed doses

4 Not prescribed

1

2 Get my hair washed(including barbershops
and salons)3

4 I do it myself

1

2 Washing rooms

3

4 Bathroom

1

2 Wash hair separatelyfrom bathing

3

4 Wash hair when bathing

Washing one’s hair
Accomplishment 0 I do not wash my hair
Distance
Frequency

0 At the bed
0 Never wash my hair

Velocity

0 Cannot do it myself at all 1 With a lot of rest

2 Take a break on the way 3 Slowly and without rest

4 Smoothly done

Dyspnea

0 Severe

1 Marked

2 Moderate

3 Slight

4 None0 Cancel by myself

1 Make changes myself

2 Mostly adhere toprescribed doses

3 Always adhere toprescribed doses

4 Not prescribed0 Stay in bed and receive
assistance

1 Sit down and receive
assistance

2 Sit down and do it bymyself if prepared

3 Sit down and do it bymyself

4 Stand up and do it bymyselfDistance

0 Above the bed

1

2 Other than washingrooms (my own room)

3

4 Washing rooms

Frequency

0 Do not brush my teeth
in the washroom

1

2 Occasionally wash in thebathroom and brush my
3
teeth

Oxygen content
HygieneAccomplishment

4 Wash and brush myteeth in the washroom
every time

Velocity

0 Cannot do it myself at all 1 With a lot of rest

2 Take a break on the way 3 slowly and without rest

4 Smoothly done

Dyspnea

0 Severe

1 Marked

2 Moderate

3 Slight

4 None0 Cancel by myself

1 Make changes myself

2 Mostly adhere toprescribed doses

3 Always adhere toprescribed doses

4 Not prescribed

Oxygen content

Z. Linwan, et al. Perioperative QOL in lung cancer patients

402
Dressing

0 Getting help to change
clothes1

2 I can do it by myself if
prepared3

4 I can do it by myself

Frequency

0 I cannot change clothes
by myself

1

2 I can do it by myself
3depending on the situation

4 I can do it by myself
each time

Velocity

0 Cannot do it myself at
all

1 With a lot of rest

2 Take a break on the way 3 Slowly and without rest

4 Smoothly done

Dyspnea

0 Severe

1 Marked

2 Moderate

3 Slight

4 None1 Make changes myself

2 Mostly adhere toprescribed doses

3 Always adhere toprescribed doses

4 Not prescribed

Accomplishment 0 Cannot walk at all

1 Can walk with help

2

3 Can walk if looked after(supervised)

4 I can walk by myself

Distance

0 Cannot walk at all

1 Only around the bed

2 Only in my own room

3 Toilets and washrooms
only

4 All inside the home

Frequency

0 Cannot walk at all

1

2 Can walk in somesituations

3

4 Can walk anytime

Velocity

0 Cannot do it myself at
all

1 With a lot of rest

2 Take a break on the way 3 Slowly and without rest

4 Smoothly done

Dyspnea

0 Severe

1 Marked

2 Moderate

3 Slight

4 None1 Make changes myself

2 Mostly adhere toprescribed doses

3 Always adhere toprescribed doses

4 Not prescribed

2 Can ascend withassistance3

4 I can ascend by myself

1 2~3 stairs

2 5~6 stairs

3 Up to the second floor

4 3rd floor and above

3

4 Can ascend at any time

Accomplishment
Distance

Oxygen content 0 Cancel by myself
Walking around indoors

Oxygen content 0 Cancel by myself
Ascending a staircase

Accomplishment 0 Cannot ascend by myself 1
Distance

0 I cannot ascend at all

Frequency

0 Inaccessible

1

2 Ascend only whennecessary

Velocity

0 Cannot do it myself at
all

1 With a lot of rest

2 Take a break on the way 3 Slowly and without rest

4 Smoothly done

Dyspnea

0 Severe

1 Marked

2 Moderate

3 Slight

4 None1 Make changes myself

2 Mostly adhere toprescribed doses

3 Always adhere toprescribed doses

4 Not prescribed

1 Can walk with help

2

3 Can walk if supervised 4 Can walk by myself

Oxygen content 0 Cancel by myself
Walking outdoors

Accomplishment 0 Cannot walk at all
Distance

Maximum distance you
can walk

Frequency

0 Cannot walk at all

Velocity
Dyspnea() meters

2 Can walk in somesituations

3

4 Can walk anytime

0 Cannot do it myself at 1 With a lot of restall

2 Take a break on theway

3 Slowly and without
rest

4 Smoothly done

0 Severe

1 Marked

2 Moderate

3 Slight

4 None1 Make changes myself

2 Mostly adhere toprescribed doses

3 Always adhere toprescribed doses

4 Not prescribed

1

2 Sitting in a wheelchair3or easy chair

Oxygen content 0 Cancel by myself

1

Conversation

Accomplishment 0 While in bed (on the
bed)
Distance

Maximum time you cantalk(

4 Can be done wherever
I sit) hours

Frequency
Velocity

0 Cannot do it myself at 1 With a lot of restall

2 Take a break on theway

3 Slowly and without
rest

4 Smoothly done

Dyspnea

0 Severe

1 Marked

2 Moderate

3 Slight

4 None1 Make changes myself

2 Mostly adhere toprescribed doses

3 Always adhere toprescribed doses

4 Not prescribed

Oxygen content 0 Cancel by myself
Special mention

State of affairs as of the year / month

Date of entry :

year

month

day