1. Outcome measures of functional capacity

2. Content
 Exercise testing
 Application of 6MWT
 6MWT Evidence
 Application of SWT
 ISWT Evidence
 Comparison

3. Exercise testing
 Role of Exercise Testing
 Assess Exercise Capacity
 Exercise Prescription
 Assess Change

4. Exercise Testing
Gold Standard- Symptom Limited Graded Exercise Testing (GXT)
 Laboratory based
 Incremental
 Symptom limited
 Externally paced
 Gas Exchange

5. Field-Based Exercise Testing
 6 Minute Walk Test
 Shuttle Walk Test

6. 6 Minute Walk test
Background
 Developed in 1963 by Balke to evaluate functional capacity in respiratory
disease and heart failure.
 Has since been used in a variety of populations including the elderly, stroke
patients and spinal cord injuries.
 Easy to implement, little equipment needed.

7. 6MWT
Application
 Measures the amount of distance and individual is able to walk over a
period of 6 minutes on a hard, flat surface.
 Self-paced. Resting allowed as necessary. Submaximal test.
 Measure Heart Rate and SpO2 before test and upon completion.

8. 6MWT Implementation:
Ideally conducted in a closed quiet hallway by a single administrator.
 Variables:
• Test Instructions: Walk at a comfortable pace/ as quickly as possible.
• Resting Instructions (American Thoracic Society ATS)
• Walkway Length: ATS recommend 30m. Others 10m/15m.
• Use of Encouragement: If used the exact protocol should be
documented.
• Number of Trials: Largest improvements seen over first three.

9. 6MWT
 Scoring:
 Range for healthy adults is 400m-600m
 Clinically important difference is 54m for healthy adults (Redelmeier et al,
1997)
 50m for stroke patients (Perera et al, 2006) 25m for coronary disease
(Gremeaux et al, 2011). % change of clinical significance not established.

10. Test Evaluation
 Validity- Does the test measure what it is said to measure?
 Reliability- If the test is repeated on the same patient by the same or
different examiners will the results be similar?
 Responsiveness- Is the test responsive to change? e.g.: following completion
of an exercise intervention.

11. Evidence
Systematic review in out-patient cardiac rehabilitation
 “Strong evidence suggests that the 6MWT is responsive to clinical
change following cardiac rehabilitation. Intra and inter-tester
reliability of the 6MWT and its validity in patients undergoing cardiac
rehabilitation requires further research.”
-Bellet et al,2012

12. 6MWT Evidence
 Validity-Moderate to high relationships have been reported between the
6MWT distance and peak VO2max obtained in persons with heart failure
and COPD (Guyatt et al, 1985, Jaeschke et al 1993)
 Reliability-Different encouragements and repeated testing produce variable
results (Guyatt et al, 1984)
 Responsiveness- Studies of responsiveness have shown that improvement in
6MWT distance is related to diminished breathlessness (pacemaker
patients), improvements in QOL (elderly, cardiac pts) and changes in VO2
max (COPD)

13. Incremental Shuttle Walking Test
Background
 Developed to overcome problems associated with fixed-time, self-paced walking
tests.
 Externally Paced
 Incremental
 Symptom-limited maximal test
Based on the 20m shuttle run test designed by Leger and Lambert to assess fitness
in healthy adults.

14. ISWT Implementation
 10m course marked by 2 cones set 0.5m from each end.
 Walking speed set by an audio signal on a tape/cd.
 Initial pace is 0.5m/sec. Walking speed increases by 0.17m/sec each minute of the
test, indicated by a triple beep from the tape.
 Number of shuttles increases by 1 each time the speed of walking increases.
 Test ends when the patient is exhausted or too breathless to continue or when the
patient is more than .5m from the cone when the turn signal sounds.
 Max 12 levels.HR, SpO2, BORG Dyspea scale used in coherence with the walking
test.

15. ISWT

16. Evidence
Validity
 Several studies have demonstrated a strong relationship between distance
walked on the ISWT and the directly determined VO2max, advocating the
tests validity in:
-COPD Patients (Singh et al, 2003. Turner et al, 2004. )
-Chronic Heart Failure (Morales et al, 2000. Green et al, 2001)
-Pulmonary Fibrosis (Moloney et al, 2003)

17. ISWT
Reproducibility
Singh et al and Green et al both reported strong test-retest reproducibility
when they compared distance walked during tests spaced 1 week apart.
Reliability
Strong as externally paced and audio cued.

18. 6MWT Vs ISWT
 Some studies in people with COPD and CCF have demonstrated that the
6MWT overestimates disability when compared to the ISWT (Singh et al
1994, Green et al 2001, Morales et al, 2000)
 Similar distances covered. Peak HR and dyspnea greater on ISWT
 Conversely, Turner et al (2004) noted a strong correlation between heart
rate (HR), dyspnea and distances covered in the two tests and strongly
encouraged the 6MWT. This test also used encouragement.

19. Comparison 6MWT Vs ISWT
6 Minute Walk Test Incremental Shuttle Walk Test
Self-Paced Externally Paced
Little Equipment Needed CD for incremental change
Greater Functional Exercise Prediction Greater Physiological Correlation-
HR,Dyspnea
Similar distances covered Similar distances covered

20. Comparison
Randomised Control Trials. ? Conflicting Evidence
 The shuttle walk test is simple and easy to implement in patients with chronic obstructive
pulmonary disease. The encouraged 6-minute walk test produced higher post-test heart
rate and greater post-test sensation of dyspnea than did the shuttle walk test. (COPD)
-Rosa et al, 2006.
 The shuttle walk test is no more responsive to change than the 6-minute walk test in older
people. It is limited by ceiling effects, and cannot be performed successfully by very frail
older people. (Elderly population)
-Witham et al, 2012.

21. Conclusion
 Further evidence is needed for specific patient populations to establish the
true validity in all patient sub-groups.
 Current evidence suggests both the 6MWT and Shuttle walk test are
suitable functional capacity outcome measures for cardiopulmonary
patients.

22. References
 Bellet et al, 2012. The 6-minute walk test in outpatient cardiac
rehabilitation: validity, reliability and responsiveness- a systematic review.
 Guyatt et al, 1985. How should we measure function in patients with chronic
heart and lung disease? J Chronic Disease.
 Jaeschke et al, 1989. Measurement of health status: Ascertaining the
minimal clinically important difference. Control clinical trials.
 Solway et al, 2001. A qualitative systematic overview of the measurement
properties of functional walk tests used in the cardiorespiratory domain.
Chest.

23. References
 Singh et al, 1994. Comparison of oxygen uptake during a conventional treadmill
test and the shuttle walking test in chronic airflow limitation. Eur Resp J.
 Turner SE et al, 2004. Physiologic responses to incremental and self-paced
exercise in COPD. A comparison of three tests. Chest.
 Moloney ED et al 2003. The Shuttle walk exercise test in idiopathic pulmonary
fibrosis. Resp. Med.
 Green DJ et al, 2001 A Comparison of the shuttle and 6 minute walking tests
with measured peak oxygen consumption in patients with CHF. J Sci Med Sports
 Morales et al, 2000. Shuttle versus six-minute walk test in the prediction of
outcome in chronic heart failure. Int J Cardiol.