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Author(s): Fabiana Sobral Peixoto-Souza, Luciana Maria Malosa Sampaio, Elaine Cristina de Campos,Marcela Cangussu Barbalho-Moulim, Poliane Nascimento de Araujo, Rafael Melillo Laurino Neto,Ross Arena, and Dirceu Costa

Article title: Reproducibility of the incremental shuttle walk test for women with morbid obesity

Article no: UPTP_A_1010242

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Contrib. No. Prefix Given name(s) Surname Suffix Degree(s)

1 Fabiana Sobral Peixoto-Souza PT

2 Luciana Maria Malosa Sampaio PT, PHD

3 Elaine Cristina de Campos PT

4 Marcela Cangussu Barbalho-Moulim PT, PHD

5 Poliane Nascimento de Araujo

6 Rafael Melillo Laurino Neto MD

7 Ross Arena PT, PHD

8 Dirceu Costa PHD, PT

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Physiother Theory Pract, Early Online: 1–5! 2015 Informa Healthcare USA, Inc. DOI: 10.3109/09593985.2015.1010242

RESEARCH REPORT

Reproducibility of the incremental shuttle walk test for women withmorbid obesity

Fabiana Sobral Peixoto-Souza, PT1, Luciana Maria Malosa Sampaio, PT, PHD

1, Elaine Cristina de Campos, PT1,

Marcela Cangussu Barbalho-Moulim, PT, PHD2, PolianeQ2 Nascimento de Araujo1, Rafael Melillo Laurino Neto, MD

3,Ross Arena, PT, PHD

4, and Dirceu Costa, PHD, PT1

1Postgraduate Program in Rehabilitation Sciences, Nove de Julho University (UNINOVE) Rua Vergueiro 235/249 2ss mestrado e doutorado em

ciencias da reabilitacao Liberdade, Sao Paulo SP, Brazil, 2Postgraduate Program in Physical Therapy, Federal University of Sao Carlos (UFSCar),

Rodovia Washington Luıs, Sao Carlos, SP, Brazil, 3Mandaqui Hospital Complex, Rua Voluntarios da Patria, 4301 – Mandaqui, Sao Paulo SP, Brazil,

and 4Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois Chicago,

Chicago, IL, USA

Abstract

Objective: The incremental shuttle walk test (ISWT) is a valuable tool for the assessment offunctional capacity. However, few studies have used the ISWT in individuals with obesity orhave determined its reproducibility in this population. Purpose: The aim of the present studywas to evaluate the reproducibility of the ISWT in women with morbid obesity. Methods:Twenty-three women with a body mass index440 kg/m2 (mean age: 39.1 ± 7.7) performed theISWT twice on the same day. Results: The mean distance traveled was 313.3 ± 100.2 m on thefirst test and 322.5 ± 98.9 on the second test, with no significant difference between tests. Theintraclass correlation coefficient (0.91) indicated excellent reproducibility. Reliability determinedthrough Bland–Altman analysis revealed a small mean difference between tests (�9.2 m).Conclusion: The practice of repeating the ISWT appears to be unnecessary for women withmorbid obesity, as demonstrated by the excellent reproducibility of the test.

Keywords

Morbidly obesity, reproducibility,shuttle walk test

History

Received 4 June 2014Revised 15 December 2014Accepted 18 December 2014Published online 2 2 2

Introduction

Obesity is related to various metabolic diseases, and theprevalence of this condition continues to increase (Sood, 2009).In 2008,41.4 billion adults were overweight, among whom4200million men and nearly 300 million women were classified asobese (World Health Organization, 2012).

A primary contributor to obesity is a sedentary lifestyle, whichnegatively impacts exercise capacity (Hulens et al, 2003). Theability to walk is an important component of activities of dailyliving and quality of life. With obesity, the work load for a givenamount of physical activity is increased substantially. Thus, anindividual with a high body mass index (BMI) typically walks alesser distance in the same amount of time as an individual withinthe ideal BMI range (Hulens et al, 2001). The assessment ofwalking capacity in individuals with obesity is of primary clinicalimportance to several clinical objectives including establishing abaseline functional capacity, developing an exercise prescription,gauging therapeutic efficacy and assessing prognosis (Fletcheret al, 2013).

A number of field tests are used to assess physical performancein both patient populations and healthy individuals. Studies inthe literature often employ the 6-min walk test for the evaluationof functional capacity, including patients who are obese

(Browning and Kram, 2005; Castello et al, 2011; Gallagheret al, 2005; Seres et al, 2003). However, few studies haveexamined the clinical utility of the incremental shuttle walk test(ISWT), which may be another easily applied means for theassessment of physical performance.

The ISWT was initially developed to assess functional capacityin patients with chronic pulmonary obstructive disease (COPD)(Singh et al, 1992). The incremental nature of this test creates thepossibility of achieving physiological responses similar to thosefound during cardiopulmonary exercise testing (Onorati et al,2003). A number of investigators posit that, as a walk test with anaccentuated pace, the ISWT is more reproducible and producesgreater physiological responses in comparison to self-paced tests(Singh, 2007). The test–retest reliability of the ISWT has beenstudied in patients with heart disease. Fowler, Singh, and Revill(2005) found no significant difference in the distance traveledamong three ISWTs, demonstrating the excellent reproducibilityin those who have undergone cardiac rehabilitation. However themean difference between Tests 1 and 2 was 42.8 m compared with1.7 m between tests 2 and 3. Jolly et al (2008) reported astatistically significant different of 29.5 m (95% CI 23.0–36.0).Therefore, in a clinical situation, a practice walk is recommendedin order to overcome the natural variability of the ISWT and toestablish a secure baseline.

Besides reproducibility, validity of the ISWT was tested in arecent study by Jurgensen et al (2015). This analysis showed goodvalidity for the ISWT in comparison to peak VO2 duringcardiopulmonary exercise testing (r¼ 0.54), the gold standardaerobic assessment.

Address correspondence to Dirceu Costa, PhD, PT, Postgraduate Programin Rehabilitation Sciences, Nove de Julho University (UNINOVE) RuaVergueiro 235/249 2ss mestrado e doutorado em ciencias da reabilitacaoLiberdade, Sao Paulo, SP, Brazil. E-mail: dcosta@uninove.br

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To this point, few studies have evaluated the ISWT inindividuals with obesity, particularly in patients with morbidobesity. Thus, the aim of the present study was to evaluate thereproducibility of the ISWT in women with morbid obesity. Thehypothesis tested herein is that the ISWT is a reliable clinical testfor the evaluation of functional capacity in women with obesity.

Materials and methods

Study design

This was a cross-sectional study carried out with a sample ofconsecutively recruited patients from the Mandaqui HospitalComplex in the city of Sao Paulo, Brazil. About 30 adult femalevolunteers were recruited, 23 of whom were able to complete allphases of the study. The inclusion criteria were: female, morbidobesity (BMI� 40 kg/m2) and an age of 18 years or older. Thefollowing were the exclusion criteria: urinary incontinency duringphysical effort, peripheral obstructive vascular disease, anobstructive or restrictive respiratory pattern as assessed bypulmonary function testing, any musculoskeletal disorder thatcould hamper the performance of the walk test and an inability tounderstand the instructions for the spirometric maneuvers.

Data collection was performed at the Respiratory FunctionalEvaluation Laboratory of the University Nove de Julho (Brazil).All volunteers received information regarding the objectives ofthe study and signed a statement of informed consent. This studyreceived approval from the Human Research Ethics Committee ofthe University.

Procedures

Information was first gathered on the clinical history of thevolunteers, as: history of previous pathologies; history of obesityand other morbidities in the family; surgical procedures; medi-cations taken; followed by the determination of anthropometricdata and evaluations of lung volume and capacity. Functionalcapacity was evaluated using the ISWT.

Anthropometric data

Subjects remained barefoot with light clothing in the standingposition. Body weight was determined using a previouslycalibrated digital scale (Filizola�, Brazil) with a maximumcapacity of 300 kg and precision of 100 g. Height was determinedusing a wall stadiometer. BMI was calculated by the equationweight in kg divided by height in meters squared (kg/m2). Neckcircumference was measured at the height of the cricoid cartilage(Goncalves et al, 2011). Waist circumference was measured at themidpoint between the lower edge of the last rib and the upperedge of the iliac crest. Hip circumference was measured at theheight of the greater trochanter of the femur (Sievenpiper et al,2001).

Lung volume and capacity

Spirometric measures involved slow vital capacity, forcedvital capacity and maximum voluntary ventilation. A portableultrasound computerized spirometer (Easy One, NDD�

Medizintechnik, Switzerland) with a flow sensor was used. Thetests and interpretation of the results followed the guidelinesestablished by Miller et al (2005). The values were expressed aspercentage of predicted values based on established equations forthe Brazilian population (Pereira et al, 1992).

Incremental shuttle walk test

Characterized as a progressive load walk test, the ISWT wasperformed twice by each volunteer for the test (ISWT1) and retest

(ISWT2) evaluation. The tests were performed on the same daydue to the body weight of the cohort assessed (i.e. morbid obesity)and limited mobility. The rest period was defined by the 30-mininterval between the tests.

The test was performed on a track measuring 10 m in distancewith cones at each end, which the volunteers walked around at anincreasing pace divided into 12 levels. Changes in speed weremarked by an audible signal with the speed increased everyminute. The test was terminated when the subject could notcomplete the 10-m distance between two consecutive signals.Following the technical guidelines of the test, the only verbalintervention of the examiner was to remind the subject to increasewalking speed at the beginning of each minute. All tests wereadministered by the same examiner.

The following data were collected before, during and after thetest (recovery period): (1) heart rate using a heart meter (Polar,model RS800cx); (2) peripheral oxygen saturation (SpO2) using apulse oximeter (Nonin Medical Inc�, model Onyx 9500) and (3)dyspnea and lower-limb fatigue using the Borg scales (Borg,1982). Q3At rest and at the end of the ISWT, blood pressure wasmeasured using a sphygmomanometer for obese individuals andrespiratory rate was determined with the aid of a chronometer.

Statistical analysis

The Shapiro–Wilk test was used to determine the distribution ofthe data. Parametric data were expressed as mean and SD.Nonparametric data were expressed as median and interquartileinterval. Either the Wilcoxon test or the Student’s t-test was usedto determine differences in the distance travelled and cardiopul-monary variables between tests 1 and 2. Intraclass correlationcoefficients (ICCs) were calculated to determine the reproduci-bility of the distance travelled and cardiopulmonary variablescollected. An ICC of 0.80–1.0 indicated excellent reproducibility,0.60–0.79 indicated good and50.60 indicated poor reproducibil-ity (de Camargo et al, 2011). A Bland–Altman plot was created todetermine reliability between the tests and evaluate agreementbias between the distances travelled on the two tests. The level ofsignificance was set to 5% (p50.05). All statistical procedureswere performed using the BioStat program, version 5.0, andMedcalc program, version 12.2.1 (MedCal Software, Mariakerke,Belgium).

Results

Among the 30 volunteers with morbid obesity who wererecruited, three exhibited an obstructive respiratory pattern andwere excluded. Four others dropped out of the study. Thus, 23female volunteers with morbid obesity made up the final sample,14 of whom (60.8%) had systemic hypertension and type IIdiabetes, 7 had systemic hypertension (30.4%) and 2 exhibitedno comorbidities. None of the volunteers included in thefinal analysis had obstructive or restrictive lung abnormalities(Table 1).

The mean distance traveled was 313.3 m (range: 207–677 m)on ISWT1 and 322.5 m (range: 209–677 m) on ISWT2. About 4volunteers (17%) walked farther on ISWT1, 13 (57%) walkedfarther on ISWT2 and 6 (26%) walked the same distance on bothtests. The ICC demonstrated excellent reproducibility, as evidentby the small differences in the distanced travelled on the two tests(highest coefficient: 0.96). Other physiologic and subjectivemeasures demonstrated varying degrees of reproducibilitybetween the two tests (Table 2).

The graphic statistical analysis using the Bland–Altman plotdemonstrated a mean difference of �9.2 m between ISWTs(confidence interval: �76.1 to 56.7 m). About 11 individuals hadabove average scores and 10 had below average scores. Only two

2 F. S. Peixoto-Souza et al. Physiother Theory Pract, Early Online: 1–5

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volunteers travelled distances outside the limit of the mean ± SD(Figure 1).

Discussion

The results of the present study indicate the good reproducibilityof the ISWT in women with morbid obesity, as evident by the lackof significant differences in the distance travelled between thefirst and second tests.

Pepera, McAllister, and Sandercock (2010) reported thatpatients tested with an interval of a few days remember theprevious result and feel motivated to surpass this result onthe second test. Thus, the volunteers in the present study werenot informed of the distance travelled on the first test in order toavoid the risk of influencing the results of the second test.

In patients undergoing cardiac rehabilitation, Jolly et al (2008)investigated whether a single ISWT would be sufficient to assessfunctional capacity and found a significant difference betweenthe first and second test, with a greater distance achieved duringthe latter. The authors attribute this increase in distance tofamiliarization with the test, which lends support to performinga second test. However, Van Bloemendaal, Kokkeler, and Van dePort (2012) found good reproducibility in the comparativeanalysis of two ISWTs performed by stroke victims.

In the present study, the ICC for the distance travelled on thetwo tests was 0.91, which indicates excellent reproducibility.There is some discrepancy as to the ICC threshold indicativeof excellent reproducibility some propose an ICC between 0.80and 1.0 indicative (de Camargo et al, 2011), whereas Fowler,Singh, and Revill (2005) suggested an ICC 40.70. Regardlessof the threshold previously proposed, the present findings

demonstrate excellent reproducibility for ISWT distance inmorbidly obese women.

Although Singh et al (1992) and Jolly et al (2008) suggestedthe need for two tests to obtain a reliable ISWT result for patientswith COPD, the present findings on women with morbidobesity demonstrate a low degree of systematic bias (�9.2 m),as demonstrated by the Bland–Altman plot, indicating the absenceof a learning effect between the first and second test if conductedon the same day. This finding is in agreement with data describedby Arnott (1997) who investigated the reproducibility of theISWT in a group of surgery patients at different postoperativetimes and also found no important differences in the resultsbetween tests.

The Bland–Altman plot also showed that the limits ofagreement for this study ranged from �75.1 to 56.7 m. Wefound wider limits in studies of patients with cardiovasculardisease and COPD, but with a much larger sample than ours. Thefirst study by Fowler, Singh, and Revill (2005) found a meandifference in shuttle walking in test 1 versus test 2 was 40.3 m,with limits of agreement between �54.2 and 134.8 m. In thesecond, Pepera, McAllister, and Sandercock (2010) the 95% limitsof agreement were large, ranging from �203 to 189 m. However,Singh et al (1992) in COPD patients found a small limit ofagreement, from �49 to 13 m. Our small sample size does notallow us to conclude that there was excellent reproducibility.

In a long-term evaluation involving 30 patients with clinicallystable cardiovascular disease, Pepera, McAllister, and Sandercock(2010) found acceptable test–retest reliability (ICC: 0.80) of amodified version of the ISWT with an 8-week interval between

Table 2. Distance walked and physiological responses and physical characteristics at the two assessments (n¼ 23).

ISWT1 ISWT2 ICC 95% CI

Distance walked (m) 313.3 ± 100.2 322.5 ± 98.9 0.91 0.79–0.96Post-exercise HR (beats/min) 128 ± 23 132 ± 20 0.60 0.18–0.78Post-exercise SpO2 (%) 94.1 ± 2.9 94.3 ± 3.2 0.54 0.16–0.78Pre-exercise SBP (mm/Hg) 120 ± 8 119 ± 8 0.77 0.53–0.90Post-exercise SBP (mm/Hg) 139 ± 10 136 ± 12 0.74 0.48–0.88Pre-exercise DBP (mm/Hg) 78 ± 7 77 ± 6 0.81 0.59–0.91Post-exercise DBP (mm/Hg) 83 ± 5 82 ± 6 0.36 �0.05–0.67Post-exercise dyspnea Borg 3.0 (0.8–5.5) 3.7 (2.5–4.5) 0.16 �0.26–0.54Post-exercise legs Borg 3.0 (0.5–4.5) 3.4 (2.5–4.0) 0.39 0.01–0.69

ICC, intraclass correlation coefficient; 95% CI, 95% confidence interval for intraclass correlation; HR, heart rate;SpO2, peripheral oxygen saturation; SBP, systolic blood pressure; DBP, diastolic blood pressure.

Figure 1. Concordance between the mean values of distance test 1 andtest 2, using Bland–Altman plots. Mean ± SD 1.96 (in cm H2O), 95% CIvs. mean difference between the mean values of distance 1 and distance 2.

Table 1. Sample characteristics.

Morbidly obese(n¼ 23)

Percent predicted(n¼ 23)

Age (years) 39.1 ± 7.7 NAHeight (m) 1.6 ± 0.1 NABody weight (kg) 126.5 ± 15.7 NABMI (kg/m2) 47.7 ± 5.8 NAFVC 3.2 ± 0.6 90.8 ± 10.6FEV1 2.7 ± 0.5 92.1 ± 10.7FEV1/FVC 0.9 ± 0.3 101.2 ± 6.3Fat mass (%) 44.5 ± 3.3 NAFat-free mass (%) 55.2 ± 3.6 NA

Values were expressed as mean and SD.BMI, body mass index; WC, waist circumference; WHR, waist-to-hip

ratio; NC, neck circumference; FVC, forced vital capacity; FEV1,forced expiratory volume in the first second; FEV1/FVC, ratio ofFEV1/FVC.

DOI: 10.3109/09593985.2015.1010242 Shuttle walk test for women with morbid obesityQ1 3

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tests. The authors stated that a large time interval between tests(weeks) neutralizes any learning effect on the ISWT, whichfurther underscores the reproducibility of this test.

In a recent study conducted by Jurgensen et al (2015) in whichonly 11% of the sample was made up of women with morbidobesity, reproducibility was evaluated between a second andthird ISWT, with the latter performed 2–7 days after the first test.The authors concluded that the ISWT is an important tool withacceptable reliability (ICC: 0.90) for the cross-sectional evalu-ation of physical fitness among women with obesity. Thus, as onlywomen with morbid obesity were analysed in the present studyand both tests were held on the same day, the present findingscan be considered an advancement regarding the reproducibilityof the ISWT in this population.

Despite the different populations analysed, the present findingsare in agreement with data reported by Fowler, Singh, and Revill(2005) who determined the reproducibility of the ISWT in cardiacpatients following revascularization. The authors administered theISWT three times, once 6–8 weeks following revascularizationand the second and third tests were performed on the second visit,and found no significant difference in the distance travelled onthe three tests, reporting an ICC of 0.94 between the first andsecond tests.

According to the American Thoracic Society (2002), a testis reproducible when the difference between two applications is510%. In the present study, the mean distance was 313 m onISWT1 and 322 m on ISWT2, which corresponds to a differenceof 2.9%, further demonstrating the reproducibility of this testwhen administered to women with morbid obesity.

Regarding the subjective perception of dyspnea and lower limbfatigue, reliability was low, with ICC values of 0.16 and 0.39,respectively. According to de Camargo et al (2011) an ICC50.60is indicative of poor reproducibility. Moreover, the 30-min restinterval between tests in the present investigation, which wasbased on studies by Coelho et al (2007); Singh, Jones, Evans, andMorgan (2008) and Soares et al (2011) may have been insufficientfor women with morbid obesity to recover properly. Thus, furtherstudies should be conducted with different rest intervals.Moreover, individual motivation, age and the presence ofcomorbidities can play an important role in the variation inperformance.

It is our view that assessment of the applicability of functionalfield tests, such as the ISWT, is an important endeavor in patientpopulations that would benefit from functional assessment. This isthe case in patients who are morbidly obese, a population thatsuffers from clear functional deficits as a result of their bodyweight and associated comorbidities. Given potential challengesassociated with clinical exercise testing in this population (e.g.treadmill weight limits, decreased mobilitiy and limited travel to aclinical setting), application of functional field tests may behighly beneficial. The ISWT has been shown to be valid andreliable in other populations (Jurgensen et al, 2015). Moreover,walking capacity is an important indicator of quality of life andthe ability to carry out daily tasks (de Souza et al, 2005). Theresults of the current study extend this body of literature,demonstrating the potential clinical applicability of the ISWT inpatients who are morbidly obese.

In the present study, however, some limitations should beconsidered. First, the fact that men with morbid obesity were notassessed limits the ability to draw conclusions regarding ISWTreliability in males. Indeed, the majority of the studies involvingthe ISWT in cohorts with other conditions have involved bothgenders. Second, the two tests were performed on the same day.Most studies in which ISWT reproducibility was assessedperformed tests on different days, in order to control for possiblelearning effects. However, due to mobility problems in the

morbidly obese population and taking into account that practice ofclinical trials on the same day are widely used in the literature, wechose to perform assessments on the same day. The fact that490% of the sample had some form of cardiovascular disease isalso a confounding factor, limiting ability to assess the isolatedeffect of morbid obesity on functional capacity. Furthermore, oursmall sample size is a limitation, which limits the applicabilityof the Bland–Altman test.

In conclusion, the present findings suggest that it may beunnecessary to perform a second ISWT in women with morbidobesity, as demonstrated by the excellent reproducibility betweentwo tests performed on the same day. Thus, a single administra-tion of this test may be considered clinically applicable and usefulfor the evaluation of functional capacity in women with morbidobesity.

Declaration of interest

The study received financial support from the Fundacao de Amparo aPesquisa do Estado de Sao Paulo, SP, Brazil (FAPESP 2012/12206-0).The authors report no conflicts of interest. The authors alone areresponsible for the content and writing of this article.

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DOI: 10.3109/09593985.2015.1010242 Shuttle walk test for women with morbid obesityQ1 5

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