A shuttle walk test for assessment of functional capacity in chronic heart failure

doi:10.1016/S0002-8703(99)70114-6

American Heart Journal

Volume 138, Issue 2, August 1999, Pages 291-298

Presented in part at the 47th Annual Scientific Sessions of the American College of Cardiology, Atlanta, Georgia, March 29 to April 1, 1998, and at the XIII World Congress of Cardiology, Rio de Janeiro, Brazil, April 26 to 30, 1998.

https://doi.org/10.1016/S0002-8703(99)70114-6 Get rights and content

Abstract

Background Peak oxygen uptake (peak VO₂ ) is a reference parameter in the assessment of functional capacity of patients with chronic heart failure, but the procedure for cardiopulmonary exercise testing with expired gas analysis is complex and expensive, so more simple and available methods are desirable. Methods We compared the usefulness of a time-limited walk test, the 6-minute walk test (6-MT), with that of a symptom-limited walk test, the shuttle walk test (SWT), in the evaluation of patients with moderate to severe chronic heart failure. We prospectively studied 46 clinically stable patients in New York Heart Association class II to IV heart failure with left ventricular ejection fraction <40% (aged 53 ± 10 years, ejection fraction 23% ± 8%, New York Heart Association functional class 2.8 ± 0.7). Each patient performed two 6-MT, two SWT and a cardiopulmonary exercise testing within 2 weeks. Results We found a close correlation between distance walked in SWT and peak VO₂ (r = 0.83, P < .001) and a moderate correlation between distance in 6-MT and peak VO₂ (r = 0.69, P < .001). Both walk tests showed to be reproducible after just one practice walk. All patients who walked > 450 m in SWT had a peak VO₂ >14 mL/kg/min. The overall discriminatory accuracy for SWT distance was greater than that for 6-MT distance for predicting a peak VO₂ <14 mL/kg/min (area under receiver operator characteristic curves 0.97 and 0.83 respectively, P = .02). Stepwise multivariate regression analysis, including clinical, exercise testing, echocardiographic, radionuclide-angiographic, and rest hemodynamic data, showed that distance walked in SWT was the only independent predictor of peak VO₂ (P < .001) and the strongest predictor of percent achieved of age- and sex-predicted peak VO₂ (%PVO₂ ) (P < .001), with only age offering additional information (P = .02). Conclusions The SWT shows to be a feasible and safe method to evaluate patients with chronic heart failure that strongly and independently predicts peak VO₂ and %PVO_2. This symptom-limited walk test seems to be more useful than 6-MT in the assessment of functional capacity in these patients. (Am Heart J 1999;138:291-8.)

Section snippets

Patients

The study population consisted of 46 patients with CHF symptoms and left ventricular ejection fraction (EF) <40% who underwent cardiopulmonary assessment in the Heart Failure Unit of our Hospital. All patients had at least a 6-month history of heart failure symptoms, and their functional class had been stable for the last 3 weeks. Exclusion criteria were acute myocardial infarction in the last 3 months, angina during exercise, sustained ventricular arrhythmias, primary pulmonary disease, or

Cycle ergometry cardiopulmonary exercise testing

The mean peak VO₂ was 17.8 ± 4.4 mL/kg/min, and %PVO₂ was 62.7% ± 17.8%. Maximal workload achieved was 56 ± 20 W. The anaerobic threshold was 14.4 ± 4.2 mL/kg/min, at a mean of 81% ± 12% of peak VO₂ (and at 49% ± 16% of %PVO₂ ). The respiratory exchange ratio at maximal exercise was 1.09 ± 0.10. One patient repeated the exercise testing because of not achieving the anaerobic threshold the first time. All tests were concluded because of fatigue or dyspnea.

Walk tests

Distances walked in 6-MT ranged from 250

Discussion

In this study we have applied the SWT to patients with heart failure first, finding that it is a simple and safe method to assess their functional capacity; in addition, it is reproducible after just one practice walk. Distance walked in SWT correlates with peak VO₂ and %PVO₂ better than distance in 6-MT does.

Peak VO₂ measurement is a reference parameter in the assessment of patients with heart failure, and its prognostic value is well known.3, 4, 5 However, CPET with expired gas analysis is

Acknowledgements

We thank Evan Loh, MD, Hospital of the University of Pennsylvania, for his critical review of this manuscript and his valuable suggestions.

References (19)

JA Patterson et al.
Treadmill exercise in the assessment of the functional capacity of patients with cardiac disease
Am J Cardiol
(1972)
AM Stelken et al.
Prognostic value of cardiopulmonary exercise testing using percent achieved of predicted peak oxygen uptake for patients with ischemic and dilated cardiomyopathy
J Am Coll Cardiol
(1996)
LP Cahalin et al.
The six-minute walk test predicts peak oxygen consumption and survival in patients with advanced heart failure
Chest
(1996)
MR Mehra et al.
Predicting prognosis in advanced heart failure: use of exercise indices
Chest
(1996)
P Faggiano et al.
Assessment of oxygen uptake during the 6-minute walking test in patients with heart failure: Preliminary experience with a portable device
Am Heart J
(1997)
E Page et al.
Comparison of treadmill and bicycle exercise in patients with chronic heart failure
Chest
(1994)
KT Weber et al.
Cardiopulmonary exercise testing
J Szlachic et al.
Correlates and prognostic implication of exercise capacity in chronic congestive heart failure
Am J Cardiol
(1985)
DM Mancini et al.
Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure
Circulation
(1991)

There are more references available in the full text version of this article.

Cited by (109)

Estimating maximum work rate during cardiopulmonary exercise testing from the six-minute walk distance in patients with heart failure
2024, International Journal of Cardiology: Cardiovascular Risk and Prevention
Exercise is recommended for patients with chronic heart failure (CHF) and its intensity is usually set as a percentage of the maximal work rate (MWR) during cardiopulmonary exercise testing (CPX) or a symptom-limited incremental test (SLIT). As these tests are not always available in cardiac rehabilitation due to logistic/cost constraints, we aimed to develop a predictive model to estimate MWR at CPX (estMWR@CPX) in CHF patients using anthropometric and clinical measures and the 6-min walk test (6 MWT), the most widely used exercise field test.
This is a multicentre cross-sectional retrospective study in a cardiac rehabilitation setting. Six hundred patients with HF in New York Heart Association (NYHA) functional class I-III underwent both CPX and 6 MWT and, through multivariable linear regression analysis, we defined several predictive models to define estMWR@CPX.
The best model included 6 MWT, sex, age, weight, NYHA class, left ventricular ejection fraction (LVEF), smoking status and chronic obstructive pulmonary disease COPD (adjusted R² = 0.55; 95% LoA −39 to 33 W). When LVEF was excluded as a predictor, the resulting model performed only slightly worse (adjusted R² = 0.54; 95% LoA −42 to 34 W). Only in 34% of cases was the percentage difference between estMWR@CPX and real MWR@CPX <10% in absolute value. EstMWR@CPX tended to overestimate low values and underestimate high values of true MWR@CPX.
Our results showed a lack of accuracy in the predictive model evaluated; therefore, for an accurate prescription of cycle-ergometer exercise training, it is necessary to assess MWR by CPX or SLIT.
Interpreting Meaningful Change in the Distance Walked in the 10-Metre ISWT in Cardiac Rehabilitation
2019, Heart Lung and Circulation
Citation Excerpt :
The 10-metre incremental shuttle walk test (ISWT) is a commonly used externally paced and incremental field exercise test in cardiac rehabilitation [9]. Previous research has supported both the retest reliability of this test when either one or two tests were performed on admission to cardiac rehabilitation [10–15] and criterion validity when either one or two tests were performed [10,11,14–17]. An important aspect of measurement properties is the interpretability of the change scores.
The interpretability of change in exercise test scores is an important measurement property. This study aimed to provide a framework for the interpretation of individual change scores of the 10 metre incremental shuttle walk test (ISWT) in cardiac rehabilitation.
In a quantitative pre-post design study, 52 patients who were referred to a hospital outpatient department for cardiac rehabilitation participated in this study. Participants completed two ISWTs prior to cardiac rehabilitation. Post cardiac rehabilitation, participants completed a global rating of change score and two ISWTs. Change scores were analysed for smallest detectable change (SDC) and minimum important change (MIC).
The SDC for an individual was 47 metres. The predicted MIC for participants to report an improvement ranged from 70 to 92 metres. The predicted MIC for participants who did not report a deterioration in the global rating of change (i.e., those who reported unchanged or improved) ranged from 16 to 42 metres.
The MIC for patients who report any improvement in physical fitness and functional capacity is 70 metres. These results suggest that over an 8-week program, patients would need to improve by at least seven shuttles to perceive an improvement in their physical fitness and functional capacity. Patients with small increases in the 10-metre ISWT distance may still report deterioration in their physical fitness and functional capacity.
Poor performance in incremental shuttle walk and cardiopulmonary exercise testing predicts poor overall survival for patients undergoing esophago-gastric resection
2018, European Journal of Surgical Oncology
Citation Excerpt :
Those achieving an ISWT result of greater or less than 350 m have a lower or higher operative risk respectively [8]. Studies have suggested that ISWT and CPET tests correlate well with each other [16,17]. As part of a perioperative enhanced recovery program an assessment of patient fitness was undertaken at initial presentation with OG cancer.
Esophageal and gastric cancer have a poor prognosis and surgical intervention is associated with considerable morbidity, highlighting the need for careful preoperative assessment. The Incremental Shuttle Walk Test (ISWT) and Cardiopulmonary exercise testing (CPET) can assess preoperative fitness. This study aims to investigate their correlation with both postoperative respiratory complications and overall survival.
Patients were identified who underwent esophageal or gastric resections for cancer between 2010 and 2014 and had ISWT and/or CPET assessments. Tumor differentiation, stage, postoperative respiratory complications, and outcome were documented and then correlated with the results of the preoperative fitness assessments.
Neither the ISWT result, anaerobic threshold (AT) nor VO2 Max correlated well with perioperative complications. However, ISWT (p < 0.001), AT (p < 0.001) and VO2 Max (p < 0.001) all correlated strongly with overall survival. No patient with a score of less than 350 m on ISWT survived beyond 3 years. In a subset of patients with ISWT results both pre and post chemotherapy (n = 49), those that had an improvement in result had a 19% incidence of post-operative respiratory complications compared to 45% where the result did not change or declined, though due to small numbers this only approached significance (p = 0.08).
ISWT and CPET can be useful preoperative tools to predict overall survival for patients undergoing esophago-gastric resection. Furthermore, patients that improve their functional status during chemotherapy seem to do better than those where it remains static or declines.
Evaluation of the Glittre-ADL test as an instrument for classifying functional capacity of individuals with cardiovascular diseases
2017, Brazilian Journal of Physical Therapy
The assessment of functional capacity in individuals with cardiovascular disease is closely related to lower limb function. The Glittre-ADL test is a global test to evaluate this patients.
We aimed to verify whether the Glittre-ADL test discriminates functional status while evaluating individuals with cardiovascular disease.
A total of 42 participants were evaluated using the Glittre-ADL test Incremental Shuttle Walking Test (shuttle test), Human Activity Profile, and Duke Activity Status Index. Data from the shuttle test, Human Activity Profile, and DASI were divided into tertiles for statistical analysis. The time required to complete the Glittre-ADL test was compared among tertiles of the shuttle test, Duke Activity Status Index and Human Activity Profile using analysis of variance.
There were significant differences between the tertiles of the shuttle test. Tertile 1 was different from tertiles 2 (mean difference, 47.63; 95% CI, 19.86–75.39) and 3 (mean difference, 67.15; 95% CI, 41.25–93.05). For the Duke Activity Status Index there were significant between-group differences. Tertile 1 was different from tertiles 2 (mean difference, 42.45; 95% CI, 8.82–76.09) and 3 (mean difference, 43.56; 95% CI, 13.68–73.44). For the Human Activity Profile there were significant between-group differences. Tertile 3 was different from tertiles 1 (mean difference, 51.46; 95% CI, 21.27–81.64) and 2 (mean difference, 33.01; 95% CI, 3.52–62.51).
The Glittre-ADL test is able to discriminate the functional status in individuals with cardiovascular disease, most of whom have hypertension. The Glittre-ADL test was sensitive to discriminate more functionally affected individuals.
Association between Modified Shuttle Walk Test and cardiorespiratory fitness in overweight/obese adults with primary hypertension: EXERDIET-HTA study
2017, Journal of the American Society of Hypertension
The aims of the study were to evaluate the relationship between Modified Shuttle Walk Test (MSWT) with peak oxygen uptake ( $\dot{V}$ O_2peak) in overweight/obese people with primary hypertension (HTN) and to develop an equation for the MSWT to predict $\dot{V}$ O_2peak. Participants (N = 256, 53.9 ± 8.1 years old) with HTN and overweight/obesity performed a cardiorespiratory exercise test to peak exertion on an upright bicycle ergometer using an incremental ramp protocol and the 15-level MSWT. The formula of Singh et al was used as a template to predict $\dot{V}$ O_2peak, and a new equation was generated from the measured $\dot{V}$ O_2peak-MSWT relationship in this investigation.
The correlation between measured and predicted $\dot{V}$ O_2peak for Singh et al equation was moderate (r = 0.60, P < .001) with a standard error of the estimate (SEE) of 4.92 mL·kg⁻¹ minute⁻¹, SEE% = 21%. The correlation between MSWT and measured $\dot{V}$ O_2peak as well as for the new equation was strong (r = 0.72, P < .001) with a SEE of 4.35 mL·kg⁻¹ minute⁻¹, SEE% = 19%. These results indicate that MSWT does not accurately predict functional capacity in overweight/obese people with HTN and questions the validity of using this test to evaluate exercise intolerance. A more accurate determination from a new equation in the current study incorporating more variables from MSWT to estimate $\dot{V}$ O_2peak has been performed but still results in substantial error.
The preoperative use of field tests of exercise tolerance to predict postoperative outcome in intra-abdominal surgery: a systematic review
2016, Journal of Clinical Anesthesia
To assess the ability of field tests of exercise tolerance, such as the 6-minute walk test (6MWT) and incremental shuttle walk test (ISWT), to predict postoperative outcome following intra-abdominal surgery.
A systematic review.
A hospital-affiliated university.
The following databases were searched: AMED, CINAHL, EMBASE, PEDro, PubMed/MEDLINE, and The Cochrane Library. Six full-text articles were included. Data extraction included author, population demographics, surgery type, postoperative outcome measure, and field test results. The risk of bias was performed using the Quality in Prognosis Studies tool.
Surgical procedures reviewed were colorectal (n = 3), upper gastrointestinal (n = 1), and intra-abdominal surgery (n = 2). Field tests of exercise tolerance showed little ability to predict postoperative mortality; however, the overall rate of mortality was low. Patients achieving lower distances on the ISWT tended to have longer hospital stays and an increased risk of overall complications. The 6MWT does not appear able to predict postoperative cardiac or pulmonary complications; however, it may be suitable to predict general complications.
Field tests may be able to predict postoperative outcome; however, further validation is needed. The ISWT appears to be the superior field test. The 6MWT and stair climb test require further validation to assess their predictive ability.

View all citing articles on Scopus

^☆: From the Departments of ^aCardiology and ^bPneumology, Virgen del Rocío University Hospital.

^☆☆: Supported by a grant from the Public Health Service of Andalucía, Spain (Consejería de Salud de la Junta de Andalucía).

^★: Reprint requests: Francisco J. Morales, MD, Cayetano del Toro, #46, 11010 Cádiz, Spain.

^★★: 0002-8703/99/$8.00 + 0 4/1/96000

View full text

A shuttle walk test for assessment of functional capacity in chronic heart failure☆,☆☆,★,★★

Abstract

Section snippets

Patients

Cycle ergometry cardiopulmonary exercise testing

Walk tests

Discussion

Acknowledgements

Am J Cardiol

J Am Coll Cardiol

Chest

Chest

Am Heart J

Chest

Cardiopulmonary exercise testing

Correlates and prognostic implication of exercise capacity in chronic congestive heart failure

Am J Cardiol

Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure

Circulation